nervous system emergencies
DESCRIPTION
Nervous System Emergencies. Chemeketa Community College Paramedic Program. Causes of Coma (We’ll be talking about these…). Structural Metabolic Drugs Cardiac (Shock, Arrhythmias, Hypertension, Stroke Respiratory (Toxic Inhalations, COPD) Infectious Process (Meningitis). And these…. - PowerPoint PPT PresentationTRANSCRIPT
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Nervous System Emergencies
Chemeketa Community CollegeParamedic Program
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Causes of Coma (We’ll be talking about these…)
• Structural
• Metabolic
• Drugs
• Cardiac (Shock, Arrhythmias, Hypertension, Stroke
• Respiratory (Toxic Inhalations, COPD)
• Infectious Process (Meningitis)
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And these…..
• Amyotrophic lateral sclerosis (ALS)
• Muscular Dystrophy
• Bell’s Palsy
• Multiple Sclerosis
• Parkinson’s
• Peripheral neuropathy
• Central pain syndrome
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The nervous system
• CNS – 43 pairs of nerves– Brain
• 12 pairs of cranial nerves– Spinal cord
• 31 pairs of spinal nerves
• PNS
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• Neurons– Dendrites, soma, axon,
synapse• Neurotransmitters
– Acetylcholine, norepi, epi, dopamine
• Skull - brain• Spine - spinal cord• Meninges
– Dura mater, arachnoid membrane, pia mater
• Cerebrospinal fluid
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Brain• Cerebrum
• Frontal lobe
• Temporal lobe
• Parietal lobe
• Occipital lobe
• Cerebellum
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Brainstem• Brain stem
– Medulla– Pons– Midbrain– Reticular formation
• Diencephalon– Hypothalamus– Thalamus– Limbic system
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Blood supply to brain
• Vertebral arteries– Through foramen magnum – Cerebellum– Basilar artery – pons and cerebellum, cerebrum
• Internal carotid arteries– Carotid canals– Anterior cerebral arteries – Frontal lobes, lateral cerebral cortex, posterior cerebral
artery• Circle of Willis
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Ventricles
• Lateral ventricle
• Third ventricle
• Fourth ventricle
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Spinal Cord
• 17-18 inches long!! To first
lumbar vertebra
• Reflexes
• Afferent - sensory
• Efferent - motor
• Interneurons - connecting
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Peripheral Nervous System
• Cranial nerves
• Somatic sensory
• Somatic motor
• Visceral sensory
• Visceral motor
• Brachial plexus
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Cranial nerves“Some say marry money, but my brother says bad boys marry
money." • I Olfactory
– smell
• II Optic– vision
• III Oculomotor– Constriction,
movement
• IV Trochlear– Downward gaze
• V Trigeminal– Facial sensation,
chewing
• VI Abducens– Lateral eye movement
• VII Facial– Taste, frown, smile
• VIII Acoustic– Hearing, balance
• IX Glossopharyngeal– Throat, taste, gag, swallowing
• X Vagus– Larnx, voice, decreased HR
• XI Spinal Accessory– Shoulder shrug
• XII Hypoglossal– Tongue movement
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Learn the cranial nerves
• On Olfactory• Old Optic• Olympus Oculomotor• Towering Trochlear• Top, Trigeminal• A Abducens• Finn Facial• And Acoustic
• German Glossopharyngeal
• Viewed Vagus• Some Spinal
Accessory• Hops Hypoglossal
OR……
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Autonomic Nervous System
• Sympathetic
– Fight or Flight
• Parasympathetic
– Feed or Breed
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Initial Assessment Be organized and systematic
• Mentation• Ensure patent airway• Spinal precautions prn• Monitor for respiratory arrest, vomiting• Oxygenate• If ventilating with BVM, use NORMAL rate
– PCO2
– SaO2
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Assessment – HistoryBe organized and systematic!
• General health• Previous medical conditions • Medications• History with complaint
• Bystanders / Family– Length of Coma, Sudden or
Gradual Onset, Recent Head Trauma, Past medical hx, alcohol/drug use or abuse, complaints before coma
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What led up to 9-1-1?
• Time of onset
• Seizure activity
• Environment
• Cold, hot, drug paraphernalia
• Medications / Medic Alerts
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Assessment - Physical
• General appearance• Mentation
– Mood– Clarity of thought– Perceptions– Judgment– Memory & attention
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Assessment - Physical(cont.)
• Speech– Aphasia
• Apraxia • Skin• Posture, balance and gait• Abnormal involuntary
movements
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Assessment - Physical
• Vital signs– Hypertension– Hypotension– Heart rate (fast, slow)– Ventilation (rate, quality)– Temperature, fever
• Cushing’s Triad
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Assessment - Physical(cont.)
• Head / neck
– Facial expression
– Eyes
• Acuity, fields, position &
alignment, iris, pupils,
extraocular muscles
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Assessment – Physical (cont.)– Ears
• Acuity
– Nose
– Mouth
• Odors
• Thorax and lungs
– Auscultate
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Assessment - Physical(cont.)
• Cardiovascular– Heart rate– Rhythm– Bruits– Jugular vein pressure– Auscultation– ECG monitoring
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Assessment - Physical(cont.)
• Abdomen• Nervous
– Cranial nerves– Motor system
• Muscle tone, muscle strength, flexion, extension, grip, coordination
• Assessment tools– Pulse Oximetry, End tidal
CO2, Blood Glucose
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Assessment
• Ongoing assessment
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Management• Airway and ventilatory support
– Oxygen– Positioning– Assisted ventilation– Suction– Intubation
• Circulatory support– Venous access
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Management(cont.)
• Non-pharmacological interventions
– Positioning
– Spinal precautions
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Pharmacological interventions
• Anti-anxiety agent• Anti-convulsant• Anti-inflammatories• Diuretic• Sedative-hypnotic• Skeletal muscle relaxant• Hyperglycemic• Anti-Emetic
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Management (cont.)
• Psychological support
• Transport considerations
– Mode
– Facility
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Head to Toe
• Pupils
• Respiratory Status
• Spinal Evaluation
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Pupils• Cranial nerve III (occulomotor)
• Brain herniation = same side
dilation
• Both dilated = anoxia, brain stem
injury
• Anisocoria = unequal pupil –
normal?
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Cardinal Positions of Gaze• Patient should be able to follow your finger
• Conjugate gaze - structural lesion
– Irritable focus - away
– Destructive focus – toward
• Dysconjugate gaze – brainstem
dysfunction
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Respiratory Status
• Cheyne-Stokes
– Brain Injury
• Central Neurogenic
Hyperventilation
– Cerebral Edema
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Respiratory Status (cont.)
• Ataxic
– CNS Damage = poor thoracic
control
• Apneustic
– Damage to upper Pons
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Respiratory Status (cont.)
• Diaphragmatic
– C-spine
• Kussmaul
– DKA
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Spinal Evaluation
• Tingling (pins & needles)
• Loss of Sensation or Function
• Pain, Tenderness
• Priapism
• Deformity, tight neck muscles
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Spinal Evaluation (cont.)
• Motion, Sensation, Position/each
extremity
• “Gas pedal”, grips
• If unconscious, pain response
• Incontinence, rectal for S-1
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Neurological Exam• Decorticate Posturing
– Above Brainstem
• Decerebrate Posturing
– Brainstem
• Flaccid
• Babinski’s sign
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Neurological Exam
• Glascow Coma Scale
– Motor, 1 - 6
– Verbal, 1 - 5
– Eye, 1 - 4
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Altered Mental
Status/Coma• Structural Lesions
– Acute onset
– Unresponsive/asymmetric pupillary response
• Toxic - Metabolic States
– Slow onset
– Preserved pupillary response
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Causes of ComaStructural
• Trauma, Tumor
• Epilepsy, Hemorrhage
• Other Lesions
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Causes of Coma - Metabolic
• Anoxia, Hepatic Coma
• Hypoglycemia, DKA
• Thiamine Deficiency
• Kidney, liver failure
• Seizure
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Causes of Coma - Drugs
• Barbiturates, Narcotics
• Hallucinogens
• Depressants
• Alcohol
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Causes of Coma - Cardiovascular
• Hypertensive Encephalopathy
• Dysrhythmias, Cardiac Arrest
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Causes of Coma - Respiratory
• COPD
• Toxic Gases
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Causes of Coma - Infections
• Meningitis
• Encephalitis
• AIDS Encephalitis
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AEIOU - TIPS
• A = Alcohol, Acidosis
• E = Epilepsy
• I = Infection
• O = Overdose
• U = Uremia
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AEIOU - TIPS• T = Trauma, Tumor
• I = Insulin
• P = Psychosis
• S = Stroke
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Management
• C-spine
• Airway
• Oxygen
• Hyperventilate if ICP is up???
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Management
• D50 - 25 grams
• Narcan - 2.0 mg
• Thiamine 100 mg
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Seizures• Behavioral alteration due to
massive electrical discharge.
• Generalized or Partial
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Generalized
• Grand Mal
• Petit Mal
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Partial Seizures
• Simple or Complex (Psychomotor)
• May spread to generalized
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Causes
• Brain Injury, Epilepsy, Tumor
• Hypoglycemia, Hyperthermia
• Eclampsia
• Hypoxia
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Grand Mal (generalized)
• Aura, Loss of consciousness
• Tonic, Hypertonic Phases
• Clonic
• Post-Seizure, Post-Ictal
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Other Types
• Focal Motor - One Area of the Body
• Psychomotor - Auras
• Petit Mal, 10-30 Seconds
• Hysterical - How Do You Tell?
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Management• Good history and physical first
• ABCs
• IV, EKG, BG
• Body Temp, Position on Side
• Suction if needed
• Calm, Quiet
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Status Epilepticus
• Two or More Seizures
• Consciousness Not Regained
• Non-compliance With Meds
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Management of Status Seizures
• 100% O2, BVM
• IV, EKG, BG
• D50, Thiamine (if needed)
• Valium 5-10 mg (or Versed 0.5 – 1.0 mg)
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Coma
• Abnormally deep state of unconsciousness
– Structural lesions
– Toxic metabolic states
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DDXStructural lesions
Commonly asymmetrical neurological signsAcute onsetUnresponsive or asymmetrical pupillary
responses
Toxic-metabolic comaNeurological findings symmetricalComa slow in onsetPreserved pupillary response
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Management
• Supportive
• Prevention
• Medication administration
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Stroke (CVA) - what do they
look like?• Motor, Speech, Sensory Centers
• Altered mentation
• Upper Airway Noises
• Unequal Pupils, Visual Disturbances
• Hemiparalysis / Hemiparesis
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Stroke (CVA)
• Eyes Deviate Away From Paralysis, or
Look Toward Lesion
• Dysphagia
• Dysphasia
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Ischemic or Hemorrhagic??
• Most common• Usually 2ndary to
tumor or atherosclerosis
• Slow onset• Long history• May be assoc. with Af• Hx angina, previous
CVA
• Least common• Usually 2ndary to
aneurysm, AV malformation, HTN
• Abrupt onset• Commonly during
stress• May be assoc. with
cocaine• May be asymptomatic
before rupture
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Transient Ischemic Attacks(TIA)
• Little Strokes, Emboli, Carotid Disease
• Stroke Symptoms Gone in a Day
• Usually Mean a Big One Is on the Way
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Cincinnati Prehospital Stroke Scale
• Facial droop
• Arm drift
• Speech “you can’t teach an old dog new
tricks”
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Management CVA / TIA
• Protect Patient
• ABCs / C-spine
• ETT? BVM? OPA?
• Hyperventilate if unresponsive
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Management CVA / TIA
• CBG, IV, EKG
• Reassure, calm (they can hear, usually)
• Position, Transport
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Headaches
• Tension – Muscle contractions
• Migraines– Constriction, dilation of blood vessels;
seratonin or hormone imbalance?• Cluster
– Bursts; occur during sleep• Sinus
– Allergies or infection/inflammation of membranes
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Management of H/A• Tension
– Aspirin, acetaminophen, ibuprofen• Migraines
– Beta blockers, calcium channel blockers, antidepressants, serotonin-inhibitors
• Cluster– Antihistamines, corticosteroids, calcium
channel blockers• Sinus
– Antibiotics, antihistamines, analgesics
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Muscular Dystrophy
• Inherited• Progressive degeneration of muscle fibers• Duchenne MD most common (1-2/10,000
male children)• No Tx• Death usually from pulmonary infection,
before age 21
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Multiple Sclerosis
• Gradual destruction of myelin in brain and spinal cord
• Autoimmune?
• 1/1000 (women 3/2 men)
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Parkinson’s Disease
• Degeneration or damage to nerve cells in basal ganglia; 130/100,000
• Lack of dopamine prevents control of muscle contraction
• Progressive• Initial; slight tremor in one extremity
– Shuffling gait– Untreated, severe incapacity in 5-7 years
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Central Pain Syndrome
• Infection/disease of trigeminal nerve– Paroxysmal episodes of severe unilateral pain
• Lips• Cheek, • Gums• Chin
• Pt usually older than 50• Trigger point• Treated with tegratol
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Bell’s Palsy
• Inflammation of 7th cranial nerve• Sudden onset• Usually temporary, usually 2ndary to
infection including Lyme disease, herpes, mumps, HIV
• 1/60-70
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Bell’s Palsy, cont.
• Sx;
– Eyelid, corner of mouth droops
– Taste may be impaired
• Tx:
– Corticosteroid, analgesics
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Amyotrophic Lateral Sclerosis
• Motor neuron disease– Pt usually over 50; more common in men
• Sx; first, weakness in hands and arms with fasciculations
• Late – pt unable to speak, swallow, move
• Awareness, intellect maintained.
• Death usually w/in 2-4 years /p Dx
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Peripheral Neuropathy
• Affects peripheral nervous system incl. Spinal nerve roots, cranial nerves– Diabetes– Vit. B deficiencies– Alcoholism– Uremia– Leprosy– Drugs– Viral infections– Lupus
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Nervous System EmergenciesSUMMARY
• Complex and Varied
• Attention to Assessment
• Attention to Treatment
• Good History and Exam
• Good DocumentationS:\HealthOccupations\EMS\EMT Paramedic\Neuro\Nervous System emergencies.ppt
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