bled ppt ch29

7/24/2019 Bled Ppt Ch29

1/62

Copyright 2006 Pearson 29-1

Chapter 29Neurology

7/24/2019 Bled Ppt Ch29

2/62


Lecture Outline

Introduction

Pathophysiolgy

General assessment findings Management of nervous system

emergencies

7/24/2019 Bled Ppt Ch29

3/62


Introduction

Nervous system disorders affect

thousands of Canadians each year

Strokes affect 50 000 Epilepsy affects 00 00

!00 000 people have "een diagnosed #ith

Parkinson$s disease

7/24/2019 Bled Ppt Ch29

4/62


Pathophysiology

%lterations in cognitive systems &%S

Cere"ral corte' Peripheral nervous systems

disorders

Peripheral neuropathy

7/24/2019 Bled Ppt Ch29

5/62


Central Nervous System

Disorders Structural lesions (umour

)egenerative

disease Intracranial

hemorrhage

Parasites

(rauma

(o'ic*meta"olic

states %no'ia

)ia"etic

ketoacidosis

+epatic failure

+ypoglycemia

&enal failure

(hiamine deficiency

(o'ic e'posure

7/24/2019 Bled Ppt Ch29

6/62


Assessment

Scene and primary assessment %,P-

General appearance Speech

Skin and facial drooping

Mood. thought. perception. /udgment.

memory. and attention

7/24/2019 Bled Ppt Ch29

7/62


History

hen did the incident occur1

2oss of consciousness1

Incontinence1 Chief complaint1

Changes1 Complicating factors1

7/24/2019 Bled Ppt Ch29

8/62


Secondary

Assessment 3ace Smile. fro#n. facial drooping

Eyes Pupils

Nose4mouth

Potential compromise of the air#ay

7/24/2019 Bled Ppt Ch29

9/62


espiratory Status

7/24/2019 Bled Ppt Ch29

10/62


Cardiovascular System

Status +eart rate ECG

ruits 6,)

7/24/2019 Bled Ppt Ch29

11/62


Nervous System

Status Sensorimotor evaluation %,P-

Incontinence

)istal properties Motor system status

Muscle tone

Strength

3le'ion4e'tension

Coordination

alance

7/24/2019 Bled Ppt Ch29

12/62


Posturing

)ecorticate %rms fle'ed. legs e'tended

2esion at or a"ove the upper "rainstem

7/24/2019 Bled Ppt Ch29

13/62


Posturing

)ecere"rate Sustained e'tension

2esion in the "rainstem

7/24/2019 Bled Ppt Ch29

14/62


Nervous System

Status Cranial nervestatus

Glasgo# Coma

Scale 7GCS8 Eye opening

,er"al response

Motor response

7/24/2019 Bled Ppt Ch29

15/62


7/24/2019 Bled Ppt Ch29

16/62


Additional Assessment

!ools End tidal C9: Pulse o'imetry

lood glucose determination

7/24/2019 Bled Ppt Ch29

17/62


"eriatric

Considerations More suscepti"le to systemicillness

Certain changes occur naturally#ith aging Pupil sluggishness

2oss of overall "ody strength Muscle atrophy

%ltered sensation

7/24/2019 Bled Ppt Ch29

18/62


"eneral

#anagement %ir#ay and "reathing Circulatory support

Pharmacological intervention Psychological support

(ransport considerations Primary treatment is supportive

7/24/2019 Bled Ppt Ch29

19/62


Altered #ental

Status% acidosisE epilepsy

I infection

9 overdose- uremia 7kidney failure8

( trauma. tumour. to'in

I insulin 7hypoglycemia. ketoacidosis8P psychosis. poison

S stroke. sei;ure

7/24/2019 Bled Ppt Ch29

20/62


#anagement

%ir#ay and "reathing

Circulatory support

Esta"lish I, lood glucose

(reat reversi"le causes +ypoglycemia Narcotic overdose

7/24/2019 Bled Ppt Ch29

21/62


Altered #ental

Status Chronic %lcoholism Significant percentage have a thiamine

deficiency

ernicke$s Syndrome

7/24/2019 Bled Ppt Ch29

22/62


Stro$e

In/ury or death to "rain tissue -sually due to an interruption in cere"ral

"lood flo#

Physiology compares to an MI

Categories

9cclusive +emorrhagic

7/24/2019 Bled Ppt Ch29

23/62


Occlusive Stro$e

Cere"ral artery "locked "y a clot or

foreign matter

Ischemia Infarction

(issue s#ells

+erniation

7/24/2019 Bled Ppt Ch29

24/62


Occlusive Stro$e

Em"olic stroke Em"olus carried to cere"ral "lood vessel from a

remote site

-sually clots arising from diseased vessels %trial fi"rillation

(hrom"otic stroke lood clot gradually develops in and o"structs a

cere"ral "lood vessel

Signs develop gradually

9ccurs at night. patient #akes up #ith signs

7/24/2019 Bled Ppt Ch29

25/62


7/24/2019 Bled Ppt Ch29

26/62


Hemorrhagic Stro$e

Sudden onset characteri;ed "y

headache and decreased 29C

Intracranial ithin the "rain

Small "lood vessels

Effects depend on location of "lood vessels

Su"arachnoid )evelops from congenital "lood vessel

a"normalities

7/24/2019 Bled Ppt Ch29

27/62


Hemorrhagic Stro$e

+emorrhage inside the "rain tears

and separates "lood vessels

Impaired drainage of CS3 +erniation of "rain tissue occurs

rapidly

7/24/2019 Bled Ppt Ch29

28/62


7/24/2019 Bled Ppt Ch29

29/62


Presentation

Signs 3acial )rooping

+eadache

%phasia4)ysphasia +emiparesis

+emiplegia

Paraesthesia

Gait )istur"ances

Incontinence

Symptoms Confusion

%gitation

)i;;iness ,ision Pro"lems

7/24/2019 Bled Ppt Ch29

30/62


!ransient Ischemic

Attac$s Indicative of carotid artery disease= Symptoms of neurological deficit>

Symptoms resolve in less than :? hours=

No long*term effects=

Evaluate through history taking> +istory of +(N. prior stroke. or (I%=

Symptoms and their progression

+igh risk of throm"otic stroke

7/24/2019 Bled Ppt Ch29

31/62


#anagement

Scene safety and SI Maintain the air#ay= Support "reathing=

9"tain a detailed history= Position the patient= )etermine the "lood glucose level=

Esta"lish I, access= Monitor the cardiac rhythm= Protect paraly;ed e'tremities=

7/24/2019 Bled Ppt Ch29

32/62


Sei%ure

(emporary alteration in "ehaviour

die to massive electrical discharge

from one or more groups ofneurons in the "rain +ypo'ia

)ecreased "lood sugar Epilepsy

Idiopathic sei;ures

7/24/2019 Bled Ppt Ch29

33/62


"enerali%ed

Sei%ures (onic*Clonic %lso called grand mal

%ura

2oss of consciousness

(onic phase

+ypertonic phase

Clonic phase Postsei;ure

Postictal

7/24/2019 Bled Ppt Ch29

34/62


"enerali%ed

Sei%ures %"sence %lso called petit mal

Presents #ith "rief loss of consciousness

May not respond to normal treatment

Pseudosei;ure

-sually stem from a psychologicaldisorder

No post ictal phase

7/24/2019 Bled Ppt Ch29

35/62


Partial Sei%ures

Simple partial sei;ures Involve one "ody area

Can progress to generali;ed sei;ure

Comple' partial sei;ure Characteri;ed "y an aura

(ypically :* minutes in length 2oss of contact #ith surroundings

7/24/2019 Bled Ppt Ch29

36/62


7/24/2019 Bled Ppt Ch29

37/62


Patient History

+istory of sei;ures

+istory of head trauma

%ny alcohol or drug a"use

&ecent history of fever. headache. or stiffneck

+istory of heart disease. dia"etes. or stroke

Current medications

Physical e'am Signs of head trauma or in/ury to tongue. alcohol or drug

a"use

7/24/2019 Bled Ppt Ch29

38/62


#anagement

Scene safety and SI= Maintain the air#ay= %dminister high*flo# o'ygen=

Esta"lish I, access= (reat hypoglycemia if present= Protect the patient from the

environment= )o not restrain the patient= Maintain "ody temperature=

7/24/2019 Bled Ppt Ch29

39/62


Protection o& a sei%uringpatient

7/24/2019 Bled Ppt Ch29

40/62


#anagement

Position the patient=

Suction if re@uired=

Monitor cardiac rhythm= (reat prolonged sei;ures=

%nticonvulsant medication

Provide a @uiet atmosphere=

(ransport=

7/24/2019 Bled Ppt Ch29

41/62


Place a sei%uring patient'ith no spinal in(ury on her

side

7/24/2019 Bled Ppt Ch29

42/62


Status )pilepticus

(#o or more generali;ed sei;ures Sei;ures occur #ithout a return of

consciousness=

Management Management of air#ay and "reathing is critical=

Esta"lish I, access and cardiac monitoring=

%dminister :5g 50A de'trose if hypoglycemia is

present=

%dminister 5B!0mg dia;epam I,=

Monitor the air#ay closely=

7/24/2019 Bled Ppt Ch29

43/62


Syncope

% sudden. temporary loss ofconsciousness

%ssessment Cardiovascular

)ysrhythmias or mechanical pro"lems

Noncardiovascular Meta"olic. neurological. or psychiatric condition

Idiopathic (he cause remains unkno#n even after careful

assessment

E'tended unconsciousness is not syncope

7/24/2019 Bled Ppt Ch29

44/62


#anagement

Scene safety and SI= Maintain the air#ay= Support "reathing=

Check circulatory status= Monitor mental status= Esta"lish I, access=

)etermine "lood glucose level= Monitor the cardiac rhythm= &eassure the patient and transport=

7/24/2019 Bled Ppt Ch29

45/62


Headache

,ascular

Migraines (hro""ing pain. photosensitivity. nausea.

vomiting. and s#eats more fre@uent in #omen May last for e'tended periods of time=

Cluster 9ne*sided #ith nasal congestion. drooping

eyelid. and irritated or #atery eye more fre@uentin men

(ypically lasts !B? hours=

7/24/2019 Bled Ppt Ch29

46/62


Headache

(ension

9rganic

9ccurs due to tumours. infection. or otherdiseases of the "rain. eye. or other "ody

system=

+eadaches associated #ith fever.

confusion. nausea. vomiting. or rash can"e indicative of an infectious disease=

7/24/2019 Bled Ppt Ch29

47/62


Assessment

hat #as the patient doing at the onsetof pain1

)oes anything provoke or relieve the

pain1 hat is the @uality of the pain1 )oes the pain radiate to the neck. arm.

"ack. or /a#1

hat is the severity of the pain1 +o# long has the headache "een

present1

7/24/2019 Bled Ppt Ch29

48/62


#anagement

Scene safety and SI Maintain the air#ay= Position the patient=

Esta"lish I, access= )etermine "lood glucose level= Monitor the cardiac rhythm=

Consider medication= %ntiemetics or analgesics

&eassure the patient and transport=

7/24/2019 Bled Ppt Ch29

49/62


*+ea$ and Di%%y,

%ssessment Symptomatic of many illnesses

3ocused assessment

Include a detailed neurological e'am=

Specific signs and symptoms>

Nystagmus

Nausea and vomiting )i;;iness

7/24/2019 Bled Ppt Ch29

50/62


#anagement

Scene safety and SI=

Maintain air#ay and administer high*flo#o'ygen=

Position of comfort=

Esta"lish I, access D monitor cardiacrhythm=

)etermine "lood glucose level=

Consider medication= %ntiemetic

(ransport and reassure patient=

7/24/2019 Bled Ppt Ch29

51/62


Neoplasms

&efers to the gro#th of a ne# tumour CNS neoplasms have a high mortality

enign %"normal gro#th

Pressure in confined spaces 7cranial vault8

Malignant

Infiltrates healthy tissue 2ikely to metastasi;e

7/24/2019 Bled Ppt Ch29

52/62


Assessment

Signs and symptoms &ecurring or severe headaches Nausea and vomiting eakness or paralysis 2ack of coordination or unsteady gait )i;;iness. dou"le vision Sei;ures #ithout a prior history of sei;ures

+istory Surgery. chemotherapy. radiation therapy. or

holistic therapy E'perimental treatments

7/24/2019 Bled Ppt Ch29

53/62


#anagement

Scene safety and SI= Maintain air#ay and administer high*

flo# o'ygen=

Position of comfort= Esta"lish I, access and monitor

cardiac rhythm= Consider medication administration=

%nalgesics. antisei;ure meds. anti*inflammatorymeds

(ransport and reassure patient=

7/24/2019 Bled Ppt Ch29

54/62


-rain A.scess

%"scess Collection of Pus

%ssessment Signs and symptoms

2ethargy. hemiparesis. nuchal rigidity

+eadache. nausea. vomiting. sei;ures

Management Similar to neoplasm

7/24/2019 Bled Ppt Ch29

55/62


Degenerative

Disorders %l;heimer$s disease Most fre@uent cause of dementia in the elderly &esults in atrophy of the "rain due to nerve cell

death in the cere"ral corte'

Muscular dystrophy Progressive muscle #eakness and degeneration

of muscle fi"res

Multiple sclerosis -npredicta"le disease resulting from

deterioration of the myelin sheath eakness and sensory loss

7/24/2019 Bled Ppt Ch29

56/62


Degenerative

Disorders )ystonia Group of disorders

Muscle contractions that cause t#istingrepetitive movements

Parkinson$s disease Chronic progressive motor system disorder

(remor. rigidity. "radykinesia. postural insta"ility

Central pain syndrome &esult of CNS in/ury

Intense. steady "urning pain

7/24/2019 Bled Ppt Ch29

57/62


Degenerative

Disorders ell$s palsy 9ne*sided facial paralysis

-nkno#n cause

%mytrophic lateral sclerosis )egeneration of motor tracts

eakness. loss of motor control

Myoclonus (emporary. involuntary t#itching of

muscles

7/24/2019 Bled Ppt Ch29

58/62


Degenerative

Disorders Spina "ifida 9ne or more fetal verte"ra fail to close

Portion of the spine left unprotected

Poliomyelitis Inflammatory. viral disease of CNS tissue

Sometimes results in permanent paralysis

i

7/24/2019 Bled Ppt Ch29

59/62


Degenerative

Disorders %ssessment 9"tain history=

E'acer"ation of chronic illness or ne#

pro"lem1

Management Special considerations

Mo"ility. communication. respiratory

compromise. and an'iety

- $ P i d

7/24/2019 Bled Ppt Ch29

60/62


-ac$ Pain and

Nontraumatic SpinalDisorders 2o# ack Pain

Most common "ack pain complaint

%ccounts for greatest amount of lost #ork time

in Canada

Causes

)egeneration or rupture of discs )egeneration or fracture of the verte"ra

Cyst or tumour that impinges on the spine

A t d

7/24/2019 Bled Ppt Ch29

61/62


Assessment and

#anagement %ssessment Evaluate history

Speed of onset=

&isk factors such as vi"ration or repeated lifting=

)etermine if pain is related to a life*threatening

pro"lem=

Management

Consider c*spine= Immo"ili;e if in dou"t=

Consider analgesics=

S

7/24/2019 Bled Ppt Ch29

62/62

Summary

Pathophysiology

General assessment findings Management of nervous system

emergencies

bled ppt ch29

Documents