Neurological Emergencies Flashcards
Cerebrum
2 hemispheres
4 lobes
Frontal Lobe
- Speech (Broca’s area)
- Abstract thinking
- Personality
- Touch (primary sensory center)
- Voluntary movement (right-left)
- Primary motor center
Parietal Lobe
•Proprioception
-The ability to tell the location of a body part
•Math
•Language processing
Occipital Lobe
- Sight
* Color vision
Temporal Lobe
•Hearing and understanding speech
•Wernicke’s
-Behavior and storage of memory
Thalamus
- Relays sensory to cerebral cortex
- Wakefulness
•Does not relay smell
Hypothalamus
- Temperature
- Pituitary control
- Links ANS to Endocrine system
Pituitary
Bridge to PNS
Cerebellum
- Movement
- Fine motor control
- Coordination
- Balance
Cerebral Cortex
•Outermost portion of cerebrum •Works with RAS= consciousness •Distributes impulses to other brain areas •Interprets sensory from body -Afferent •Motor muscular control -Efferent •Aids judgment •Concentration •Analysis
Limbic System
•Hypothalamus •Amygdala -Temporal Lobe •Hippocampus •Limbic cortex •Controls- -Emotions -Fear -Pleasure -Mood -Behavior -Long term memory -Motivation
Midbrain
- Hearing and visual reflexes
- Posture
- Muscle tone
- Reticular Activating System (RAS)
- Consciousness
Pons
•Relays impulses to and from medulla and cerebrum •Apneustic and pneumotaxic centers •Regulating- -Respiratory rate -Arousal -Sleep
Medulla Oblongata
- Heart rate
- Blood pressure
- Breathing
Diencephalon
Comprised of the Thalamus and Hypothalamus
RAS and Cerebral Cortex
•Work together to maintain consciousness •1 disrupted -Altered LOC •Both disrupted -Unresponsive
Brain Blood Supply
Circle of Willis
Ensures blood supply to all parts of the brain if blockages occur
Brain Blood Supply
Blood Brain Barrier
Capillaries tightly packed together allowing only certain molecules into brain’s circulation
Ventricles of the Brain
- Space in cerebral hemispheres
- 2 hemispheres
- Cerebrospinal fluid is created here
Neurons- Fundamental unit
•Cell body, axon, and dendrites •Cell body = gray matter -Brain, brain stem, cord •Axons = white matter -Myelin- fatty insulation -Increases speed of impulse conduction •Bundles of neurons = nerve
Anatomy- CNS & PNS
•Central nervous system -Brain and spinal cord •Peripheral nervous system •Spinal nerves- 31 pairs -Sensory ➡️ Afferent (arrives) -Motor ➡️ Efferent (exits) -8 cervical -12 thoracic -5 lumbar -5 sacral -1 coccygeal •Cranial nerves- 12 pairs -Affect SAME side of body as place of origin
CN I
Olfactory- smell
CN II
Optic- vision
CN III
- ***Oculomotor (part of PNS)
- Eyeball movement
- Raising eyelid
- Pupil constriction
CN IV
•Trochlear
-Eye move down / inward
CN V
•Trigeminal
- Sensation forehead to chin
- Mastication
CN VI
Abducens- eye movement outward
CN VII
- Facial expression
* part of PNS
CN VIII
•Acoustic-Vestibulocochlear
-Hearing and balance
CN IX
•Glossopharyngeal -Swallowing -Gag reflex -Speech •Part of PNS
CN X
•Vagus -Sense hypo pharynx -Throat -Heart rate -Respirations -Digestion •Part of the PNS
CN XI
•Spinal accessory
- Turn head
- Shrug shoulders
CN XII
•Hypoglossal
-Tongue movements
Dermatones
•Spinal nerves •Specific area of skin -Carries sensory impulse to brain •Key locations -Collar region: C-3 (turtle neck) -Middle finger: C-7 -Nipple line: T-4 -Umbilicus: T-10 -Small toe: S-1 •Sensory assessment findings
Neuro Assessment
•Focal deficit- specific -Part of body -Pinpoint damaged area •General impression -Muscle tone- Posture, facial, extremities •Flacid paralysis= weakness/paralysis with ⬇️ muscle tone -Involuntary movements or tremors -One side or both sides? -Facial droop
Pupil Eye Exam
•Pupils
-Unequal >1 mm - consider ⬆️ ICP
-Dilated = CNS stimulant
-Constricted = CNS depressant
-Aniscoria = Normal difference- pupil size
•PERRLA
-Accommodation- able to focus both eyes as distance changes
-Consensual response- Both eyes react to light
•Eyes
-Nystagmus- smooth eye movement one direction
•Jerky, fast movement in opposite direction
-Dysconjugate gaze- failure of eyes to turn together in same direction
-Diplopia- double vision
Posturing
Decorticate
•Flexion •Cerebral cortex to thalamus •Upper arms pulled inward to core •Flexed elbows •Flexed wrists -Clenched fists •Extended lower extremities -Toes point down •GCS of...
Posturing
Decerebrate
•Extension •Brain stem injury •Upper arms pulled inward to side •Extended elbows •Pronated wrists -Turned outward •Extended lower extremities -Toes point down •GCS of...
Meningeal Exam
Brudzinski sign
- Flexion of neck painful
- Patient will flex hips and knees
- Meningitis
- Subarachnoid bleed
Meningeal Exam
Kernig’s Sign
- Flex hip to 90 degrees
- Extend lower leg
- Causes extreme pain
- Meningitis
- Subarachnoid bleed
Motor/Sensory Exam
Assess both sides at the same time
Hemiparesis
One sided weakness
- Strength
- Grips, pedal
Hemiplegia
Paralysis one side
Paresthesia
Abnormal sensation
Anesthesia
Absence of sensation
Babinski
•Stroke lateral, plantar foot •Positive -Dorsiflexion great toe -May fan toes •Positive Babinski is bad •Not for babies -12-18 months
Mental status
Level of Consciousness
Arousability
Responsiveness
AVPU scale
Mental Status
Glasgow Coma Scale
Detailed responses
BEST response
Compare to baseline
<8 ➡️ intubate!
Retrograde Amnesia
Prior to event
Antegrade Amnesia
After event
Coma
Absolute unresponsive
Confusion
- Memory not correct
* Can’t learn new material
Lethargy
Slow response to stimuli
Reticular Activating System
•Brainstem to cerebral cortex •Initiates, maintains arousal & awareness •Cerebral cortex & RAS intact -Maintains consciousness •If one or other is altered, damaged -Altered mental status •If both altered, damaged -Unresponsive •ANY ⬇️ LOC at ANY time = HIGH PRIORITY
Altered Mental Status- Tx
•ABC’s •Oxygen; SpO2 monitoring •Ventilate prn •Vitals; IV; cardiac monitor •Check BGL -<60 ➡️ D50 or glucagon (Consider thiamine 100mg) ->350 ➡️ fluid boluses(unless contraindicated) •Consider naloxone- suspect what? •Rapid transport, med control contact
Delirium
•Acute •Temporary •Confusion •Changing LOC •Possible -Hallucinations- visual or auditory -Delusions- false beliefs •Causes -Illnesses, meds, cardiac, CVA, alcohol •MADCAP
Dementia
- Chronic
- Progressive
- Decline mental function
- Memory
- Judgement
- Concentration
- Bizarre behavior
- Irrational
- Violent
- Neurological cause
Seizures
•Temporary •Altered LOC or behavior •Massive firing of neurons in the brain -Electric storm •3 types -Generalized •Involves both hemispheres of the brain •Consciousness is involved -Focal (partial) •Isolated area(s) of one brain hemispheres •Motor or non-motor •May also include consciousness -Unknown onset •Doesn’t fit other categories
Seizures
Generalized onset- non-motor
•Absence seizure •Children = >5 years old; girls •Lapse of awareness -Vacant stare •No loss of muscle tone -Eye blinking or fluttering •Sudden onset •Duration-30 sec •NO aura •NO postictal state •May progress to Grand Mal Seizures -Adolescence
Seizures
Generalized - motor
•Tonic- 15-20 sec -Whole body muscle contraction -Stiff, rigid •Clonic- 90 sec- 2 min - Rhythmic jerking -Alternating relaxation -Incontinence urine -Ventilations inadequate •Grand Mal is no longer used •Sudden •4 phases •Aura- sensation •(Actually focal aware seizure) -Smell -Taste -Visual- lights -Stomach -Not all patients have auras •Postictal-15-30 min or longer -Gradual return -Drowsy, confused, combative -Fatigue! -Check BGL - high demand glucose -Amnesia -Headache, VOMITING •History event •Onset -Consider C-spine -Tongue biting? •Appearance -Typical or atypical •Time and duration •Previous Hx -Meds? Changes? •Recent trauma, fever, H/A, stiff neck?
Status Epilepticus
•Medical emergency •May lead to death! •Single lasting >5 min •Recurrent without full recovery and >5 minutes -Brain still seizing! •Convulsive and non-convulsive •Hypoxia Brain cells -Acidosis (kind??) •Postictal without improvement? -Brain may still be seizing
Tx-Prolonged Status
- Airway-NPA, nasal ETT
- O2, ventilation, suction
- Position protect Injury
- Spinal precautions?
- IV
- Benzodiazepines
- BGL check and treat
- Thiamine?
- Transport
Benzodiazepines
Diazepam (Valium)
- 5-10 mg IM or slow IV (rectal)
- IV preferred
- Repeat 10-15 min
- Max 30 mg
- Onset 1-5 min
- Short duration 20 min
Benzodiazepines
Lorazepam (Ativan)
- 4 mg IM or slow IV
- Dilute with equal mL saline
- Max 8 mg
- Onset 1-5 min
- Duration 6 hours
- Status Epilepticus
- Stops a prolonged seizure longer
Benzodiazepines
Midazolam (Versed)
•1.0-2.5 mg IV, IO •Slowly over 2 minutes •Repeat in small increments -Max 5 mg •Elderly, chronic ill -Reduce 1.0-1.5 mg -Slowly 2 minutes •If opiate concurrent -Reduce 50% •Dose is individualized •Allow 2-4 min to gauge therapeutic effects
Focal Seizures
Aware
•Old: simple partial •Awareness intact •Motor or non-motor •Twitching rhythmic muscle contractions •One part of body •Hallucinations -Auditory -Visual -Olfactory •See note chart •These may be aura for generalized motor
Focal Seizures
Impaired Awareness
•Old: complex partial •Altered awareness •Blank stare •Automatisms -Lip smacking -Chewing or twitching in face •Mumbling •Dazed, disoriented •Oblivious-surroundings •Violent???
Myoclonic Seizures
- Generalized type
- Sudden, brief jerking both upper arms (typical) or legs
- After awakening or prolonged sleep deprivation
Atonic Seizures (Drop Seizures)
- Generalized type
- Loss of muscle control
- Neck ➡️ head falls forward
- Legs ➡️ body collapses
Psychogenic Non-Epileptic Seizures
PNES
- Conversion Disorder (PTSD often)
* Diagnosed by neurologist- rule out epilepsy as cause
Febrile Seizures
•Children 3 months to 5 years -6-18 months most common -1st relative (parent, sibling) predispose •Sudden spike in temperature •Short duration, frightening to parents •Treatment -Supportive -Passive cooling ➡️ no shivering -Antipyretic(Tylenol) -Possible benzodiazepine -transport, calming, parents
Syncope
•Transient loss of consciousness •Atony •Falling •Regain consciousness -Supine position •Near syncope -No LOC -Hearing/vision loss •Vasovagal -Common •Stimulate vagus nerve -Pain, fright, stress •Overcompensation sympathetic stimulation -Needle stick -Bearing down abdomen -forceful cough, swallow -Prolonged sitting, then standing -Shaving -Micturition- urination •Full bladder
Syncope Assessment
•Syncope vs cardiac, seizures, neuro, trauma issues •SCENT -Before syncope -Supine, no warning -Cardio/neuro •TIPS -During •CHAN -After •Treat- underlying cause •ABC’s -Oxygen, ventilation’s •C-spine?? •IV-fluids?? •Cardiac monitor-SpO2 •BGL •Transport recommended
Atony
Loss of muscle tone
Headache- Vascular Migraine
•Recurrent •Nausea/vomiting •Photophobia •Sound sensitive •Throbbing, pulsating •One or both sides •Auras •Rest/sleep alleviates •Family Hx/ Triggers -Tyramine foods -Msg •Medication Rx -Beta-blockers -Tricyclic antidepressants -Depakote -Topamax •Other possible causes -Neuron hyper-excitability -Hypomagnesemia
Cluster Headache- Vascular
•Severe stabbing -Eye, temple, forehead, cheek •One side •Watery eye, rhinorrhea •Rock back and forth •Pace •Males > females
Rhinorrhea
Runny nose
Cerebral Vascular Accident- Stoke
•Neurological deficits -Decrease in blood flow to brain •Ischemic-80% -Blocked artery -Thrombus or embolism •Hemorrhagic-20% -HTN -Arteriovenous malformations •Abnormal connections-Arteries and veins •Congenital -Aneurysm- weaken area
Ischemic Stroke - Thrombotic
•Atherosclerotic plaques •Bifurcation of arteries •Slower to develop -Than hemorrhagic •Risks -HTN -Diabetes
Ischemic Stroke Findings
•Dysarthria -Slurred speech; lacking muscle control •Aphasia -Expressive- understands; unable to verbalize -Receptive- no understanding; verbal response inappropriate -Global- no understanding; unable to verbalize •Hemiparesis •Hemiplegia •Hemiparesthesia -Abnormal sensation, unilateral •Arm drift, facial droop •Ataxia -Uncoordinated movements •Headache •Seizures •Hypertension •Vertigo- dizziness •Vision loss -Half sight -Left or right
Hemorrhagic Stroke
•Morbidity/mortality- often fatal •Sudden -“Worse headache of my life” •⬆️ICP -Excessive pressure in cranium -“pushes” brain downward -Herniates into foreman magnum •Cushing’s triad -High BP w/ wide pulse pressure -Bradycardia -Abnormal, irregular, bradypneic respiration’s •Unresponsive •Hyperthermia
Subarachnoid Hemorrhage
•Cause- aneurysm •Sudden onset SEVERE headache -“Thunderclap” headache -To occiput •Brief loss of consciousness •Forceful vomiting •Unilateral pupil dilation •Rapid progression •Females 20-30 years old •Supportive ABC’s, expedite transport
Transient Ischemic Attacks
- Cerebral dysfunction lasting from minutes to several hours
- Return to normal <24 hrs
•No permanent neurological deficit
-Indication of impending stroke
•S/S same as CVA
Prehospital Stroke Management
•Rapid transport •Determine time of onset -Last known normal -3 hour window •Manage airway/ Oxygen •Ventilation •Monitor vital signs and ECG •Initiate IV- KVO en route •Assess blood glucose -D-50 for low BGL •Control seizures -Benzodiazepines •Supine, head elevated •On side -Affected side down •Stroke screen •Stroke center
Cincinnati Stroke Scale
•Arm drift -Both arms out, palms up -Close eyes -One arm drifts down •Speech -“The sky is blue in Ohio” -“No if’s, ands or but’s” •Facial droop (CN 7) -Smile and show teeth
Parkinson’s Disease
•Degeneration or damage to nerve cells within basal ganglia in brain •Lack of DOPAMINE •Leading neurologic disability in persons over 60 years old •Characterized by: -Muscle rigidity -Tremors (start on one side) -Weakness -Shuffling gait -May lead to dementia
Alzheimer’s
•Degenerative •Dementia-senile •Neurons get choked off protein growth -Dying brain •⬇️ memory, cognition •⬇️ ability to care for self •Personality changes -Combative, hostile, angry •Supportive care -Cautious if combative
