Neurologic Emergencies

The two main categories of the nervous system
CNS and PNS

Transmits commands from the brain to the body and receives feedback from the body
Peripheral Nervous System (PNS)

Where does the brain store memories?
In the areas that are initially stimulated

Filters out unneeded information from the cerebral cortex
diencephalon

Part of the brain stem that regulates the level of consciousness
midbrain

Regulates your respiratory pace and depth at which you breathe
pons

Controls the blood pressure, respiratory rate, and heart rate
medulla oblongata

Where rage and anger are generated
the limbic system

Where pleasure, thirst, and hunger are found
hypothalamus

Lobe of the brain that manages complex motor activity (balance, etc)
cerebellum

Examples of neurotransmitters
serotonin, epinephrine, norepinephrine, dopamine, acetylcholine

Myelin
a type of “insulation” that allows the cell to consistently send its signal along the axon without “shorting out” or losing electricity to surrounding fluids and tissues; speeds up conduction

New growth
neoplasm

The body begins to attack its own cells
autoimmune disorders

The most common sign of infectious disease
fever

Proteins that are released by gram-negative bacteria when they die
endotoxins

Proteins that are secreted by some bacteria or fungi to aid in death and digestion of other cells
exotoxins

Three substances that fill the skull
brain, blood, CSF

The pressure of blood within the cranial vault
cerebral perfusion pressure (CPP)

How can you calculate CPP?
CPP=MAP-ICP

What is the average MAP?
80-90 mm Hg

What is normal ICP?
1-10 mm Hg

What is normal CPP?
70-80 mm Hg

Results when pressure increases within the skull and the brain is pressed down through the foramen magnum
herniation

The two main abnormal postures that the patient may demonstrate with painful stimulation
decorticate and decerebrate

Decorticate posturing
the patient flexes the arms and curls them towards the chest

Decerebrate posturing
The patient points the toes and extends the arms outward and rotates the lower arms in a palms-down manner; wrists are flexed

What is the more severe posturing?
decerebrate

Nerves responsible for airway control
trigeminal, glossopharyngeal, vagus, hypoglossal

Clenched teeth
trismus

Cushing’s triad
widening pulse pressures (hypertension), bradycardia, irregular respirations

What happens as ICP continues to increase?
downward forces on the brain stem begin to damage the medulla’s ability to send signals to the body

A state in which the patient does not respond to verbal or painful stimuli
coma

3 Parts of the GCS
eye opening, verbal, motor

Drooping eyelids
ptosis

What can drooping eyelids (ptosis) indicate?
Bell’s palsy or stroke

Patients will be unable to name common objects because connections between visual interpretation of objects and the words that name them have become damaged
agnosia

Inability to know how to use a common object
apraxia

What are the three main forms of aphasia?
receptive, expressive, and global

The patient cannot understand speech but is able to speak clearly
receptive aphasia

The patient will not follow commands and can’t answer your questions
global aphasia

The patient can speak clearly, but is unable to understand speech
expressive aphasia

How do the pupils usually look with depressants?
constricted

Unequal pupils
anisocoria

The involuntary rhythmic movements of the eye
nystagmus

Weakness on one side of the body
hemiparesis

Paralysis on one side of the body
hemiplegia

Nerves cross as they leave the cerebral cortex, move through the brain stem, and arrive at the spinal cord
decussation

Which nerves do not decussate?
facial nerves; the left side of the brain controls the right side of the body but the left side of the face (a left cerebral stroke would therefore result in right-sided arm and leg weakness, but left-sided facial droop)

When we ask stroke patients to close their eyes and hold their arms out in front of them, what are we testing?
the cerebellum function (with the eyes closed, the patient’s only way tp tell where the arms are located is from the sensations being processed by the cerebellum); if the individual has suffered a stroke, one of the arms may drift down

Walking patterns
gait

Changes in a person’s ability to perform coordinated motions like walking
ataxia

Routine motions are slowed dramatically
bradykinesia

A type of involuntary contraction of the muscles that is rapid and jerky in nature
myoclonus

Part of the body contracts and remains contracted
dystonia

Type of tremors that occur when the patient is at rest and not in motion (common in Parkinson’s disease)
rest tremors

Type of tremors that occurs when the patient tries to reach out and grab an object. These tremors may increase as the patient gets closer to the object to be grabbed (common in MS)
intensive tremors

Type of tremors that occurs when a body part is required to maintain the same position for along period of time
postural tremors

Two basic types ofmovement that patients can perform while seizing:
tonic activity, clonic activity

A very rigid, contracted body posture in seizures where the arms, legs, neck, and back can contract so tightly that the body part will shake slightly from the intensity of the contraction
tonic activity

A rhythmic contraction and relaxation of muscle groups seen in sezirues; arms and legs may flail, teeth may clench, the head may bob, and the torso may move wildly
clonic movement

A sensation of numbness or tingling
paresthesia

What is the fuel that runs the brain?
glucose

What is a normal blood glucose level?
60-120mg/dL

If incontinence is present, what should we suspect?
that the level of consciousness has decreased below that of sleep

The three major elements that the brain needs to function
glucose, oxygen, and normal temperature

Cushing’s Triad:
bradycardia, widening pulse pressure (hypertension), irregular respiratory rate (bradypnea)

Signs of increased ICP
posturing, anisocoria, cushing’s triad, biot respirations, apneustic respirations, cheyne-stokes respirations

What should you administer for a low blood glucose level?
25g of D50 IV

Dosage of Narcan
0.4-2.0mg IV, IM, SC, ET, IO

Two medications available for prehospital treatment of hyperglycemia
Dextrose 50% (D50) and glucagon

Vitamin B1
thiamine

How long do the effects of D50 take?
30 seconds to 2 minutes

What does thiamine do in the body?
It allows the body to convert its store of glycogen into glucose as part of the Krebs cycle

Dosage of thiamine in an emergent situation
50-100mg slow IV bolus

What can thiamine cause if adminstered too quickly?
hypotension

Dosage of glucagon
0.5-1mg

If you cannot obtain vascular access for D50, what can you give?
glucagon SC or IM

Dosage of oral glucose
one tube (25g)

Management for trismus
if ventilation is poor or unsuccessful, attempt to place an NPA and bag; if unsuccessful, consider using a paralytic agent to relax the mouth and allow for airway management

How does Narcan work?
it competes with any narcotic, displacing it from its receptors and allowing LOC to increase

The goal of treatment for strokes
early recognition, and rapid, appropriate intervention

Two basic types of strokes
ischemic and hemorrhagic

The more common type of stroke
ischemic

How hemorrhagic strokes develop
bleeding into the brain gradually worsens over time and increases ICP which leads to herniaiton of the brain stem

Most common complaint of hemorrhagic stroke
“worst headache of my life”

Signs and symptoms of stroke
slurred speech, aphasia, agnosia, apraxia, hemiparesis, hemiplegia, arm drifting, facial droop, ptosis, ataxia, headache, decreasing LOC, difficulty thinking, seizures

Assessment for a stroke patient
Cincinatti Prehospital Stroke Scale

Fibrinolytics need to be administered within….
3 hours of stroke onset

TIAs
Transient ischemic attack; episodes of cerebral ischemia that do not inflict any permanent damage (“mini strokes”)

The number one preventable cause of strokes and TIAs
hypertension

AEIOU-TIPS
Alcohol/acidosis, epilepsy, insulin, overdose, uremia, trauma, infection, pyshoses, stroke

Prehospital management for altered level of consciousness/coma
ABCs, gather information about the possible cause of the altered LOC

Classifications of seizures
generalized or partial

What are some causes of seizures?
alcohol, birth defect, hypoglycemia, fever, brain trauma, brain infections, idiopathic, organic brain syndromes, drugs, stroke or TIA, systematic infection, tumor, uremia (kidney failure)

A sensation a patient may experience before a seizure occurs
aura

Two types of generalized seizures
petit mal (absence seizures) and grand mal (tonic/clonic seizures)

Two types of partial (focal) seizures
simple partial sezirues, complex partial seizure

“Jacksonian March seizures”
simple partial seizures

Reset period of the brain after a seizure
postictal

Prehospital management for seizures
monitor and protect from injury, provide ventilatory assistance ONLY if the seizure or apnea is prolonged, reorient the patient after the seizure, anticonvulsants if indicated, transport

What are the drugs of choice to stop seizures?
diazepam and lorazepam

Rectal dosage of diazepam
0.2mg/kg

Status Epilepticus
seizure that lasts longer than 4-5 minutes or consecutive seizures that occur without consciousness returning between seizure episodes

Goal of prehospital care for status epilepticus
stop the seizure and ensure adequate ABCs

Dosage of diazepam
5.0-10.0mg IV/IM

Dosage of Lorazepam
2-4mg IV

Fainting
syncope

The main question you need to ask in syncope
what caused the sudden decrease in cerebral perfusion?

What is a more typical cause of syncope in older adults?
cardiac dysrhythmia

Signs or symptoms that precede a disease or condition
prodrome

Prehospital management of syncopal episodes
c-spine if needed, focus on blood glucose and likely cardiac causes, orthostatic vitals, transport

The most common type of headaches
tension headaches (dull ache or squeezing in nature)

What are migraine headaches caused by?
changes in blood vessel size within the base of the brain (throbbing, pounding, pulsating, nausea, vomiting, photophobia)

Rare vascular headaches that start in the face
cluster headaches

What are sinus headaches caused by?
inflammation or infection within the sinus cavities of the face (worsens when bending over and when first waking)

Clues to drug-seeking behavior
history of calling 911 for headaches, allergies that limit them to a small number of narcotic medications, is the patient very reluctant to try other pain management options besides narcotics? Does the patient suddenly relax after being told thta narcotics are on the way?

Results when an infectious agent invades the brain or spinal cord
abscess

Two major consequences of abscess
damage to the brain tissue and the presence of an abscess within the cranial vault that leads t increased ICP

Multiple sclerosis (MS)
an autoimmune condition in which the body attacks the myelin sheath of the neurons in the brain and spinal cord, leading to areas of scarring

Prehospital managment for MS
supportive

Cancer within the brain or spinal cord
neoplasm

Primary neoplasms
begin within the nervous system

metastatic neoplasms
begin in some other part of the body, gain access to the blood stream or lymphatic system, and then take up residence within the nervous system

Dystonia
marked by severe, abnormal muscles spasms that cause bizarre contortions, repetitive motions, or postures; involuntary and painful

Secondary dystonia
sudden onset of bizarre contortions of the face or body in patients taking antipsychotic medications

Primary dystonia in which the neck muscles contract, twisting the head to one side and pulling it forward or backward; the head then remains painfully frozen there
spasmodic torticollis

Prehospital management of dystonia
rule out other problems, if you suspect a dystonic reaction to antipsychotics, diphenhydramine (Benadryl) is the drug of choice to stop the contraction

Parkinson’s Disease
the substantia nigra (portion of the brain that produces dopamine) becomes damaged

Four characteristics of the classic presentation of Parkinson’s disease
tremor, postural instability, rigidity, bradykinesia

Inflammation of the trigeminal nerve
trigeminal neuralgia

Cranial nerve that receives sensory information from the face
trigeminal nerve

Temporary paralysis of the facial nerve (7th)
Bell’s palsy

Amyotrophic lateral sclerosis (ALS)
Lou Gehrig’s disease; disease that involves the death of involuntary motor neurons

Guillan-Barre Syndrome
begins as weakness and tingling sensations in the legs, moves up the legs and begins to affect the thorax and arms and can quickly become severe and lead to paralysis

How is poliomyelitis transmitted?
fecal-oral route

Cerebral Palsy
developmental condition in which damage is done to the brain (often the frontal lobe)

In this condition, patients may have a classic scissors walk in which the lower legs turn inward, with the legs remaining stiff and the knees almost touching
cerebral palsy

Spina Bifida
developmental condition resulting from a neural tube defect in which the neural tube does not close and a portion of the spinal cord remains outside the body

An important neurotransmitter needed to allow for muscular contraction
acetylcholine

Condition in which the body creates antibodies against the acetylcholine receptors, resulting in muscle weakness (most commonly in the eyes, eyelids, and facial muscles)
myasthenia gravis

Myasthenia crisis
a sudden increase in the destruction of acetylcholine, resulting in weakness in the respiratory muscles

The most common form of dementia
Alzheimer’s disease ( a progressive organic condition in which neurons die)

Dementia
chronic deterioration of a person’s personality, memory, and ability to think

A group of conditions in which the nerves leaving the spinal cord become damaged
peripheral neuropathy

Examples of peripheral neuropathy
trigeminal neuralgia and Guillain-Barre syndrome

Muscular Dystrophy
nonneurologic condition of genetic origin marked by the degeneration of muscular tissues

What age is muscular dystrophy diagnosed in and who does it affect?
2-5 years; only males

The most common type of muscular dystrophy
Duchenne’s

Neurotransmitter that ensures smooth muscle contraction
dopamine

Which of the following is an action of insulin? Answer It increases the transfer of sugar from the stomach and small intestine to the bloodstream. It increases the movement of sugar from the bloodstream to the cell. It increases the …

Reticular activating system Series of neurologic circuits in the brain that control the functions of staying awake, paying attention, and sleeping Things that can harm brain tissue Lack of oxygen, water, glucose Trauma, infection, chemical toxins WE WILL WRITE A …

1. A patient with a headache describes it as affecting both sides of his head with a moderate intensity that becomes worse when he is physically active. The nurse knows that the patient’s clinical manifestations are characteristic of 1. cluster …

Chief Complaint: Reported having headaches relieved by dimming lights and resting for a few hours within the past three months coupled with instances of feeling as if she may “fall when walking, but it only happens every few weeks. ” …

The eyes of a 9-year-old who suffered a head injury are crossed. Besides checking ICP, which intervention would be most important for the nurse to perform? Assess the child’s level of consciousness. Decreased level of consciousness is frequently the first …

ANS: C It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal anti-inflammatory medications …

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