Nervous System

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Nervous System Emergencies

• Chemeketa Community College
• Paramedic Program

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Causes of Coma (Well 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
• Bells Palsy
• Multiple Sclerosis
• Parkinsons
• 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 nervesSome 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
• Cushings 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
• Babinskis 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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DDX

• Structural lesions
• Commonly asymmetrical neurological signs
• Acute onset
• Unresponsive or asymmetrical pupillary responses
• Toxic-metabolic coma
• Neurological findings symmetrical
• Coma slow in onset
• Preserved 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 cant 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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Parkinsons 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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Bells 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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Bells 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 Documentation

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