Emergency Nursing Course

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Emergency Nursing Course

• Neurological Emergencies
• Dr. Fu Tat Lee
• (?????)
• Princess Margaret Hospital
• (?????)

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Outline

• Neurological assessment
• Stroke
• Seizure
• Acute generalized weakness
• Headache

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Neurological assessment

• What is it?
• Where is it?

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The Neurological Assessment

• History should direct the neurological
  examination to the most relevant areas.
• Symptoms may occur before signs can be detected.
• In the absence of symptoms, any signs are less
  likely to be important.

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The Neurological Assessment

• Look for asymmetrical abnormalities
• Tendon reflexes can be absent in health but may
• indicate an abnormality in the sensory or motor
  system
• An EXTENSOR PLANTAR REFLEX which is reproducible
  is never normal (except in infants)

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The Neurological Assessment

• A. Mental Status
• Glasgow Coma Scale eye opening
• motor response
• verbal response
• B. Cranial nerves (1st - 12th)
• C. Upper lower limbs
• - motor
• - sensory
• - coordination
• - reflexes

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Decerebrate posture
Decorticate posture
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Neurological Examination

• Cranial nerves
• (1) 1st (olfactory) nerve
• - anosmia (loss of smell)

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• 2nd (optic) nerve
• - visual acuity
• - visual field

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Homonymous hemianopia
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Bitemporal hemianopia
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• 3rd (Oculomotor), 4th (Trochlear) and
• 6th (Abducent) nerves
• - eye movements, upper eyelid pupil size

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5th (Trigeminal) nerve

• Motor Masseter
• Sensory ophthalmic, maxillary mandibular
  divisions

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VII nerve (Facial nerve)
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Lower Motor Neuron lesion of VII nerve palsy
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Bells palsy

• 1st described by Dr Charles Bell in 1882
• Lower Motor neuron lesion of 7th nerve
• idiopathic etiology
• - Dx on i) no identifiable cause (viral/post
  viral Sx)
• ii) peripheral

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Symptoms

• Pain
• Tearing
• Drooling
• Hypersensitivity to sound
• Impairment of taste

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• DDx Central 7th nerve palsy - sparing
  ipsilateral frontalis muscle

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• Other causes of LMN lesion of VII nerve
• Acoustic neuroma
• Parotid gland tumour
• Ramsey Hunt Syndrome
• facial nerve palsy due to Herpes Zoster
• vesicles at the external auditory canal and
  ear.

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Bells palsy

• Treatment - Prednisolone 60 mg daily for 5
  days
• - ? Acyclovir
• - physiotherapy
• - eyedrops and cover
• - refer medical or ENT if fail to recover
• Prognosis 80 recover completely within 3
  months

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• 8th (Acoustic) nerve
• - balance
• - deafness
• Weber Rinnie Test to distinguish conductive
  deafness
• from sensory deafness

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Rinnie test
Weber test
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• 9th Glossopharyngeal nerve
• Muscles for swallowing

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10th Vagus nerve

• Smooth muscles of GI respiratory tract
• Pacemaker
• Muscles of heart, pharynx Larynx

• gag reflex
• (sensory 9th)
• (motor 10th)

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• 11th (accessory) nerve
• - sternomastoid trapezius muscle

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• 12th (hypoglossal) nerve
• - tongue

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Neurological Examination

• Upper Lower limbs assessment
• Motor
• Posture, Muscle wasting, Fasciculation
• Muscle Tone Hypertonic or Hypotonic
• Muscle power
• Grading 0 complete paralysis
• I flicker of contraction
• II movement is possible where gravity
• excluded
• III movement is possible against gravity
• but not if any further resistance is
• added
• IV movement is possible against gravity
• and some resistance
• V normal power

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• Coordination
• Pastpointing, dysmetria, dysdiadochokinesia
• Romberg testing
• Gait
• Tendon Reflex
• Hyperreflexia or Hyporeflexia
• Plantar Reflex
• Upgoing or Downgoing

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Line of Stroke
Normal Planter reflex
Barbinski reflex
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• Signs of Upper Motor Neurone Lesions
• Little muscles wasting unless from disuse
• Spasticity Clonus
• Hyperreflexia
• Extensor Plantar response
• Signs of Lower Motor Neurone Lesions
• Wasting is prominent
• Fasciculation
• Hypotonia
• Hyporeflexia
• Normal or equivocal plantar reflex

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• Sensation
• Temperature
• Light touch
• Temperature
• Pain
• Proprioception and vibration

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• Dermatone

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Assessment of Brainstem function

• Brainstem reflex
• pupillary reactions
• corneal responses
• spontaneous eye movements
• oculocephalic responses (Dolls eye reflex)
• oculo vesticular responses (Caloric test)
• respiratory patterns

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Stroke
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Stroke

• Stroke is a syndrome of rapidly developing
  clinical symptoms and signs of focal or global
  disturbances of cerebral functions due to
  non-traumatic vascular causes, with symptoms
  lasting more than 24 hours.
• Not a cerebrovascular accident but a
  consequence of cerebrovascular disease

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Stroke is preventable

• Modifiable risk factors
• History of stroke or TIA
• Hypertension
• Cardiac diseases
• Atrial fibrillation
• DM
• Internal carotid artery stenosis
• Smoking
• Alcohol abuse
• Hypercholesterolemia
• Obesity
• Lack of exercise
• Haematological diseases, coagulopathies

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• Major types of stroke
• Ischaemic (70)
• Cortical
• Subcortical
• Posterior circulation
• Lacunar infarction
• Intracerebral haemorrhage (25)
• Supratentorial
• Infratentorial
• Both
• Subarachnoid haemorrhage (5)

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Mortality Morbidity
Mortality at 1 month Mortality at 1 year Morbidity in survivors
SAH 50 Severe
Intracerebral haemorrhage 40 50
Cortical infarct 20 35 Poor
Lacunar infarct lt2 Mild
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Circle of Willis
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Principles of management

• Assess vital signs
• Confirm the diagnosis
• Differentiate ischaemic from haemorrhagic stroke
• Look out for clues for aetiology
• Screen for early complications

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Specific management of Ischaemic Stroke

• Stroke is an emergency
• Acute therapy is available for ischaemic stroke
  within 3 hours of onset.
• Tissue Plasminogen activator (TPA) 0.9mg/kg
• 10 as bolus and 90 infusion over 1 hour
• within 3 hours increases the proportion of
  patients with minimal or no disability by 13-16
• 6 risk of transforming infarction into
  symptomatic haemorrhagic

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• Antiplatelet therapy
• Low dose Aspirin (160 to 300mg daily) within 48
  hours
• of onset prevents 11 recurrent ischaemic strokes
  or
• deaths at the expense of 2 extra cases of
  haemorrhagic
• transformation per thousand patients treated.
• ?? Glycoprotein IIb/IIIa inhibitor

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• Anticoagulation
• Spontaneous haemorrhagic transformation of
  infarction
• commonly occurs within 2-4 days
• Clinical trials not support indiscriminate use of
• anticoagulation

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• Neurosurgery
• Not needed in most cases
• Obstructive hydrocephalus
• Cerebellar haematoma or infarct
• Large superficial or lobar haematoma
• Markedly raised ICP

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Seizure
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Seizure

• - Primary epilepsy, idiopathic, onset before 20
• - Secondary epilepsy, symptomatic, by parenchymal
  abnormality e.g. tumor, AVM, aneurysm,
  contusion/hematoma

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Different types of seizure

• - generalized/grand mal witnessed LOC with
  generalized activities
• - minor/petit mal (absence) prolonged
  unresponsive staring without LOC, focal
  muscular activity
• - focal repetitive motor activity without LOC
• - temporal lobe hallucinations (visual,
  auditory, and olfactory), memory loss, and/or
  bizarre behavior which may progress to
  focal-generalized motor activity

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• - Todds paralysis - focal weakness/paralysis
  after seizure lasting up to several days
• febrile convulsion
• 3 months to 5 years, rapidly rising fever

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Clinical evaluation

• ABCs
• examine for trauma including head/facial
• abrasions, contusions, lacerations, tongue,
• buccal lacerations
• Is patient seizing? Is patient awake?
• Look for eye deviation and
• focal/generalized tonic/clonic
• Hstix

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Treat reversible causes

• H3O
• H ypotension due to hypovolemia, arrhythmia
• H ypoxia
• H ypoglycemia
• O verdose others
• (Electrolyte disturbance,Intracranial SOL,
• CVA, Infection)

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• mnemonics of A E I O U T I PS

A Alcohol withdrawal T Temperature, Trauma
E Epilepsy I Infection
I Insulin P Psychogenic
O Overdose drug withdrawal S SOL, Shock
U Uraemia Metabolic
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Status epileticus

• Traditional definition
• 30 minutes of continuous seizure activity or a
  series of seizures without return to full
  consciousness between the seizures.

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• (D) Treatment
• - support airway, IV, O2 and monitor
• - treat reversible causes
• 1st line - Diazepam 0.25mg/kg IV or
• 0.5mg/kg PR
• - Lorazepam 0.1mg/kg iv
• - Midazolam 0.1 mg - 0.3 mg/Kg IVI
• or 0.2mg/kg IMI
• 2nd line - Phenytoin 18 mg/Kg IV load at
  50mg/min with cardiac monitoring
• 3rd line - Consider phenobarbitone
  (200mg1ml1 Ampule) imi, generalized
  anaesthesia

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Discharge?

• Breakthrough seizure
• No underlying cause
• No head or other serious injury
• Good drug compliance
• No recent change on medication
• Escort by an responsible adult

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Acute generalized weakness

• Spinal cord compression
• Neuropathies
• Guillain-Barre syndrome
• Metallic poisons (lead arsenic)
• Vitamin deficiencies (B12)
• Systemic diseases (DM, Renal failure)
• Drugs

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Acute generalized weakness

• Motor end plate
• Myasthenia gravis
• Botulism
• Eatom-Lambert syndrome
• Myopathies
• Acute periodic paralysis (Hyper, hypo or
  normokalemia)
• Alcoholic myopathy
• Polymyositis
• Drug (steroid)

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Guillain Barre Syndrome(GBS)
George Charles Guillain
Jean Alexandre Barre
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Guillain Barre Syndrome

• Pathology An autoimmune disease causing
• acute demyelinating inflammatory
• polyradiculopathy

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GBS

• usually follow acute febrile illness, URTI,
  (days/weeks)
• typical pattern symmetrical ascending flaccid
• motor paralysis, commonly with some sensory
• Symptoms (tingling sensation)
• Impaired breathing, BP and Heart rate
• BEWARE !
• AE patient with lower extremity weakness and
  loss of lower extremity reflexes

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Investigations treatment

• Investigation
• Nerve conduction test
• CSF high protein
• Management (mainly supportive)
• ICU care
• Ventilatory circulatory support
• Plasmaparesis
• High dose Ig
• Psychological support

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GBS

• 90 weakest at the 3rd week
• Most patients recover

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What is the physical sign illustrated?
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Myasthenia Gravis

• - autoimmune disease
• - antibodies against acetylcholine receptors at
  the neuromuscular junction of striated muscle
• -

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Myasthenia Gravis

• bimodal distribution in age and gender, 2nd/3rd
  decade female 6th/7th decade male
• - associated with thymic hyperplasia/thymoma

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• complaints of muscle weakness, worsened by
  prolonged activity and improved with rest
• most common begin with ocular ptosis, diplopia
  and blurred vision
• Respiratory failure
• Confirm by bedside Tensilon test (Endrophonium)

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Headache
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Headache

• Tension headache
• Migraine
• Cluster headache
• Subarachnoid hemorrhage
• Hypertension (DBP gt130mmHg)
• Meningitis
• Space occupying lesion
• Sinusitis
• Acute Glaucoma
• Postconcussion
• Temporal arteritis
• Trigeminal neuralgia

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Possible causes

• Intracranial
• Hemorrhage
• SAH, Subdural, Intracerebral
• Tumour
• Meningitis
• Vessel
• Migraine, Hypertension
• Extracranial
• Vessel
• Temporal arteritis
• Nerve
• Trigeminal neuralgia
• Muscle
• Tension
• Referred pain
• Acute glaucoma, Sinusitis

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Meningitis
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Meningitis

• Viral
• Bacterial
• Pneumococcus
• Meningococcus
• Haemophilus Influenzae Type B

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Kernigs sign
Brudzinskis sign
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Temporal arteritis
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Trigeminal Neuralgia
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Watch out !!!!

• The first or the worst headache of patients
  life, especially the onset is acute and
  associated with neurology
• Progressively gets worse over days or weeks and
  subacute in onset
• Associated with fever, nausea and vomit
• Associated with neck stiffness, focal neurology,
  papilloedema, and changes in conscious level and
  cognition
• No obvious identifiable cause

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