Neurovascular

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Neurovascular
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Nervous System

• Is the major controlling, regulatory and
  communicating system
• Works with the endocrine system to regulate and
  maintain homeostasis
• Maintains and internal and external check of the
  environment
• Consists of
• The brain
• The spinal cord
• The nerves
• The ganglia

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Functions

• Sensory
• Detect changes (internal/external)
• Integration
• Decisions made upon the signals received from the
  body
• Motor
• A response to the sensory input and integration
• Causes muscles and glands (effectors) to respond

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Nerve Tissue

• Two main types
• Neuron
• The conducting cell
• Is the structural unit of the nervous system
• Neuroglia (glial) cell
• Are nonconductive
• Give support to the neurons

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Neurons

• Specialized cell that is amitotic
• Each neuron has three main parts
• Cell Body (Soma)
• Dendrites (Afferent)
• Axon (Efferent)
• Axon may branch out to Axon collaterals
• End with many short branches (teledendria)
• The end of the teledendria are enlarged to form
  synaptic bulb

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Neuron

• Many axons are surrounded by a segmented white
  fatty substance called myelin (or myelin sheath)
• These fibers make up the white matter of the CNS
• Unmylenated fibers make up the grey matter
• Breaks between myelin bulbs are called Nodes of
  Ranvier

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Neuron

• In PNS myelin is produced by Schwann cells
• The cytoplasm, nucleus and cell membrane for a
  tight covering around the myelin and the axon
• This is called the neurilemma which plays an
  important role in regeneration of nerve fibers
• In the CNS myelin is produced by oligodendrocytes
• Does not produce a neurilemma
• Are unable to regenerate

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Neuron

• Afferent (Sensory) Neurons
• Carry impulses from PNS to CNS
• Have long dendrites and short axons
• Efferent (Motor) Neurons
• Carry impulses from CNS to Effector Organs
• Have short dendrites and long axons
• Interneurons (association neurons)
• Are totally in CNS
• Connect link between efferent and afferent
  neurons
• Have short denrites and may have long/short axons

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Neuroglia

• Do not conduct impulses
• Support, nourish and protect neurons
• More numerous
• Are capable of mitosis
• Types (Table 8-2) Nice to Know
• Astrocytes Olgiodendrocytes
• Ependymal cells Schwann Cells
• Microglia Satellite Cells

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Nerve Impulses

• Functional characteristics of neurons
• Excitability
• Conductivity
• Resting Membrane
• Non-conducting neuron
• Membrane is impermeable to Na and K
• Na-K still plays a part
• RMP is -70 mV

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Nerve Impulses

• Depolarization
• Stimulus (Chemical, electrical or physical)
  allows Na to enter
• Reverse Polarization
• Membrane is now permeable to K but not Na
• K moves out
• Repolarization
• Na-K kicks in

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Nerve Impulses

• Propagated Action Potential
• Occurs on unmyelinated fibers
• Stimulus causes action potential which continues
  down the length of the fiber
• Saltatory Conduction
• Occurs on myelinated fibers
• Myelin insulates fiber so no conduction takes
  place
• Impulse jumps node to node
• Is faster than propagation

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Nerve Impulses

• Refractory Period
• Absolute
• During Na influx
• Relative
• During K movement
• Nerve fibers follow the All-or-None Principle

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Conduction at the Synapse

• Synapse has three parts
• Synaptic bulb
• Contains synaptic vesicles which release
  neurotransmitters
• Synaptic cleft
• Postsynaptic membrane
• First neuron is pre-synaptic neuron
• Second neuron is postsynaptic neuron

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Conduction at the Synapse

• Impulse reaches synaptic bulb
• Release neurotransmitters into synaptic cleft
• They react with receptor sites on postsynaptic
  membrane
• Impulse continues on
• Neurotransmitters quickly inactivated by enzymes

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Conduction at the Synapse

• Common Neurotransmitters
• Acetylcholine
• Norepinephrine
• Epinephrine
• Dopamine
• Serotonin
• Gamma-aminobutyric Acid (GABA)
• Endorphins

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Conduction at the Synapse

• Excitatory transmission
• NTM excites next neuron to continue impulse (ACh)
• Inhibitory transmission
• NTM causes the fiber to allow K to move but not
  Na causing the Membrane Potential to become even
  more negative (hyperpolarized)
• GABA

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Conduction at the Synapse

• Sympathetic Nervous System
• Preganglionic NTM ACh
• Postganglionic NTM NorEpi
• Parasympathetic Nervous System
• Preganglionic NTM ACh
• Postganglionic NTM ACh

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Neuron Pools

• Functional groups of neurons
• Can be
• Simple series circuit
• Neuron to neuron to neuron
• Divergence circuit
• Neuron to many neurons (muscles)
• Convergence
• Many neurons to one neuron (senses)

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Reflex Arcs

• A functional unit of the nervous system
• Involuntary response
• Contains
• Receptor
• Sensory Neuron
• Center
• Motor Neuron
• Effector

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CNS
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CNS

• Consists of brain and spinal cord and are
  continuous with each other
• Major regions of the adult brain
• Brainstem
• Medulla
• Pons
• Midbrain
• Diencephalon
• Thalamus
• Hypothalamus
• Cerebrum
• Cerebellum

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Brainstem

• Comprised of medulla, pons, and midbrain
• Connects spinal cord to remainder of brain

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Medulla

• Most inferior portion of brainstem
• Provides pathway for both ascending and
  descending nerve tracts
• Pathways crossover from R to L (Decussation)

• Regulates
• Heart rate
• Blood vessel diameter
• Breathing
• Swallowing
• Vomiting
• Coughing
• Sneezing

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Pons

• Relays information from cerebrum to cerebellum
• Houses sleep center and respiratory center
• Helps control breathing

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Midbrain

• Smallest region of brain stem
• Involved in
• Audio pathways in the CNS
• Visual reflexes
• Helps regulate coordination of motor activities
  and muscle tone

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Reticular Formation

• A group of nuclei scattered throughout the brain
  stem
• Part of the reticular activating system
• Involved in sleep-awake cycle and in maintaining
  consciousness

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Diencephalon

• Located between the brain stem and the cerebrum
• Major components are the thalamus and
  hypothalamus

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Thalamus

• Largest portion of diencephalon
• Receives sensory input and relays impulses to
  cerebral cortex
• Influences mood and general body movements
  associated with strong emotions

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Hypothalamus

• Major controller in the brain
• Gatekeeper" to cerebrum
• Active in
• Emotions
• Hormonal cycles
• Sexual activity
• Temperature regulation

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Cerebrum

• Largest portion of brain
• Divided into right and left hemispheres
• Each hemisphere is divided into lobes named for
  the bones that lie over them

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Cerebrum
Personality Behavior Emotion Intellect
Sensation
Vision
Hearing Smell
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Limbic System

• Consists of portions of cerebrum and diencephalon
• Influences
• Emotions (and visceral responses)
• Motivation
• Mood
• Sensations of pain and pleasure

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Cerebellum

• Second largest part of human brain
• Major functions
• Motor coordination
• Compares impulses from motor cortex with those
  from moving structures
• Compares intended movement with actual movement
• Responsible for precise movements

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Meninges

• Dura matter
• Arachnoid layer
• Pia matter

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PNS
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PNS

• Consists of nerves and ganglia
• 43 pairs of nerves originate from the CNS to form
  the PNS
• 12 pairs originate from brain
• 31 pairs originate from spinal cord
• Afferent division (from PNS to CNS)
• Efferent division (from CNS to PNS)
• Somatic nervous system (Voluntary)
• Autonomic nervous system

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Autonomic

• Transmits action potentials from CNS to
• Smooth muscle
• Cardiac muscle
• Certain glands

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Peripheral

• Collects information from both inside body and
  body surface
• Relays information by afferent fibers to CNS
• Relays information by efferent fibers from CNS to
  various parts of body

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Spinal Nerves

• First pair exits between skull and first cervical
  vertebrae
• 8 pairs exit in cervical region
• 12 pairs exit in thoracic region
• 5 pairs in lumbar region
• 5 pairs in sacral region
• 1 pair in coccygeal region

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Dermatomes

• Each spinal nerve (except C1) has a specific
  cutaneous sensory distribution
• A dermatome refers to skin surface area supplied
  by a single spinal nerve

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Cranial Nerves

• Three categories
• Sensory functions
• 5 senses
• Somatomotor and Proprioception functions
• Somatomotor control of muscles through motor
  neurons
• Proprioception position of the body and its
  parts
• Parasympathetic functions
• Autonomic nervous system

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Autonomic

• Functions to maintain or quickly restore
  homeostasis
• Sympathetic and parasympathetic impulses affect
  the body in antagonistic ways

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Neurovascular Disease
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Seizures
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Seizures

• Temporary alteration in behavior or consciousness
• Caused by abnormal electrical focal activity
• May be caused by
• Stroke
• Head trauma
• Toxins (Alcohol and drugs withdrawal)
• Hypoxia
• Hypoperfusion
• Hypoglycemia
• Infection
• Metabolic abnormalities
• Tumors
• Vascular disorders
• Eclampsia
• OD

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Types

• Most Common
• Generalized
• Focal (Partial)

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Types

• Generalized
• No definitive origin
• Petit mal (absence seizures)
• Brief lapse of consciousness without loss of
  posture
• Usually no motor activity
• May have eye blinking, lip smacking or isolated
  clonic activity
• Usually last less then 15 seconds and then pt
  returns to normal LOC

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Types

• Generalized
• Grand mal (Tonic-clonic seizures)
• Aura
• Seizure
• Sudden LOC
• Loss of organized muscle control and apnea
• Tonic phase
• Clonic phase
• Usually lasts 1 to 3 minutes
• Postictal
• Pseudoseizures
• Status Epilepticus
• A continuation of seizures without a return of
  consciousness
• Or a seizure lasting longer then 10 minutes

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Types

• Partial
• Specific seizure focus or cortical lesions
• Simple
• Activity in the motor or sensory cortex
• Clonic activity to a specific area
• Complex
• Temporal lobe (Psychomotor) activity
• Changes in behavior
• Aura stage followed by abnormal repetitive
  behavior

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Signs and Symptoms

• Sudden cry or stiffening of the body
• Noisy breathing
• Frothy saliva
• Convulsion
• Apnea, hyperventilation
• Cyanosis
• Incontinence

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Assessment

• Scene assessment
• Protect the patient
• ABCs
• Oxygen
• History
• History of seizures?
• Frequency
• Medication compliance
• Description
• Duration, typical pattern, aura?
• Recent or PHx of head trauma
• Recent Hx of fever, headache, nuchal rigidity
• PHx
• DM, IHD, CVA, TIA, pregnancy

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Assessment

• Physical Exam
• Consider C-spine
• LOC
• LOC (Amnesia?)
• Cranial nerve findings
• Motor and sensory findings
• H N
• Tongue
• Lacerations present
• Gums
• Gingival hypertrophy (chronic phenytoin use)
• Incontinence
• Automatisms
• Dysrhythmias

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Treatment

• Seizing
• Diazepam 5.0 mg IV (PR) - ALS
• Reassess A/W
• Reassess B/P
• Transport
• Postictal
• Reassess A/W
• Reassess B/P
• Transport

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Febrile Seizures

• Usually seen in children between 6 months and 3
  years of age
• Caused by sudden spike in Core temp above 40 ºC
• Child has a high fever, most commonly above
  38.3C and usually on the first day of a rapid
  rise in body temperature
• Two types
• Simple febrile seizures
• more common and relatively harmless
• usually last less than 15 minutes and have no
  after-effects
• neurological examination yields no abnormalities
• Complex febrile seizures
• may be more threatening
• can occur at body temperatures lower than 38.3C
  and can last longer than 15 minutes
• only 1 side of the body is affected during a
  complex febrile seizure
• neurological reports may indicate abnormalities

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Febrile Seizures

• Less than 2 will develop an epilepsy later in
  life
• incidence is higher in males than in females
• There are a number of possible causes of febrile
  seizures
• Vulnerability of the brain to an oncoming seizure
• Children have a higher susceptibility to seizure
  activity in the brain
• Family history of seizures
• Chronic maternal ill health
• Parental fertility problems
• Breech birth
• Caesarean birth
• Small birth weight
• Developmental delay
• Cerebral problems
• Smoking and drug intake (including anti-epileptic
  drugs) during pregnancy can further increase the
  risk

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Febrile Seizures

• Treatment
• Seizing
• Diazepam 0.2 mg/kg IV (0.5 mg/kg PR) - ALS
• Reassess A/W
• Reassess B/P
• Attempt to relieve temp
• Transport
• Postictal
• Reassess A/W
• Reassess B/P
• Attempt to relieve temp
• Transport

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Strokes
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Cerebrovascular Accident (CVA)

• Deaths
• 4th leading cause of death in Canada.
• Each year, about 16,000 Canadians die from
  stroke.
• Each year, more women than men die from stroke.
• Prevalence
• 40,000 to 50,000 strokes in Canada each year.
  (60 are women)
• For every 10,000 Canadian children under the age
  of 19, there are 6.7 strokes.
• About 300,000 Canadians are living with the
  effects of stroke.
• After age 55, the risk of stroke doubles every 10
  years.
• A stroke survivor has a 20 chance of having
  another stroke within 2 years.
• Effects
• Of every 100 people who are hospitalized for
  stroke
• 20 die before leaving the hospital
• 50 return home
• 10 go to an inpatient rehabilitation program
• 15 require long-term care

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Risk Factors

• Uncontrollable Risk Factors
• Age
• 2/3 of all strokes occur over the age of 65 years
• A womans risk of having a stroke increases
  significantly after menopause
• Gender
• Men have a higher risk than women of having a
  stroke
• Ethnicity
• First Nations/Aboriginal, African, Hispanic,
  South Asian and Black have higher rates of high
  blood pressure and diabetes
• Family History
• Prior Stroke or TIA
• 1/3 of people who survive a first CVA or TIA have
  another stroke within 5 years

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Risk Factors

• Controllable risk factors
• Hypertension
• single most important modifiable risk factor for
  stroke
• 65 of all strokes are associated with HTN
• Diabetes
• have to a 2 to 4 times greater risk of stroke
• Smoking
• Men 40 greater chance
• Women 60
• Women who smoke and take the birth control pill
  have an even higher risk for stroke
• Heart disease/Atrial Fibrillation
• About 6 of the population age 65 and older have
  atrial fibrillation
• High blood cholesterol
• Inactivity
• twice the risk for heart disease and stroke
• Excessive alcohol consumption

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Risk Factors

• Risk Factors Unique to Women
• Oral contraceptives
• Risk is greater if they
• Smoke
• Already have high blood pressure
• Already have a blood clotting problem
• Are over age 40
• Pregnancy and childbirth
• three to 13 times higher
• are usually the result of an underlying problem
  such as a pre-existing blood vessel malformation
  or eclampsia
• eight in 100,000 women during pregnancy or
  childbirth.
• greatest in the 6 weeks following childbirth.
• Gestational diabetes
• Menopause
• risk of heart disease and stroke increases
• hormone replacement therapy

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CVA

• Sudden interruption of blood flow to the brain
• It is caused by the
• interruption of the flow of blood to the brain
  (an ischemic stroke)
• rupture of blood vessels in the brain (a
  hemorrhagic stroke).
• The interruption of the blood flow or the rupture
  of blood vessels causes neurons in the affected
  area to die.
• The effects of a stroke depend upon where the
  brain was injured as well as how much damage
  occurred.
• As the brain controls everything we say, do and
  think, a stroke can have a wide variety of
  effects. A stroke can affect
• Ability to move and coordinate movement
• Ability to feel touch, temperature, pain and
  movement
• Ability to see or to interpret what you see
• Ability to think, to remember, understand, plan,
  reason or problem-solve
• Ability to communicate (speaking and
  understanding speech, as well as reading, writing
  and the ability to do mathematics)
• Personality
• Emotions
• Behaviour

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Ischemic Stroke

• 80 of strokes are ischemic
• An ischemic stroke is the result of the
  interruption of the flow to blood to the brain by
  a blood clot.
• Atherosclerosis is involved in most ischemic
  strokes.
• Often referred to as being either "thrombotic" or
  "embolic."
• thrombotic stroke
• caused by a thrombus that forms in an artery
  going to the brain
• embolic stroke
• artery is blocked by a clot that formed elsewhere
  in the body (an embolus) and is carried through
  the blood stream to the brain

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Thrombotic Stroke

• Signs and Symptoms
• Usually slow onset

• Hemiparesis or Hemiplegia (opposite side of
  lesion)
• Numbness
• Aphasia
• Confusion or coma
• Convulsions
• Incontinence
• Diplopia (Double vision)

• Monocular blindness (Loss of vision in one eye)
• Numbness of the face
• Dysarthia (slurred speech)
• Headache
• Dizziness or vertigo
• Ataxia

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Ischemic Stroke

• Transient Ischemic Attacks (TIA)
• caused by a temporary interruption of blood flow
  to the brain.
• S/S are similar to an ischemic stroke except they
  go away in a few minutes or hours (no more than
  24 hours).
• Important warning sign that you may be at risk of
  having an ischemic stroke in the future.

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Hemorrhagic Stroke

• About 20 of strokes are hemorrhagic (High
  mortality)
• As well as interrupting the normal flow of blood
  within the brain, the uncontrolled bleeding
  "floods" and kills brain cells.
• High blood pressure increases the risk
• Usually occur during stress or exertion (and
  possible drug use)
• There are two main types of hemorrhagic stroke
• Subarachnoid hemorrhage
• Intracerebral hemorrhage
• Both can be caused by structural problems with
  the blood vessels in the brain
• Aneurysms
• Arteriovenous malformation (AVM)
• an area of the brain where there are many
  thin-walled blood vessels (may be born with)

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Hemorrhagic Stroke

• Signs and Symptoms
• Abrupt presentation
• Usually begins with a headache
• N/V
• Progressive deterioration in LOC
• Often have syncope or seizure at time of
  hemorrhage
• Cushings Reflex

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Other Causes

• Stroke-like damage to the brain can be caused by
  cardiac arrest
• Hypoxemia and lack of nutrients to the brain
  tissue increases the risk of ischemia
• Traumatic Injuries
• Uncontrolled bleeding and permanent brain damage
• Usually referred to as an Acquired Brain Injury

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Stroke Assessment

• Same sequence as any other illness or injury
• ABCs
• Thorough history
• Previous neurological symptoms (TIA)
• Previous neurological deficits
• Initial symptoms (and progression)
• ALOC
• Precipitating factors
• Dizziness?
• Palpitations?
• Significant PHx
• HTN, DM, Smoker, Birth control, CAD, Previous
  stroke

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Stroke Assessment

• Cincinnati Prehospital Stroke Scale
• Identifies patients with strokes
• It evaluates three major physical findings
• Facial droop
• Motor arm weakness
• Speech abnormalities

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Facial Droop

• Have the patient show their teeth or smile.
• Normal
• Symmetrical movement
• Abnormal
• Asymmetrical movement

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Arm Drift

• Have the patient close his/her eyes and hold both
  arms out.
• Normal
• both arms move the same way, or both arms do not
  move at all.
• Abnormal
• one arm does not move or one arm drifts down
  compared to the other arm.
• Other findings such as pronater grip, may be
  helpful

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Speech

• Have the patient say You cant teach an old dog
  new tricks.
• Normal
• patient uses correct words with no slurring.
• Abnormal
• patient slurs words, uses inappropriate words, or
  is unable to speak

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Cincinnati Prehospital Stroke Scale

• 1 of these 3 findings - as a new event
• 72 probability of an ischemic stroke
• all 3 findings are present
• probability of an acute stroke is more than 85
• Transport to appropriate facility
• Contact OLMC for permission to bypass

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Management

• LOC
• AVPU / GCS
• Airway
• Paralysis of throat?
• Partial or obstructed airway?
• Suction as required

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Management

• Breathing
• Hypoventilation?
• Hypoxia?
• Oxygen via NRB, BVM, ETI
• Circulation
• Arrhythmias?
• Blood pressure? (R and L)
• A difference of 10 mmHg may indicate aortic
  dissection

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Management

• Other supportive measures
• IV Access
• Glucose check
• Protect paralyzed limbs
• Maintain body temp
• Control seizures as per protocol
• Comfort
• Gentle transport
• In Hospital Treatment
• CT Scan
• Fibrinolytic therapy

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Degenerative Diseases of the Nervous System
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Adult Neurological Disease

• Amyotrophic Lateral Sclerosis
• Bells palsy
• Cerebral palsy
• CVA TIA
• Dementia
• Guillian Barre syundrome
• Meningitis
• Multiple Sclerosis
• Muscular Dystrophy
• Parkinsons
• Poliomyelitis
• Structural tumors

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ALS

• Amyotrophic Lateral Sclerosis
• AKA Lou Gehrigs Disease
• Progressive neurodegenerative disease attacking
  the motor neurons of the voluntary system

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ALS

• Signs?
• Early
• Muscle weakness mainly in arms and legs
• Aphasia
• Difficulty swallowing and SOB
• Later
• Atrophy of muscle
• Fasciculations
• Impaired use of limbs, chewing, talking
• Respiratory Compromise
• Survival 3 5 y (may be as long as 10 y)

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ALS

• Signs?
• Since only affects motor neurons cognitive
  functions still available
• Eye an urinary control still possible
• Senses still function
• Respiratory muscle involvement death in 4 years
• Other common causes of death
• Aspiration pneumonia
• Anorexia
• Inanition (Severe weakness and wasting)

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Bells palsy

• 7th Cranial nerve inflammation
• Causes facial muscle paralysis
• Sudden onset, transient, and unilateral
• Possible related to previous infections such as
• Lyme disease
• Herpes
• Mumps
• HIV et al

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Cerebral palsy

• Cerebral - pertaining to the brain
• Palsy - muscle weakness / lack of control
• Term used to describe a group of conditions
  caused by damage to one or more specific areas of
  the brain
• characterized by loss of movement or other nerve
  functions
• Occurs in 2-4 of every 1000 births
• One of the first to be identified was discovered
  by William Little in the 1860s and was
  originally known as Littles disease, now known
  as spastic diplegia

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CP

• This damage can occur during fetal development,
  before, during, or after birth, or during infancy
• Caused by brain insult during fetal development
  or just prior to delivery
• Usually hypoxia but can also be traumatic or from
  diseases such as hepatitis, encephalitis or
  meningitis
• The damage affects the brains ability to control
  movement and posture
• Congenital CP present at birth
• Acquired CP develops post delivery

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CP

• 3 principle categories
• spastic
• athetoid ( dyskenetic )
• ataxic
• Fourth category is a combination of two or more
  of the above

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Spastic cerebral palsy

• 70 - 80 of all CP patients
• Stiffly and permanently contracted musculature

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Athetoid ( dyskinetic ) CP

• 10 - 20 of CP patients
• Characterized by uncontrolled, slow writhing
  movements
• Affects hands, extremities, and facial muscles
• Symptoms increase during stressful periods and
  disappear during sleep

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Ataxic CP

• Rare - 5 - 10
• Balance and sense perception affected
• Characterized by unsteady wide based gait,
  difficulty with quick / precise movements
• Tremor begins and increasingly worsens during a
  movement, i.e. reaching for a book

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Cerebral Palsy

• Signs?
• Spastic movements
• One arm or leg (spastic hemiplegia)
• Both legs (spastic paraplegia)
• Both arms and legs (spastic quadriplegia)
• May be paralysis
• Sensory abnormalities
• Defects in hearing and vision
• Seizures
• Speech impairments
• Intellect from normal to sever retardation
• Symptoms usually appear before age 2

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Cerebral Palsy

• Other Signs?
• Difficulty sucking during feeding
• Dyspnea
• Delayed development of motor skills
• Limited range of motion
• Peg teeth

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Cerebral Palsy

• Treatment?
• No cure
• Goal is for maximum independence
• Guided by symptoms
• May need braces, glasses, hearing aids, etc
• Physiotherapy
• Medications
• Muscle relaxants
• Anticonvulsants
• May need feeding tubes
• Life long disorder, may need long-term care
• Does not affect length of life

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Cerebral Palsy

• Complications?
• Seizures
• Injuries from falls
• Reduced mobility
• Reduced communication skills
• Reduced intellect
• These can also make examinations difficult

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Delirium

• An abrupt disorientation for time and place,
  usually with illusions and hallucinations
• The patients mind may wander, speech may be
  incoherent, and the patient may be in a state of
  mental confusion or excitement
• Commonly brought on by physical illness
• Signs and symptoms vary according to personality,
  environment, and severity of illness
• Causes of delirium are associated with organic
  brain dysfunction

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Dementia

• A slow, progressive loss of awareness for time
  and place, usually with an inability to learn new
  things or remember recent events
• Often a result of brain disease caused by
• Stroke
• Genetic or viral factors
• Alzheimers disease
• Generally considered irreversible

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Dementia

• May be difficult to differentiate from delirium
  in the prehospital setting
• The key difference between the two conditions is
  that delirium is new with a rapid onset
  dementia is progressive
• A history of the event from a rational witness
  (e.g., friend or family member) is the best
  source of information
• If a rational witness is not available, the
  patient should be treated for delirium that may
  be a life-threatening emergency

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Overview to Dementia

• 4,000,000 USA (400,000 annually)
• 360,000 Canada (60,000 annually)
• 8 of pop.
• Approximately 10 of persons ? 65 y/o
• 25 - 55 of persons ? 85 y/o
• 4th leading cause of death in elderly

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Dementia

• 6 main categories
• Alzheimers
• Structural (Dementia with Lewy bodies )
• Vascular
• Medical
• Substance induced
• Otherwise not specified

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Dementia ( contd )

• Age and family Hx major predictors of dementia
• Researchers believe multiple factors involved,
  not a single gene
• Dementia also affected by persistent hypotension,
  fever, dehydration, medication reactions, and
  thyroid inefficiency

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Alzheimers dementia

• Approx. 50 of all dementia
• Affects the cerebral cortex (thought, reasoning,
  personality, memory )
• Caused by loss of nerve cells as well as loose
  connections between nerve cells
• Plaque deposits form between neurons
• Protein threads become twisted and tangled
• Avg. 8 yr mortality
• 20 yrs with disease not unheard of

106
Structural dementia

• Lewy bodies
• abnormal lumps inside nerve cells
• 2nd most common form of dementia

107
Vascular dementia

• Caused by small strokes / aneurysms that
  interrupt blood supply to the brain

108
Medical dementia

• Creutzfeldt-Jakob disease
• Head injury
• HIV
• Huntingtons
• Hypoglycemia
• Metabolic disorders
• Parkinsons
• Picks disease

109
Creutzfeldt-Jakob disease

• Rare but fatal brain disorder first documented in
  1920s
• aka subacute spongiform encephalopathy
• Onset in 50s - 70s - 5 cases per million pop.

110
Guillain-Barre Syndrome

• AKA
• Acute inflammatory demyelinating polyneuropathy
• Landry's ascending paralysis
• Is an inflammatory disorder of the peripheral
  nerves
• It is characterized by the rapid onset of
  weakness and often, paralysis of the legs, arms,
  breathing muscles and face.  Abnormal sensations
  often accompany the weakness.

111
Guillain-Barre Syndrome

• Many patients require an intensive care unit
  during the early course of their illness,
  especially if support of breathing with a machine
  is required.
• Although most people recover, this can take
  months, and some may have long term disabilities
  of varying degrees.
• Less than 5 die.
• GBS can develop in any person at any age,
  regardless of gender or ethnic background.

112
Guillain-Barre Syndrome

• What causes it?
• The cause is not known.
• Perhaps 50 of cases occur shortly after a
  microbial (viral or bacterial) infection such as
  a sore throat or diarrhea.
• Many cases developed in people who received the
  1976 swine flu vaccine.
• Some theories suggest an autoimmune mechanism, in
  which the pt's defence system of antibodies and
  WBCs are triggered into damaging the myelin
  sheaths, leading to weakness and abnormal
  sensation

113
Guillain-Barre Syndrome

• How is it treated?
• Progression of the disease in its early stages is
  unpredictable
• Most newly diagnosed patients are hospitalized
  and usually placed in an ICU to monitor breathing
  and other body functions.
• Care involves use of general supportive measures
  for the paralyzed patient
• Plasma exchange
• High dose intravenous immunoglobulins are often
  helpful to shorten the course of GBS.
• When medically stable, rehabilitation program to
  help learn optimal use of muscles as nerve supply
  returns.

114
Encephalitis

• What is it?
• Inflammation of the brain and may include the
  meninges
• Is usually, but not always, bacterial
• Some conditions that may cause encephalitis
• Polio
• HIV
• Herpes
• Measles
• Mumps
• Vaccine reactions
• Mono
• Hepatitis

115
Encephalitis

• Signs and Symptoms?
• Mild cases
• Febrile
• Headache
• Loss of energy
• Loss of Appetite

116
Encephalitis

• Signs and Symptoms?
• Severe cases
• Irritability
• Restlessness
• hallucinations
• unusual behavior
• confusion
• drowsiness
• loss of muscle power in the arms or legs 
• double vision
• impaired speech, hearing or balance
• seizures
• coma

117
Encephalitis

• Signs and Symptoms?
• If the membranes covering the brain and spinal
  cord are involved, a person with encephalitis can
  also have
• neck pain 
• photophobia
• Risk of brain damage with encephalitis and may
  leave permanent defects (seizures)

118
Encephalitis

• Who can it affect?
• People of all ages
• Autoimmune disorders
• Treatment?
• Few drugs for viral, antibiotics for bacterial
• Most recover well from mild cases, though damage
  may occur with any amount of encephalitis

119
Meningitis

• What is it?
• Irritation or inflammation of the meninges
• Can be either viral, bacterial or fungal

120
Viral meningitis

• Aka aseptic meningitis and serous meningitis
• The most common form of meningitis
• Caused by coxsackie virus, echovirus, and mumps
• Herpes and rabies can also cause meningitis
• No reliable numbers available
• Rarely fatal
• often requires no treatment and should resolve
  within 10 days

121
Bacterial meningitis

• Most deadly form of disease
• 10 mortality
• 1 in 7 left with severe handicap
• Two primary types
• meningococcal and pneumococcal
• Haempohilus influenza b virtually eradicated as a
  cause though infant vaccinations
• Spread through airborne fluid contact (smooching,
  coughing, sneezing, and sharing drink containers)

122
Meningococcal infection

• Caused by bacteria Neisseria meningitidis
• 3000 cases annually in US
• Less than 200 cases annually in Canada
• Commonly fatal to immunosuppressed patients

123
Pneumococcal infection

• Caused by bacteria Streptococcus pneumoniae the
  most lethal bacteria in North America
• Over 7,000,00 cases and 40,000 deaths attributed
  to pneumococcal infections in U.S annually
• 800 - 1000 cases annually in Canada
• More frequent occurrence in Blacks and Native
  Americans

124
Fungal meningitis

• The rarest of the three
• Often occurs in immunosuppressed patients and
  sometimes in premature babies
• Affecting organism most commonly found in dried
  bird sh (aka droppings )

125
Meningitis

• Signs and Symptoms?
• General malaise
• Fatigue
• Febrile
• Sore Throat
• Severe headache
• Photophobia
• N/V
• Stiff neck (may be in back)
• Changes in LOC
• Skin rash (reddish-purple blotches)
• Note S/S may start suddenly and progress rapidly

126
Meningitis

• Signs and Symptoms?
• In infants
• Behavior changes
• Febrile
• Refusing feedings
• Vomiting
• High-pitched cry
• Bulging fontanels
• Seizures
• Rash
• Loss of Consciousness

127
Meningitis

• Bacterial Meningitis
• Commonly caused by meningococcal bacteria
• Also caused by
• Hemophilus influenza type B (Vaccine available)
• Pneumococcal bacteria
• Bacteria spread from an infection elsewhere in
  the body
• Commonly spread by droplets from nose or throat
• Sharing items puts at risk
• Generally no risk with normal contact

128
Meningitis

• Treatment?
• If bacterial, antibiotics started immediately
• Rest
• Fluids
• Nutrition
• Control fever
• (No Aspirin for children Reyes syndrome)
• Control pain
• Dim light

129
Multiple Sclerosis

• What is it?
• An immune attack on the myelin sheaths cause
  improper transferring of impulses
• Causes problems with movement, eyesight, and
  sensation.
• There are many different forms of MS, affecting
  each person differently.
• The course of the disease varies greatly in that
  the initial onset can be gradual over weeks,
  months, or years, or it may occur within minutes
  or hours.
• The common duration of MS is approximately 30
  years.

130
MS

• 4 clinical courses of disease
• Relapsing - remitting
• Primary - progressive
• Secondary - progressive
• Progressive - relapsing

131
Relapsing - remitting

• 85 of all cases of MS
• Involves clearly defined flare ups when
  neurological function is further impaired
• These episodes are followed by a recovery period
  ( remission ) during which no disease worsening
  occurs

132
Primary - progressive

• These patients suffer a slow deterioration of
  neurological function
• No remission period
• Rare _at_ approximately 10 of MS patients

133
Secondary - progressive

• These patients suffer a period of relapse -
  remission followed by steady deterioration
• 50 of patients with relapsing - remission
  develop this for within 10 yrs of diagnosis

134
Progressive - relapsing

• These patients steadily deteriorate but also have
  acute episodes of flare up
• The period between relapses are characterized by
  continuing disease progression
• Approx 5 of all MS patients

135
Multiple Sclerosis

• Symptoms?
• unsteady balance
• poor coordination, vertigo
• numbness and/or weakness in the extremities
• speech, visual, and auditory disturbance
• urinary tract infections
• facial pain or numbness
• Fatigue
• spasticity, muscular wasting
• impaired sensation to temperature
• impotence in males
• emotional disturbances.

136
Muscular dystrophy

• Group of muscle disorders in which muscle
  function weakens or is lost
• Muscle tissue is replaced by fatty and connective
  tissue
• Genetic

137
Parkinsons

• is a slowly progressive neurodegenerative illness
  characterized by
• Tremor
• Stiffness
• Rigidity
• slowness of movement (bradykinesia)
• difficulty with balance (postural instability)
• Believed to be a result of a lack of dopamine in
  the brain

138
Parkinsons

• Today in Canada, there are approximately 100,000
  people suffering with Parkinson's (gt 50
  diagnosed before retirement age)
• People with Parkinson's may also suffer from any
  of a long list of secondary symptoms
• Depression, dimentia
• sleep disturbances
• Dizziness
• stooped posture
• Constipation
• and problems with speech, breathing, swallowing,
  and sexual function

139
Parkinsons

• Commonly prescribed medications
• Levodopa
• Levodopa/carbidopa (Sinemet)
• Symmetrel (amantadine hydrochloride)
• originally an anti-flu medication, is thought to
  work in PD by either blocking the reuptake of
  dopamine or by increasing the release of dopamine
  by neurons, thereby increasing the supply of
  dopamine in the synapses
• Anticholinergics (trihexyphenidyl, benztropine
  mesylate, procyclidine, etc.)
• act to decrease the activity of the balancing
  neurotransmitter, acetylcholine.
• Dopamine agonists
• activate the dopamine receptor directly, and can
  be taken alone or in combination with Sinemet
• Surgical interventions
• Pallidotomy (A destructive operation on the
  globus pallidus, done to relieve involuntary
  movements or muscular rigidity)
• Brain tissue transplants
• Deep brain stimulation

140
Poliomyelitis

• Highly infectious viral illness
• Nervous system invasion resulting in paralysis in
  hours
• Enteral invasion - intestinal multiplication
• S/S include fever, fatigue, headache, vomiting,
  nuchal rigidity
• 1-200 infections irreversible paralysis
• 5 - 10 mortality rate if paralyzed
• Majority risk - under 3 y/o

141
Poliomyelitis

• Vaccine discovered by Dr. Jonas Salk in 1955
• Vaccination occurs _at_ 6 months and is repeated x 3
• Polio eradication a major goal of WHA
• 1988 125 countries 350,000 cases
• 2000 30 countries 3500 cases
• 2002 7 countries 1919 cases

142
Poliomyelitis

• Americas, Western Pacific Region, and European
  Regions polio free
• Sub-Saharan Africa and Indian subcontinent still
  polio contagious
• World polio free target date 2005

143
Spina bifida

• Split spine
• One or more vertebrae fail to properly develop
• Spinal cord is exposed and damage occurs

144
Myasthenia Gravis

• What is it?
• Chronic disorder of the muscles
• Characterized by weakness and tendency to tire
  easily
• Caused by autoimmune response to attack the
  acetylcholine receptor of the post synaptic
  neuron
• The initiating event causing the immune response
  is unknown
• Commonly seen in women 20 40, but may hit anyone

145
Myasthenia Gravis

• What is it?
• The muscles of the neck, throat, lips, tongue,
  face, and eyes are primarily involved.
• Exertion quickly brings on difficulty in
  swallowing, chewing, and talking.
• The eyelids may droop, and there are visual
  disorders.
• Can be transmitted passively to fetuses from
  infected mothers, a syndrome call neonatal
  myasthenia.
• Life-threatening myasthenic crisis, in which the
  diaphragm is affected and the patient has
  respiratory failure, occurs in 10 of the
  patients.

146
Myasthenia Gravis

• Treatment?
• Use of cholinesterase inhibitors
• Thymectomy
• Corticosteroids
• Immunosuppressive agents
• Plasmapheresis
• Prolonged rest is likely to restore some of the
  muscle function
• Restricted activity at all times and complete
  rest during periods of aggravation of the illness
  are necessary.

147
Huntington Chorea

• What is it?
• An inherited disorder characterized by abnormal
  movements and dementia
• Involves degeneration of the neurons in the
  cerebrum
• Is an inherited single faulty gene
• If one parent has gene then 50 of offspring will
  have disease

148
Huntington Chorea

• What is it?
• Symptoms do not usually appear until adulthood,
  typically between 35 - 50 y/o
• However, the disorder may appear in younger
  people.
• There is progressive
• loss of mental function, including personality
  changes, and loss of cognitive functions such as
  calculating, judgment, and speech.
• Abnormal facial and body movements develop,
  including quick jerking movements.
• Huntington disease affects about 5 out of
  1,000,000 people.

149
Huntington Chorea

• Signs and Symptoms?
• Behaviour changes
• irritability, moodiness, restlessness, fidgety
• antisocial behaviors, Psychosis, paranoia,
  hallucinations, etc.
• facial movements, grimaces
• need to turn head to shift the gaze
• progressive dementia
• Loss of memory, loss of judgment
• speech changes, personality changes
• loss of other functions (calculating, etc.)
• disorientation or confusion
• Unsteady gait
• progressive development of abnormal (choreiform)
  movements
• quick, sudden, jerking movements of arms, legs,
  face, trunk
• Additional symptoms that may be associated with
  this disease
• Speech impairment
• Anxiety, stress and tension
• Difficulty swallowing

150
Huntington Chorea

• Treatment?
• No cure
• Drugs basically prolong progression
• May take dopamine blockers (haldol or
  phenothiazine) for abnormal movements and
  psychosis
• Lose ability to care for self and are at
  increased risk of infection
• Life expectancy is 15 20 y
• Common cause of death is infection, but suicide
  is high

151
Head Injuries
152
Protection of the Brain

• The head is designed to protect the control
  center inside
• Hair
• Skin
• Muscle
• Skull
• Meninges
• CSF

153
Scene Assessment

• Look for possible causes
• Falls
• Weapons
• Information from bystanders/family
• Where they are (construction site, ball game)
• Were forces applied to the body (MOI)

154
Mechanisms of Injury
155
General S/S

• Unresponsiveness
• Changes in LOC
• Changes in Pulse , BP and Respirations
• Lacerations
• Abrasions
• Deformities
• Penetrations
• Swelling/bruising
• Blood/clear fluid from ears or nose
• Unequal pupils
• N/V
• Posturing

156
Concussion

• A temporary disruption of brain function
• Most common but least serious
• Signs and Symptoms
• Temporary LOC
• Followed by drowsiness, restlessness, confusion
• Return to normal behaviour
• Retrograde amnesia
• Antegrade amnesia
• Anxiety
• Repetitive questions
• N/V
• Possible combativeness
• General go home after assessment in hospital with
  someone to check in on them every few hours

157
Basil Skull Fractures

• History of trauma to head (MOI, bruising, LACs
  or abrasions)
• Battles Signs
• Raccoon eyes (bilateral periobital ecchymosis)
• Blood and/or CSF for ears, nose or mouth (could
  cause meningitis)

158
Cerebral Bleeding

• Contusion
• Eipdural
• Subdural
• intracerebral

159
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160
Epidural Hemorrhage

• A collection of blood between the cranium and the
  dura in the epidural space
• Usually a rapidly developing lesion associated
  with laceration or tear of the middle meningeal
  artery
• Common causes
• Low velocity blows, violent alterations and
  deceleration injuries
• Depressed skull fracture of temporal bone
• Signs and symptoms
• LOC with possible return for 6 18 hours
• ICP increases in this time showing
• Headache
• Lethargy
• LOC changes
• Contralateral hemiparesis

161
Subdural Hemorrhage

• A collection of blood between the dura and the
  surface of the brain in the subdural space
• Usually results from bleeding of the veins that
  bridge the subdural space
• Classifications
• Acute - symptoms occur within 24 hours (50 80
  mortality)
• Subacute - symptoms occur between 2 and 10 days
  (25)
• Chronic - symptoms occur after 2 weeks (20)
• Signs and symptoms
• Headache
• N/V
• LOC changes
• Posturing
• Paralysis

162
Subarachnoid Hemorrhage

• Refers to intracranial bleeding into the CSF,
  resulting in bloody CSF and meningeal irritation
• Signs and symptoms
• Sudden on set of localized headache that spreads
• Dizziness
• Nuchal rigidity
• Unequal pupils
• N/V
• Seizures
• LOC
• Permanent brain damage
• Coma and death

163
Intracerebral Hemorrhage

• A collection of more than 5 mL of blood somewhere
  within the substance of the brain
• Most commonly occurs in the frontal or temporal
  lobe
• Causes
• Multiple lacerations from penetrating trauma
• Arterial tear
• Signs and symptoms
• Dependant on location and size
• Onset dependant on location and size

164
Cerebral Blood Flow

• Oxygen and glucose delivery are controlled by
  cerebral blood flow
• A function of cerebral perfusion pressure (CPP)
  and resistance of the cerebral vascular bed
• CPP is determined by the mean arterial pressure
  (MAP) (the diastolic pressure plus one-third
  pulse pressure) minus intracranial pressure

165
Cerebral Blood Flow

• As ICP approaches MAP
• Gradient for flow decreases
• Cerebral blood flow is restricted
• When ICP increases, CPP decreases
• As CPP decreases, cerebral vasodilation occurs
• Results in increased cerebral blood volume
  (increasing ICP) and further cerebral vasodilation

166
Cerebral Blood Flow

• Vascular tone in the normal brain is regulated
  by
• Carbon dioxide pressure (PCO2)
• Oxygen pressure (PO2)
• Autonomic and neurohumoral control
• PCO2 has the greatest effect on intracerebral
  vascular diameter and subsequent resistance

167
Increased Intracranial Pressure

• Early signs and symptoms
• Headache
• Nausea and vomiting
• Altered level of consciousness
• Eventually followed by Cushings triad
• Increased systolic pressure (widened pulse
  pressure)
• Decreased pulse rate (Vagus nerve stimulation)
• Irregular respiratory pattern

168
Increased Intracranial Pressure

• As volume increases, herniation through the
  temporal lobe causes compression of cranial nerve
  III (oculomotor)
• Patient rapidly becomes unresponsive to verbal
  and painful stimuli
• Exhibits decorticate posturing or decerebrate
  posturing

169
Respiratory Patterns

• Abnormal respiratory patterns associated with
  increased ICP and significant brainstem