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Nervous System Emergencies

Chemeketa Community College

Paramedic Program

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Causes of Coma (We’ll 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

• Bell’s Palsy

• Multiple Sclerosis

• Parkinson’s

• 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 nerves“Some 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

• Cushing’s 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

• Babinski’s 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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DDXStructural lesions

Commonly asymmetrical neurological signsAcute onsetUnresponsive or asymmetrical pupillary

responses

Toxic-metabolic comaNeurological findings symmetricalComa slow in onsetPreserved 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 can’t 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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Parkinson’s 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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Bell’s 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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Bell’s 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 Emergencies

SUMMARY

• Complex and Varied

• Attention to Assessment

• Attention to Treatment

• Good History and Exam

• Good DocumentationS:\HealthOccupations\EMS\EMT Paramedic\Neuro\Nervous System emergencies.ppt

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