In the next 2 hours: Anatomy & Physiology Focused
Assessment & Examination Differential Diagnosis Management
& Critical Thinking What we will not cover in the next 2 hours:
Trauma patients with neurological findings Psychiatric emergencies
OVERVIEW
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Neurology (Greek):V (neuron), (study); medical specialty
studying diagnosis & treatment of nervous system disorders
Neuron:Single nerve cell Neurotransmitter: Chemicals allowing
impulses to travel between neurons Ipsi / Unilateral:Same-sided,
one sided Contralateral:Opposite-sided Paralysis:Complete loss of
function Paresis:Limited function Anesthesia:Complete loss of
sensation Paresthesias:Abnormal sensation Lesion:Focus for
neurological abnormality TERMINOLOGY
Billions of neurons allow body functions via neurotransmitters
Neurotransmitters are excitatory or inhibitory Excitatory:
acetylcholine, norepinephrine Inhibitory: dopamine, serotonin, GABA
Each neurotransmitter directly or indirectly influences specific
type(s) of neuron NEURONS & NEUROTRANSMITTERS
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Nerve impulse travels from neuron through axon to terminal
& synaptic knob Synaptic knob communicates with dendrite of
neighbor neuron via neurovesicles that store & release
neurotransmitters into synapse If stimulated in a lock & key
manner, the next neuron picks up & continues the impulse
Seizures: continuous release / stimulation of impulses = spasm
Botulism: neurotransmitters bound so no impulses = flaccidity
NEURONS & NEUROTRANSMITTERS
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Depressants Increase GABA (inhibitory neurotransmitter),
decreasing nervous system activity Barbiturates, Benzodiazepines If
combined other depressants can be fatal Abrupt discontinuation
leads to withdrawal & seizures Stimulants Increase
norepinephrine, dopamine to increase nervous system &
catecholamine response Dexromethorphan, methylphenidate, cocaine
CNS PHARMACOLOGY
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CNS PROTECTIVE STRUCTURE - SKULL
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CNS PROTECTIVE STRUCTURES VERTEBRAE (SPINE)
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CNS PROTECTIVE STRUCTURES - MENINGES
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Frontal Lobe Thinking, planning Executive functions Motor
execution Parietal Lobe Somatosensory perception Integration of
visual & somatospatial information Temporal Lobe Language
function Auditory perception Memory Emotion Occipital Lobe Visual
perception & processing CNS - BRAIN
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CNS VASCULAR SUPPLY
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CNS SPINAL NERVES & DERMATOMES
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ROOT MOTOR SENSORY C3 Diaphragm, Trap Lower neck C4 Diaphragm
Clavicle C5 Bicep & deltoid Below clavicle C6 Bicep Thumb,
forearm C7 Tricep Index, middle fingers C8 Finger flexors Pinky T1
Hand intrinsics Medial Arm CERVICAL DERMATOMES C 3 4 5 keeps the
diaphragm alive
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1Olfactory 2Optic 3Oculomotor 4Trochlear 5 Trigeminal 6Abducens
7Facial 8 Vestibulocochlear 9Glossopharyngeal 10 Vagus 11Spinal
Accessory 12 Hypoglossal "On Old Olympus's Towering Tops, A Fine-
Vested German Viewed Some Hops" "Oh, Oh, Oh, To Touch And Feel, A
Good Velvet, Spot in Heaven" Motor (M), sensory (S), or both (B)
"Some Say Money Matters But My Brother Says Big Brains Matter Most"
CRANIAL NERVES
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Autonomic Nervous System Sympathetic: Fight or Flight
Parasympathetic: Feed or breed, Rest & Repair Clinically: Point
& Shoot Peripheral Nerves 43 pairs of nerves originate from CNS
to form PNS 12 pairs of cranial nerves from brain 31 pairs of
spinal nerves from spinal cord ANATOMY & PHYSIOLOGY - PNS
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PREHOSPITAL ASSESSMENT
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Altered Mental StatusFocal Neurological Complaints THE BIG
PICTURE Sick vs Not Sick
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Exact quotes words are clues The room is spinning vs I feel
like Im spinning My vision is blurred vs I have double vision
Obtain from pt, witnesses, family while beginning assessment &
management CC, HPI & exam should focus on neurological aspects,
without overlooking non-neurological processes causing AMS or
deficits CHIEF COMPLAINT
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Provokes / Progression / Palliation Quality Region/radiation
Severity Time of onset Family/Social history Allergies Medications
PMH Sz, trauma, HA, HTN, DM, infections, tumors Cardiac, renal,
hepatic, neuro, psychiatric diseases Last oral intake Events
leading up to event Environmental clues Indoors or outdoors? Any
unusual odors? Suicide notes? HISTORY OF PRESENT ILLNESS
Eye Opening 4 = Spontaneous 3 = To Voice 2 = To Pain 1 = None
Verbal 5 = Oriented 4 = Confused 3 = Inappropriate words 2 =
Inappropriate sounds 1= None Motor 6 = Obeys commands 5 = Localizes
pain 4 = Withdraws to pain 3 = Decorticate 2 = Decerebrate 1 = None
GLASGOW COMA SCALE (3-15) The number is less important than the
category & what you do with it!
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Speech and language Hear them talk, watch them talk, & look
at their eyes; thats 90% of the brain (Henry, 2004) Normal speech
inflected, clear, fluent, articulate, varies in volume Language
Dysphonia: Inability to make laryngeal sounds Dysprosody:
Inflection, pronunciation, pitch or rhythm (cerebellum) Dysarthria:
Difficulty making individual sounds (motor integration) Aphasia:
absence of speech Dysphasia: word finding difficulty (cortex)
Expressive aphasia: understands but cannot speak (frontal Brocas)
Receptive aphasia: words clear, content scrambled (parietal
Wernickes) Apraxia: difficulty in both forming & phonating
NEUROLOGICAL EXAM - SPEECH
Head Skull: trauma; infants bulging membranes Mouth: odors,
bites to lateral tongue Neck Meningismus Skin Trauma, rash, IVDA,
temperature Lungs, Cardiac, Abdomen Systemic illnesses and
secondary effects of CNS insults Extremities Trauma, deformity,
pulses PHYSICAL EXAM
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Pupil size, symmetry, reactivity Miosis Mydriasis Extraocular
movements Resting eye position Deviation Nystagmus / direction
Conjugate movement NEUROLOGICAL EXAM - EYES
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Cranial nerves Reflexes Cerebellar Gait Finger pointing
Psychiatric Posturing Any asymmetry Seizure activity Look at eyes
NEUROLOGICAL EXAM MOTOR & SENSORY
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Test glucose & you have the Miami / LA Stroke Scale
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DIFFERENTIAL DIAGNOSIS / NEUROLOGICAL EMERGENCIES
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Altered Mental StatusFocal Neurological Complaints THE BIG
PICTURE Sick vs Not Sick
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AEIOU TIPS A Alcohol / Drugs / Toxins E Endocrine, Exocrine,
Electrolyte I Insulin O Opiates, OD U Uremia T Trauma, Temperature
I Infection P Psychiatric disorder S Seizure, Stroke, Shock, Space
occupying lesion CAUSES OF AMS
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History often initially more important than exam What is MOST
important question with a neuro deficit or AMS? Physical Exam Keys
Odors Respiration Eyes Trauma? IVDA? Serial GCS If
Hypothermia: AMS / coma 42.0C Environmental Sepsis Drug
reaction Neuroleptic malignant syndrome TEMPERATURE
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Most Common Hypo / hyperglycemia Hypo / hyperkalemia
Hyponatremia Thyroid storm Cause vs effect AMS Seizures Syncope
Often related to arrhythmias EXOCRINE / ENDOCRINE /
ELECTROLYTE
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STROKE EPIDEMIOLOGY Disability affects 75% survivors #1 cause
adult disability in the US & Europe #3 cause death worldwide
after CAD & cancer 10% deaths worldwide US Management costs $43
billion annually Incidence increases exponentially >30 yrs
Etiology varies by age 95% of strokes occur in people >45 yo 75%
of strokes occur in people >65 yo Rule of two thirds 2/3 all
strokes ischemic 2/3 of those thrombotic
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STROKE - GENDER DIFFERENCES Men 1.25 x more likely to suffer
strokes than women However, 60% of deaths from stroke occur in
women Since women live longer than men, they are older on average
when they have their strokes & therefore more often killed Some
risk factors for stroke apply only to women: Pregnancy Childbirth
Menopause HRT
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STROKE - RISK FACTORS Advanced age Previous stroke or TIA
Diabetes High cholesterol Cigarette smoking Atrial fibrillation HRT
Migraines Thrombophilia Patent foramen ovale HTN Most important
& modifiable
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STROKE - MIMICS Seizure Infection Hypoglycemia Syncope Brain
abscess or tumor Drug Overdose Head Trauma Vascular Lesions HTN
Encephalopathy Migraine
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Thrombotic Slow, progressive onset Causes: Atherosclerosis (#1
cause) Infective Inflammatory (vasculitis) Hypercoaguable states
Embolic Abrupt onset Maximal deficit may improve over time as
embolus breaks Causes Mural thrombus (#1 ) Aortic plaques
Endocarditis Long bone injuries Dysbarism STROKE PATHOPHYSIOLOGY -
ISCHEMIC
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Altered neuro status that resolves completely
Answer to ALL must be YES: >18yo Acute ischemic stroke
causing a measurable non- improving neurologic deficit NO clinical
suspicion for SAH Time of onset to treatment is
1 2% general population Primary / Idiopathic Onset ages 10-20
Often outgrow their medications Secondary precipitated by something
Intracranial: trauma, mass, abcess, infarction Trauma, mass,
abscess, infarct Extracranial: toxins, metabolic, HTN, eclampsia
SEIZURES - EPIDEMIOLOGY
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Grand Mal: Aura, tonic-clonic, LOC, apnea, incontinence,
post-ictal Petit Mal Absence Myoclonic Simple Partial Seizures
Involve one body area Can progress to generalized seizure Complex
Partial Seizures Characterized by auras Typically 12 minutes in
length Loss of contact with surroundings SEIZURE
CLASSIFICATION
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ECLAMPSIA Any pregnant patient who seizes, regardless of prior
history Often secondary to undertreated / undiagnosed pre-eclampsia
Medical emergency for both mother & child Management: IV, O2,
Monitor Left lateral recumbent position Rapid Transport Magnesium
sulfate
ABCs + C spine + Glucose + Pregnancy IV, O2, Monitor HPI
Timeframe? Prior history? Pregnancy? DM? Trauma? Infection? Serial
neuro exams SEIZURE - MANAGEMENT
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Seizure >5 mins OR 2 seizures between which there is
incomplete recovery of consciousness Management: ABCs IV, O2,
Monitor Benzodiazepines Treat other causes: Glucose Magnesium
Pyridoxine (B6) SEIZURE - STATUS EPILEPTICUS
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Acute & temporary loss of consciousness Pre-syncope: No LOC
Pt often states I thought I was going to pass out Syncope is a
symptom, not a diagnosis DDX: Cardiovascular: a rrhythmias, valve
stenosis, hypotension Noncardiovascular: m etabolic, neurological,
psychiatric Idiopathic Pearls: Extended unconsciousness is NOT
syncope All drunks have head & C spine injuries if unconscious
+ fall SYNCOPE
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ABCs & support ventilations Maintain airway IV, O2,
Monitor, Glucose Look for other causative / contributive factors
Heat stroke MI CVA CHI Dehydration SYNCOPE MANAGEMENT
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SEIZURE VS SYNCOPE
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US Incidence 1.5 per 100,000 Rare in young pts (Hflu &
pneumovax vaccines)* CDC: median age 39 years; in 1986, it was 15
months Mortality/Morbidity Depends on pathogen, age, general
physical state & severity of acute illness Pneumococcal
mortality 21%, morbidity 15% Mortality 90% if severe neurologic
impairment at time of presentation even with immediate medical
treatment INFECTIOUS - MENINGITIS *PLEASE immunize your kids!
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Bacterial Rapid onset of symptoms Fever, HA, photophobia,
meningismus, AMS Etiology varies by age / exposure / PMH Neisseria
meningitis associated with diffuse, purpuric rash Aseptic/ Viral/
Lymphocytic Gradual onset over 1-7 days Less virulent Atypical PMH
/ HPI critical as onset insidious TB(#1) Fungal: coccidiomycosis /
crytococcus INFECTIOUS - MENINGITIS
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Brain inflammation Cases self-limited unless virulent
strain/immunocompromised Presents similarly to meningitis Viral /
tick-borne etiology most common West Nile Herpes Simplex (HSV)
Varicella Zoster (VZV) Arboviruses Eastern Equine viruses St. Louis
Encephalitis INFECTIOUS - ENCEPHALITIS
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Acutely ill patient + fever in a dPT deficient patient Bleeding
membranous pharyngitis Exotoxin causes multi-organ system failure
Myocarditis/AV Block Nephritis Hepatitis Neuritis with bulbar /
peripheral paralysis Ptosis, strabismus, loss of DTRs Management
ABCs, intubation, volume resuscitation IN ED: PCN, emycin, horse
serum antitoxin, pressors INFECTIOUS CORNYBACTERIUM DIPTHERIA
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Triad: diplopia, ophthalmoplegia, ptosis Descending neurologial
deficits causing respiratory paralysis Normal mentation / sensation
Infant FTT / floppy baby Raw honey contains C. botulinum
Management: ABCs, intubation In ED: trivalent serum antitoxin
INFECTIOUS CLOSTRIDIUM BOTULINUM
Most common acute polyneuropathy 2/3s have preceding URI or
gastroenteritis Generalized paresthesias then ascending paralysis
Miller-Fischer variant: ataxia, areflexia, and ophthalmoplegia 1976
swine flu tainted vaccine caused 25 deaths from GBS & the
foundation for current anti-vaccine sentiment Management: ABCs,
intubation INFECTIOUS GUILLAIN-BARRE SYNDROME
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Facial nerve paralysis affecting entire unilateral face In
supranuclear lesions like a cortical stroke (UMN defect), the upper
1/3 of the face spared while lower 2/3 paralyzed Orbicularis,
frontalis & corrugator muscles innervated bilaterally, which
explains facial paralysis pattern Eye closure on affected side
impaired Bell Phenomenon: on attempting to close eye, the eye on
the affected side rolls upward & inward Ramsay-Hunt: zoster
vesicles along ear canal, pinna, mouth INFLAMMATORY - BELLS
PALSY
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Migraine (w/ wo aura)* Cluster Traumatic Inflammatory History:
Worst HA? Onset? Fever / AMS? Trauma? Prior history? Management:
IV, O2, antiemetics Cool, dark environment Abortive therapy Believe
it or not, narcotics actually make headaches worse physiologically
HEADACHE *Pet peeve
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Though to be related to neurogenic inflammation &
abnormalities of serotonergic transmission* HA either preceded by a
visual aura or motor disturbance N/V, photophobia, sound
sensitivity Provocation factors: Menstruation Sleep/food
deprivation Physical activity Foods Contraceptive estrogens
HEADACHE - MIGRAINE *i.e. neurologists really have no freakin clue
why they occur
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Cluster: Resemble CVAs Unilateral & persistent Thought to
be a form of seizures by some neurologists Temporal Arteritis
Temporal artery inflammation (branch of external carotid)
Unilateral HA with temporal artery tenderness & decreased
vision in middle-aged white females Rapid initiation of steroids
will save patients vision Be concerned with any HA plus fever,
confusion, nausea, vomiting or rash HEADACHES - OTHER
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Common Causes: Labrynthitis Cerumen Impaction OM / OE URI
Menieres Disease: tinnitus, hearing loss, vertigo History: Acute
onset of severe dizziness, N/V Positional worsening of symptoms
Often recent URI or prior vertiginous episodes Exam: Fatigable
horizontal nystagmus URI SSX PERIPHERAL VERTIGO
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10-15% cases of vertigo Causes: Brainstem ischemia or
infarction Cerebellar hemorrhage Vertebralbasilar insufficiency MS
Brainstem /cerebellar lesions SSX: Disequilibrium N/V Nonfatigable
nystagmus Focal findings: Ptosis Facial palsy Dysarthria Cerebellar
findings Ataxia Vertigo Management IV, O2, Monitor Antiemetics
Cannot be differentiated from a posterior circulation CVA in the
field Always treat as if a CVA CENTRAL VERTIGO
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Underlying disease with extensive differential diagnosis Often
the presenting symptom of CVA, MI, sepsis Pay attention to weak
& dizzy with: Nystagmus Nausea/vomiting Focal neuro deficits
AMS Management: I, O2, Monitor, Glucose, EKG WEAK & DIZZY
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Alzheimers Dementia Most frequent cause of dementia in the
elderly Brain atrophy due to cerebral cortex neuron death Muscular
Dystrophy Characterized by progressive ascending muscle weakness
Multiple Sclerosis Unpredictable Resulting from deterioration of
myelin sheath Dystonias Often related to psychiatric medications
OTHER NEUROLOGICAL DISORDERS
ABC + Glucose Ensure patent airway maintaining C-spine Limited
airway protection may lead to vomiting / aspiration IV, O2, Monitor
Serial examinations Rapid recognition of underlying neurological
emergencies Sick vs Not Sick Pre-notification Time is brain!
GENERAL NEUROLOGICAL EMERGENCIES MANAGEMENT PRINCIPLES
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Anatomy and Physiology Pathophysiology General Assessment
Findings Differential Diagnosis Management of Nervous System
Emergencies SUMMARY