Nervous System Emergencies

2. Nervous System Emergencies Chemeketa Community College Paramedic Program

3. Causes of Coma (We’ll be talking about these…) • Structural • Metabolic • Drugs • Cardiac (Shock, Arrhythmias, Hypertension, Stroke • Respiratory (Toxic Inhalations, COPD) • Infectious Process (Meningitis)

4. And these….. • Amyotrophic lateral sclerosis (ALS) • Muscular Dystrophy • Bell’s Palsy • Multiple Sclerosis • Parkinson’s • Peripheral neuropathy • Central pain syndrome

5. The nervous system • CNS – 43 pairs of nerves • Brain • 12 pairs of cranial nerves • Spinal cord • 31 pairs of spinal nerves • PNS

6. Neurons • Dendrites, soma, axon, synapse • Neurotransmitters • Acetylcholine, norepi, epi, dopamine • Skull - brain • Spine - spinal cord • Meninges • Dura mater, arachnoid membrane, pia mater • Cerebrospinal fluid

7. Brain • Cerebrum • Frontal lobe • Temporal lobe • Parietal lobe • Occipital lobe • Cerebellum

10. Brainstem • Brain stem • Medulla • Pons • Midbrain • Reticular formation • Diencephalon • Hypothalamus • Thalamus • Limbic system

11. 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

12. Ventricles • Lateral ventricle • Third ventricle • Fourth ventricle

18. Spinal Cord • 17-18 inches long!! To first lumbar vertebra • Reflexes • Afferent - sensory • Efferent - motor • Interneurons - connecting

19. Peripheral Nervous System • Cranial nerves • Somatic sensory • Somatic motor • Visceral sensory • Visceral motor • Brachial plexus

20. 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 Cranial nerves“Some saymarry money, but my brothersays bad boysmarry money."

21. 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 Learn the cranial nerves OR……

22. Autonomic Nervous System • Sympathetic • Fight or Flight • Parasympathetic • Feed or Breed

24. 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

25. 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

26. What led up to 9-1-1? • Time of onset • Seizure activity • Environment • Cold, hot, drug paraphernalia • Medications / Medic Alerts

27. Assessment - Physical • General appearance • Mentation • Mood • Clarity of thought • Perceptions • Judgment • Memory & attention

28. Assessment - Physical(cont.) • Speech • Aphasia • Apraxia • Skin • Posture, balance and gait • Abnormal involuntary movements

29. Assessment - Physical • Vital signs • Hypertension • Hypotension • Heart rate (fast, slow) • Ventilation (rate, quality) • Temperature, fever • Cushing’s Triad

30. Assessment - Physical(cont.) • Head / neck • Facial expression • Eyes • Acuity, fields, position & alignment, iris, pupils, extraocular muscles

32. Assessment – Physical (cont.) • Ears • Acuity • Nose • Mouth • Odors • Thorax and lungs • Auscultate

33. Assessment - Physical(cont.) • Cardiovascular • Heart rate • Rhythm • Bruits • Jugular vein pressure • Auscultation • ECG monitoring

34. 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

35. Assessment • Ongoing assessment

36. Management • Airway and ventilatory support • Oxygen • Positioning • Assisted ventilation • Suction • Intubation • Circulatory support • Venous access

37. Management(cont.) • Non-pharmacological interventions • Positioning • Spinal precautions

38. Pharmacological interventions • Anti-anxiety agent • Anti-convulsant • Anti-inflammatories • Diuretic • Sedative-hypnotic • Skeletal muscle relaxant • Hyperglycemic • Anti-Emetic

39. Management (cont.) • Psychological support • Transport considerations • Mode • Facility

40. Head to Toe • Pupils • Respiratory Status • Spinal Evaluation

41. Pupils • Cranial nerve III (occulomotor) • Brain herniation = same side dilation • Both dilated = anoxia, brain stem injury • Anisocoria = unequal pupil – normal?

42. 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

43. Respiratory Status • Cheyne-Stokes • Brain Injury • Central Neurogenic Hyperventilation • Cerebral Edema

44. Respiratory Status (cont.) • Ataxic • CNS Damage = poor thoracic control • Apneustic • Damage to upper Pons

45. Respiratory Status (cont.) • Diaphragmatic • C-spine • Kussmaul • DKA

46. Spinal Evaluation • Tingling (pins & needles) • Loss of Sensation or Function • Pain, Tenderness • Priapism • Deformity, tight neck muscles

47. Spinal Evaluation (cont.) • Motion, Sensation, Position/each extremity • “Gas pedal”, grips • If unconscious, pain response • Incontinence, rectal for S-1

48. Neurological Exam • Decorticate Posturing • Above Brainstem • Decerebrate Posturing • Brainstem • Flaccid • Babinski’s sign

49. Neurological Exam • Glascow Coma Scale • Motor, 1 - 6 • Verbal, 1 - 5 • Eye, 1 - 4