NEUROLOGIC EMERGENCIES

Two of the top Three of the top Stroke is the fifth While stroke is
10 causes of 15 causes of leading cause of common in
death are death are death Stroke is geriatric Homework
neurologic in neurologic in the leading patients, it may
nature. nature. cause of adult happen to
disability anyone.

INTRODUCTION
STRUCTURE OF THE NERVOUS SYSTEM

Two major structures

• Brain
• Spinal cord
The brain is the body’s computer.

It controls breathing, speech, and all other body functions.

Responsible for fundamental functions

STRUCTURE OF THE NERVOUS SYSTEM

Central nervous system

• Thought
• Perception
• Feeling
• Autonomic body functions
Peripheral nervous system
• Communication between the brain and the body
STRUCTURE OF THE NERVOUS SYSTEM
© Jones & Bartlett Learning
THE BRAIN IS DIVIDED
INTO THREE MAJOR PARTS:

the brain stem,

the cerebellum, and
the cerebrum
THE BRAIN STEM

controls the most basic

functions of the body, such
as
• breathing,
• blood pressure,
• swallowing, and
• pupil constriction.
BRAINSTEM
Midbrain Pons Medulla oblongata

• LOC • Respiratory • Pulse rate, blood

• Location of the pattern and depth pressure, and
reticular activating respiratory rate
system (RAS),
which
• controls arousal
and consciousness
• Muscle tone and
posture
 responsible for
coordinating complex
tasks that involve
controls muscle and many muscles, such
body coordination. as standing on one
foot without falling,
walking, writing,
picking up a coin.

THE CEREBELLUM
 located above the
cerebellum, is divided
down the middle into
the right and left
cerebral hemispheres.
THE CEREBRUM
Each hemisphere
controls activities on
the opposite side of
the body.
 THE BRAIN LOBES
occipital
• Vision and storage of visual memories

Parietal
• Sense of touch and texture and storage of tactile memories

Temporal
• Hearing and smell
• Language
• Storage of sound and odor memories
Frontal
• Motor cortex:
• Voluntary muscle control
• storage of spatial memorie
Prefrontal cortex:
• Judgment and prediction of consequences of a person’s actions,
• abstract intellectual functions
THE BRAIN
 A neuron contains:
 Cell body
 Axon: projection extending toward another cell
 Axon terminal: where neurotransmitters are made

NEURONS AND
IMPULSE
TRANSMISSION
 Synapses: slight gap between each cell
Neurotransmitters: connects synapse to next cell
 Relay electrically conducted signals

NEURONS AND
IMPULSE
TRANSMISSION
NEURONS AND IMPULSE TRANSMISSION
Axons
 Many are coated with myelin.
 Insulating substance that allows the cell to transmit its signal consistently
 Increases the speed of conduction
PATIENT ASSESSMENT

The brain is sensitive to change in

• Temperatures
• Levels of Oxygen
• Glucose.
SCENE SIZE-UP

Standard precautions protect you from harmful organisms or

environments.
• Gloves are a standard approach.
• Based on the procedure you are conducting and the likelihood of contamination

patient with neurologic symptoms may have meningitis.

When people use illegal drugs, weapons and crime are likely to
be close at hand.
SCENE SIZE-UP
The patient’s location may place you in a
dangerous situation.
 Assessment begins at dispatch.
 Examine the scene as you approach.
 Ensure that you have a way to remove yourself.
PRIMARY ASSESSMENT
Form a general impression.
 Where is the patient?
 Drug paraphernalia?
 In distress or pain?
 Living conditions?
 Position?
 Conscious or unconscious?
 Inside or outside?
 Stable or unstable?
 Obvious injuries?
 Environment?
PRIMARY ASSESSMENT
Form a general impression (cont’d).
 Information can be used to:
 Identify social service needs.
 Help direct injury prevention education.
 Assess patient needs upon discharge.
 Determine the effects of past interventions.
 Assessing Level AVPU GCS
of Consciousness

PRIMARY ASSESSMENT
PRIMARY ASSESSMENT
AVPU
• A: Awake and alert
• V: Responds to verbal
stimuli
• P: Responds to painful

MED, NREMT-P
Courtesy of Chuck Sowerbrower,
stimuli
• Fingernail pressure
• Pressure to the
supraorbital foramen
PRIMARY ASSESSMENT

AVPU
• P: Responds to painful stimuli
(cont’d)
• Decorticate posturing
(abnormal flexion)
• Decerebrate posturing
(abnormal extension)
• U: Unresponsive
PRIMARY
ASSESSMENT
Glasgow Coma Scale (GCS)
 Scores are added together to
define brain function
PRIMARY
ASSESSMENT
Glasgow Coma Scale (cont.’d)
 Determines:
 How to proceed
 Care to be given
 Where the patient should be
transported
PRIMARY ASSESSMENT
Methods For Measuring Response To Pain
PRIMARY ASSESSMENT

Airway and breathing

• Listen to the quality of the patient’s voice.

• Nerves responsible for airway control allow for:
• Swallowing
• Controlling the tongue
• Slightly contracted muscles in hypopharynx
PRIMARY ASSESSMENT

Airway and breathing (cont’d)

• If patient is unresponsive, assess the airway.

• Stridor may indicate partial obstruction.
• In the unresponsive, Trismus may indicate:
• A seizure in progress
• Severe head injury
• Cerebral hypoxia
PRIMARY ASSESSMENT

Airway and breathing (cont’d)

• If you suspect an obstruction:

• Evaluate the airway.
• If there is no response, examine for obstructions.
• Use Magill forceps to remove any objects.
• Be prepared to perform endotracheal intubation.
• Ensure oxygen saturation level of 94%.
PRIMARY ASSESSMENT

Airway and breathing (cont’d)

• Provide routine hyperventilation only to those
patients with both:
• Documented unconsciousness
• Signs of increased intracranial pressure (ICP).
PRIMARY ASSESSMENT
PRIMARY ASSESSMENT
Circulation
 Evaluate peripheral and central pulse patterns.
 Evaluate skin.
PRIMARY ASSESSMENT
CIRCULATION (CONT’D)

Evidence of ICP:
• Cushing reflex
• Decorticate posturing
• Decerebrate posturing
• Biot’s respirations
• Apneustic respirations
• Cheyne-Stokes respirations
• Unresponsive and dilated pupils
21 October 2018
 Establish Establish vascular access.

PRIMARY
ASSESSMENT Consider Consider drawing blood samples.

CIRCULATION
(CONT’D) Check
Check blood pressure and pulse rate.
• Target systolic pressure: 110 to 120 mm Hg

Perform Perform continuous heart monitoring.

PRIMARY ASSESSMENT
Circulation (cont’d)
As the ICP rises:
 Blood flow to the brain diminishes.
 Heart increases contraction force.
 Systolic pressure rises.
Ability to send signals is
damaged.
Ability to control respiratory
and pulse rates is damaged.
PRIMARY ASSESSMENT

Transport decision
Consider how to transport:
Complete a rapid secondary assessment.
Complete a secondary assessment and evaluate only the
area(s) of patient complaint(s).
 Ask Ask what happened.

Look Look for signs and symptoms. HISTORY TAKING

Evaluate Evaluate the patient’s speech.

HISTORY TAKING

As a paramedic in the field, you may

be the only person with the opportunity
to obtain crucial information about the
time of onset.
SECONDARY ASSESSMENT

Head Neck Chest Abdomen

Pelvis Extremities Back

SECONDARY ASSESSMENT
Note the symmetry of the face.
 Ptosis: the dropping sagging, or prolapse of a part of the
body
SECONDARY ASSESSMENT
SECONDARY ASSESSMENT

Level of consciousness
•There can be many variations.
SECONDARY ASSESSMENT
AVPU
• A: Awake and alert
• V: Responds to verbal
stimuli
• P: Responds to painful

MED, NREMT-P
Courtesy of Chuck Sowerbrower,
stimuli
• Fingernail pressure
• Pressure to the
supraorbital foramen
SECONDARY ASSESSMENT

AVPU
• P: Responds to painful stimuli
(cont’d)
• Decorticate posturing
(abnormal flexion)
• Decerebrate posturing
(abnormal extension)
• U: Unresponsive
SECONDARY
ASSESSMENT
Glasgow Coma Scale (GCS)
 Scores are added together to
define brain function
SECONDARY
ASSESSMENT
Glasgow Coma Scale (cont.’d)
 Determines:
 How to proceed
 Care to be given
 Where the patient should be
transported
SECONDARY ASSESSMENT
Orientation Confusion may
indicate:
• Tests mental status.
• Evaluates four • Low blood glucose
areas: • Decreased oxygen
• Person
• Place • Overdose
• Time • Decreased blood
• Event pressure
SECONDARY ASSESSMENT

Corneal reflex
• Determines intact cough and gag reflexes.
• Tap between the patient’s eyes.
• Patients with reflexes will blink reflexively.
• If the patient does not blink or twitch,
assume that the patient does not have an
intact cough or gag reflex.
 SECONDARY
ASSESSMENT
Pupillary Response
SECONDARY ASSESSMENT
Cranial nerve functioning
 Abnormal functioning may occur with stroke, trigeminal neuralgia, or myasthenia gravis.
SECONDARY ASSESSMENT
SECONDARY ASSESSMENT

• Listen to the quality of the

patient’s speech
Speech • Assess the patient’s ability to
recognize objects.
• Ask questions to which you and
the patient know the answer,
SECONDARY ASSESSMENT
BODY MOVEMENT
Hemiparesis:
weakness of one
side of the body
Hemiparesis and
hemiplegia
Hemiplegia:
paralysis of one
side of the body
SECONDARY ASSESSMENT
BODY MOVEMENT
• Have
Hemiparesis patient
and close eyes
hemiplegia and hold
out arms.
Examine the • If stroke,
function of one arm
the may drift
cerebellum. away from
the other.
© Jones & Bartlett Learning. Courtesy of MIEMSS.
SECONDARY
ASSESSMENT

• Gait: walking
patterns
Gait • Assess by asking
and patient to walk
posture several steps.
• Posture may
become rigid.
SECONDARY ASSESSMENT

Alterations in smooth motion

• Rigidity: stiffness of motion

• Tremors: fine, oscillating movement
• Rest tremor: occurs when at rest and not moving
• Intention tremor: occurs when asked to grab object
• Postural tremor: occurs when a body part is required to
maintain a particular position
SECONDARY ASSESSMENT

Alterations in smooth motion (cont’d)

• Seizure: larger, less focused movement

• Tonic activity: rigid, contracted body posture
• Clonic activity: rhythmic contraction and
relaxation of muscle groups
SECONDARY ASSESSMENT

Sensation

• Paresthesia: sensation of numbness or

tingling
• Anesthesia: no feeling within a body part
SECONDARY ASSESSMENT

Blood glucose level

• Normal reading is 60 to 120

mg/dL.
• Below 10 mg/dL is usually fatal.
SECONDARY ASSESSMENT

Vital signs, Document

• Pulse rate, rhythm, and quality

• Respiratory rate, rhythm, and quality
• Blood pressure
• Skin temperature, color, and condition
• Pupil size and reactivity
SECONDARY
ASSESSMENT

Vital signs (cont’d)

• Ensure maintenance of a systolic blood pressure of at

least 110 to 120 mm Hg.
• Ensure adequate respiratory rate and pattern.
• Ensure effective pulse rate and rhythm.
• If hypothermia or hyperthermia is suspected, use a
thermometer to establish temperature.
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
Remember, the brain needs oxygen, glucose, and
normal temperature to function.

Ensure scene safety and take standard precautions.

Assess airway and breathing.

Assess circulation.
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
Administration of dextrose 50%
• Dose: 25 g or one full syringe
• Effects begin in 30 seconds to 2 minutes.
• If there is no effect, administer a second dose.
• Can substitute dextrose 25% (two syringes)
One guideline to consider is if the blood glucose level is
below 60 mg/dL, then the patient needs glucose.
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT

If you cannot obtain IV access,

then administer 0.5 to 1 mg
of glucagon subcutaneously or
intramuscularly.
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
If the patient is unresponsive or has decreased
LOC and no blood glucose monitor is available,
• Administer 12.5 g (1/2 syringe) of dextrose
50%.
• Reassess.
• Proceed with additional dextrose cautiously.
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
If the blood glucose level is high, then be
aware that
• No safe way to decrease blood glucose in
the prehospital setting currently exists.
• Patients with hyperglycemia are often
dehydrated and may need volume support.
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
Airway management

• Provide oxygen, ventilation, and protection.

• Ensure that pulse oximeter reading is 95% or
better.
• Provide oxygen and ventilatory assistance as
needed.
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
If trismus is noted:

• If ventilation is poor and patient is breathing on

his/her own, attempt a nasotracheal airway.
• If unsuccessful, consider a paralytic agent.
• If paralytics are unavailable, transtracheal
airway management is the only option.
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
Administration of naloxone

• Used for unresponsive/unknown patients or those with

suspected narcotic overdose
• Initial dose is 0.4 to 2 mg IVP.
• intranasal (IN) device provides a safe, noninvasive,
rapid-acting method of naloxone delivery.
• Can result in rapid change in LOC
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
Rectal administration of diazepam

• Dose is 0.2 mg/kg.

• Take standard precautions.
• Draw up dose, then remove and dispose of
needle.
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
Communication and documentation

• Notify the receiving facility of:

• Time the patient was last seen healthy
• Findings of neurologic examination
• Anticipated time of arrival at the hospital
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT

• Time of the onset

• Findings from stroke scale and GCS
score
Document • Airway management and interventions
performed
• Any change in patient during transport
• Reason for choice of hospital
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT
For patients who have had a seizure, document:
• Description of seizure activity
• Bystanders’ comments
• Onset and duration
• Evidence of trauma
• Interventions performed
• History of seizures
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT

When documenting interventions

include:
• Time of each intervention
• How the patient responded
• What the findings showed
STANDARD CARE GUIDELINE FOR
THE NEUROLOGIC PATIENT

Interventions for Increased The target is a systolic

Intracranial Pressure blood pressure of 110 mm
Hg to 120 mm Hg.
COMMON NEUROLOGIC EMERGENCIES

Most diseases or conditions are caused by

more than one factor.
• Development of embryo/fetus
• Effectiveness of body’s defense and repair functions
• Exposure to pathogen, toxin, or other damaging
factor
STROKE

Blood supply to areas of the brain is

interrupted, causing ischemia

Goal of treatment: early recognition

and rapid, appropriate intervention
 PATHOPHYSIOLOGY OF STROKE
Neurologic conditions can have a vascular origin.
Typically result of emboli or aneurysms
 PATHOPHYSIOLOGY OF STROKE
Aneurysm development
process
PATHOPHYSIOLOGY OF STROKE

• A blood vessel becomes

blocked, causing tissue
beyond it to become
ischemic.
Ischemic • The severity is dictated
stroke by:
• Artery involved
• Portion of the brain
being denied oxygen
PATHOPHYSIOLOGY OF STROKE

• Tend to get worse over time

• Bleeding causes increased
ICP and brainstem
Hemorrhagic herniation.
stroke
• Primary symptom: “worst
headache of my life”
 CPP = MAP – ICP
PATHOPHYSIOLOGY OF STROKE

High ICP

Cerebral
The brain may perfusion
become ischemic pressure (CPP)
begins to fall.
PATHOPHYSIOLOGY OF STROKE
 PATHOPHYSIOLOGY OF STROKE

When ICP climbs and

remains high
Herniation may occur.
• Shift or displacement of intracranial contents
• Brainstem will eventually become compressed.
• Patient will lose control of his/her functions.
ASSESSMENT OF STROKE
Language effects Movement effects
 Slurred speech  Hemiparesis
 Aphasia  Hemiplegia
 Arm drifting
 Facial droop
 Tongue deviation
 Swallowing difficulties
 Ptosis
 Ataxia
ASSESSMENT OF STROKE
Cognitive effects
Sensory effects  Decreased LOC
 Headache (hemorrhagic)  Difficulty thinking
 Sudden blindness  Seizures
 Sudden unilateral paresthesia  Coma

Cardiac effects
 Hypertension
MANAGEMENT OF STROKE
Administer fluids as needed.

Elevate the patient’s head 30°.

Ensure airway is clear.

Watch for seizures.

Monitor blood pressure closely.

MANAGEMENT OF STROKE

High oxygen level constricts arteries.

Lower level of carbon dioxide lowers ICP.

MANAGEMENT OF STROKE

EMS providers need to be involved in

educating the community about strokes.

All levels should recognize stroke.

• Use a standard stroke assessment tool.
MANAGEMENT OF STROKE
MANAGEMENT OF STROKE
Transport decisions
 Transport to stroke centers.
 If you suspect hemorrhagic stroke, consider a facility that can perform neurosurgery.
 Call ahead to ensure rapid evaluation.
28 october
TRANSIENT ISCHEMIC ATTACKS

Pathophysiology
• Episodes of cerebral ischemia without
permanent damage
• Presentations will resolve within 24 hours.
• May be a sign of a vascular problem
TRANSIENT ISCHEMIC ATTACKS

Many TIAs resolve completely within 1 hour—

which can mean you are dispatched for stroke,
but arrive to find a patient who appears
perfectly normal. 1

About one-third of patients with TIAs will have an

acute stroke sometime in the future
TRANSIENT ISCHEMIC ATTACKS
Assessment
 Same as assessment for stroke

Management
 Follow the stroke management guidelines.
 Encourage the patient to be transported and to talk with his/her physician.
COMA
COMA

• History of present illness is

vital to determine the
Pathophysiology underlying cause
(cont’d) • Determine when the patient
was last seen normal.
• Evaluate the speed of onset.
COMA
Assessment  Speech effects
 Cognitive effects  Movement effects
 Decreasing LOC  CNS effects
 Confusion  Total unresponsiveness
 Hallucinations
 Psychosis
 Difficulty thinking
 Sleepiness
COMA
Management
 Support vital functions.
 Gather information about the
cause.
 Administer naloxone if you
suspect narcotic overdose.
 Patients may need:
 Urine and blood analysis
 Radiography
 Computed tomography
 Magnetic resonance imaging
SEIZURES

Pathophysiology
• Sudden erratic firing of neurons
• Signs and symptoms include:
• Muscle spasms
• Increased secretions
• Cyanosis
SEIZURES

Pathophysiology (cont’d)
• If a seizure continues for a long time:
• Cerebral glucose and oxygen supplies can be
depleted.
• There can be serious, long-term effects,
including death.
 SEIZURES

• Medication
Try to compliance
determine • Fever
the cause
of the • Low blood
seizure. glucose level in
diabetics
SEIZURES
Assessment of generalized seizures
 Tonic/clonic steps:
 Aura
 Loss of consciousness
 Tonic phase
 Hypertonic phase
 Clonic phase
 Postseizure
 Postictal
SEIZURES
Assessment of generalized seizures (cont’d)
 Absence seizures (petit mal seizures)
 Typical patient: child
 Patient stops and freezes mid-action.
 Usually no longer than several seconds
SEIZURES
Assessment of generalized seizures
 Pseudoseizures
 Cause is of psychiatric origin
 Triggered by emotional event, stress, lights, or pain
 Motion is relatively organized.
SEIZURES
Assessment of partial seizures
 Only a limited part of the brain is involved.
 Simple partial seizures involve either:
 Movement of one part of the body (frontal lobe)
 Sensations in one part of the body (parietal lobe)
SEIZURES MANAGEMENT

Determine Do not restrain

Remain calm. whether trauma is the patient.
a concern.

Prevent the Do not place

patient from anything in the
becoming injured. patient’s mouth.
SEIZURES MANAGEMENT

Correct Ventilatory
hypoglycemia as assistance may
needed. be necessary.

Provide All patients

emotional should be
support. transported.
STATUS EPILEPTICUS
• Seizure that lasts longer
than 4 to 5 minutes or
consecutive seizures
• May result in neurons
being damaged or
killed
• Goal: stop seizure and
ensure adequate ABCs.

Pathophysiology
STATUS EPILEPTICUS
Assessment
 Same as for a seizure

Management
 Administer a benzodiazepine.
 Be prepared to control airway and ventilation.
 Paralytics may be needed.
SYNCOPE
Pathophysiology
 Sudden and temporary loss of
consciousness with loss of postural tone
 A short interruption in blood flow
causes loss of consciousness.
SYNCOPE
Assessment
 Patient is often in a standing position.
 Vasovagal syncope typical in younger adults
 Cardiac dysrhythmia is a typical cause in older
adults.
SYNCOPE
Assessment (cont’d)
 Prodromal signs and symptoms may include:
 Dizziness
 Chest pain
 Loss of vision
 Incontinence is possible.
SYNCOPE
Management
 Determine if trauma has occurred.
 Focus on blood pressure and cardiac causes.
 Evaluate blood glucose and oxygen saturation.
 Obtain orthostatic vital signs.
 Provide emotional support and transport.
HEADACHE
Pathophysiology and assessment of muscle tension headaches
 Stress causes residual muscle contractions.
 Pain is generally felt on both sides of the head.
 Usually a dull ache or a squeezing pain
HEADACHE
Pathophysiology and assessment of migraine headaches
 Caused by changes in the size of blood vessels at the base of the brain
 Patient may report an aura.
 Pain is generally unilateral and focused.
HEADACHE
Pathophysiology and assessment of cluster headaches
 Begins as minor pain around one eye
 Intensifies and spreads to one side of the face.
 Occur in groups and last 30–45 minutes each
HEADACHE
Pathophysiology and assessment of sinus headaches
 Inflammation/infection within sinus cavities
 Pain is located in superior portions of the face.
 May be accompanied by postnasal drip, sore throat, and nasal discharge
HEADACHE
Management
 Treat for stroke if other signs are
present.
 Ask what medications patient has
taken.
HEADACHE
Management (cont’d)
 Medication for pain management:  For nausea and vomiting, consider:
 Ketorolac tromethamine  Promethazine
 Meperidine  Ondansetron
 Morphine
DEMENTIA
Pathophysiology
 Chronic deterioration of:
 Memory
 Personality
 Language skills
 Perception, reasoning, or judgment
 Changes occur over weeks to years.
DEMENTIA
Pathophysiology (cont’d)
 Causes vary.
 Wernicke encephalopathy is caused by vitamin B1 deficiency
 Alzheimer’s disease is a progressive condition in which neurons die.
DEMENTIA
Assessment
 Obvious that it is not simple memory loss
 Patients may become aggressive or violent.
 Confusion is the hallmark sign.
DEMENTIA
DEMENTIA
Management
 Ensure that no reversible cause is present.
 Check:
 Blood glucose level
 Oxygen level
 Blood chemistry
DEMENTIA
Management (cont’d)
 Wernicke encephalopathy
 Administer thiamine before glucose is given.
 Perform ECG monitoring.
 Obtain blood chemistries.
NEOPLASMS
Pathophysiology
 Growths within the body that are caused by errors that occur during cellular reproduction
 Mitosis: cellular reproduction
 A parent cell divides into two daughter cells.

© Jones & Bartlett Learning

NEOPLASMS
Pathophysiology (cont’d)
 Daughter cells are copies of the parent cell.
 Ensures continued functioning of vital structures
 If a severe error occurs, the cell will have too much damaged DNA to survive.
 If a subtle error occurs, the cell may survive.
NEOPLASMS
Pathophysiology (cont’d)
 Benign neoplasms
 Not cancerous
 Malignant neoplasms
 Take over blood supplies.
 Move to other sites.
 Primary neoplasms
 Cancers that arise within the
nervous system
 Metastatic neoplasms
 Cancers that spread to the
nervous system
NEOPLASMS
Assessment
 Signs and symptoms of brain  Signs and symptoms of spinal
tumors: tumors:
 Headache  Back pain
 Vomiting  Weakness
 Seizures  Loss of limb sensation
 Stroke-like symptoms  Incontinence
NEOPLASMS
Management
 Watch for status epilepticus.
 Administer diazepam if needed.
 Protect limbs from injury.
MULTIPLE SCLEROSIS
Pathophysiology
 Autoimmune condition in which the body attacks the myelin of the brain and spinal cord
 Results in demyelination
 The body begins to attack its own cells.
MULTIPLE SCLEROSIS
Assessment
 Follows a pattern of attacks and remissions
 Common complaints of initial attack include:
 Double vision
 Blurred vision
 Nystagmus
MULTIPLE SCLEROSIS
Assessment (cont’d)
 Other signs may include:
 Muscle weakness
 Speech disturbances
 Vertigo
 Euphoria
 Electrical sensations
MULTIPLE SCLEROSIS
Management
 Prehospital management is supportive.
 Be prepared for trauma related to a fall.
 In-hospital treatment is aimed at controlling the symptoms.
GUILLAIN-BARRÉ SYNDROME
Pathophysiology
 Disease in which the immune system attacks portions of the nervous system
 May report previous respiratory or GI infection
 Some patients recover completely; others require assistance for the rest of their lives.
GUILLAIN-BARRÉ SYNDROME
Assessment
 Begins as weakness in the legs
 Moves up the legs and affects the thorax and arms.
 Can lead to paralysis
 Patients are prone to severe swings in pulse rate and blood pressure.
GUILLAIN-BARRÉ SYNDROME
Management
 Assess ability to protect the airway.
 Monitor closely with ECG.
 Repeat vital signs.
 Obtain continuous end tidal CO2 readings.
 Be prepared to administer IV fluids.
 Provide comfort.
AMYOTROPHIC LATERAL SCLEROSIS
Strikes the voluntary motor neurons
Cause is unclear
Most common in middle-aged men
AMYOTROPHIC LATERAL SCLEROSIS
Assessment
 Initially subtle and progresses without notice
 Signs and symptoms include:
 Fatigue
 General weakness of muscle groups
 Difficulty doing routine activities
AMYOTROPHIC LATERAL SCLEROSIS
Management
 Monitor the airway.
 Transportation may become complicated.
 In-hospital care includes:
 Physical therapy
 Medication to mitigate certain symptoms
PARKINSON’S DISEASE
Pathophysiology
 Neurologic condition in which past injuries to the brain can have an influence
 The substantia nigra is damaged.
PARKINSON’S DISEASE
Assessment
 Onset is gradual (months to years)
 Classic presentation involves:
 Tremor
 Postural instability
 Rigidity
 Bradykinesia
PARKINSON’S DISEASE
Management
 Prehospital management is supportive.
 Treat any injuries.
 In-hospital treatment includes levodopa.
CRANIAL NERVE DISORDERS
Pathophysiology
 May mimic other conditions
CRANIAL NERVE DISORDERS
Assessment
 Test for vertigo.
 Have patient lie supine.
 Move the head rapidly from side to side.
 Look at patient’s eyes.
 If patient has vertigo, nystagmus will be seen.
CRANIAL NERVE DISORDERS
Management
 For nausea and vomiting, patient may need:
 Promethazine
 Ondansetron
DYSTONIA
Pathophysiology
 Severe, muscle spasms that cause
bizarre contortions, repetitive motions,
or postures
 Occur for unknown reason

© Dr. P. Marazzi/Photo Researchers, Inc.

DYSTONIA
Assessment
 Spasms are involuntary and often painful

Management
 Focus on ruling out other problems.
 Pain management may be appropriate.
 Be calm and reassuring.
CNS INFECTIONS/INFLAMMATION
Pathophysiology
 Encephalitis: inflammation of the brain
 Meningitis: inflammation of the meninges
 Damage is caused by:
 Body’s reaction to the infection, or
 Activities of the attacking organisms
CNS INFECTIONS/INFLAMMATION
Pathophysiology (cont’d)
 If temperature becomes too high, a person may:
 Hallucinate
 Become delusional
 Lose consciousness
 Have a febrile seizure
CNS INFECTIONS/INFLAMMATION
Pathophysiology (cont’d)
 Proteins that damage cells
 Endotoxins: released by gram-negative bacteria
 Exotoxins: secreted by some bacteria or fungi
 Virus attacks the axons.
CNS INFECTIONS/INFLAMMATION
Assessment

© Jones & Bartlett Learning

 Both illnesses begin with flulike
symptoms.
 Meningitis may elicit:
 Kernig’s sign
 Brudzinski’s sign

© Jones & Bartlett Learning

CNS INFECTIONS/INFLAMMATION
Management
 If meningitis is suspected:
 Place a mask over the patient’s mouth.
 Wear a mask if the patient is coughing.
 Be prepared for seizures.
CNS INFECTIONS/INFLAMMATION
Management (cont’d)
 Paramedic may need antibiotic treatment.
 Hospital treatment includes:
 Decreasing swelling in the brain and spinal cord
 Fighting the infection
 Supporting the patient’s vital signs
ABSCESSES
Pathophysiology
 Caused by an infectious agent within the brain or spinal cord
 Often preceded by an infection of the sinuses, throat, gums, or ear
ABSCESSES
Assessment
 Signs and symptoms may include:
 Low- or high-grade fever
 Generalized or focal seizures
 Nausea and vomiting
 Focal motor or sensory impairments
ABSCESSES
Management
 Pay attention for increased ICP.
 Take seizure precautions.
 Evaluate temperature.
POLIOMYELITIS AND POSTPOLIO SYNDROME
Pathophysiology Assessment
 Viral infection transmitted by fecal-oral route  Severe cases:
 Most patients do not become ill.  Sore throat
 Nausea, vomiting, diarrhea
 Stiff neck
 Muscle weakness/ paralysis
POLIOMYELITIS AND POSTPOLIO SYNDROME
Management
 In-hospital care is directed at:
 Hydration
 Ventilation
 Calorie support
POLIOMYELITIS AND POSTPOLIO SYNDROME
Management (cont’d)
 Prehospital treatment: managing the airway
 In-hospital treatment for postpolio includes:
 Physical therapy
 Experimental medications
PERIPHERAL NEUROPATHY
Pathophysiology
 Nerves leaving the spinal cord are damaged.
 Causes may include:
 Trauma
 Toxins
 Autoimmune attacks
PERIPHERAL NEUROPATHY
Assessment
 Signs and symptoms may include:
 Sensory or motor impairment
 Numbness
 Pain
 Muscle weakness
PERIPHERAL NEUROPATHY
Management
 Supportive in the prehospital setting
 In-hospital management includes:
 Pain medication
HYDROCEPHALUS
Pathophysiology
 Result of an error in the manufacture, movement, or absorption of cerebrospinal fluid
 Two main types:
 Normal pressure
 Increased pressure
HYDROCEPHALUS
Assessment (cont’d)
 Infant may have:
 Increased head circumference
 Sun-setting eyes
 Tense or bulging fontanelles
 Seizures

© M. Ansary/Custom Medical Stock Photo

HYDROCEPHALUS
Assessment (cont’d)
 Older children and adults may have:
 Headache
 Projectile vomiting
 Poor coordination
 Memory and personality impairments
HYDROCEPHALUS
Management
 A shunt is placed in most patients.
 Complications of shunts include:
 Inappropriate drainage of CSF
 Infection at the site
 Length of the tube may become too short.
HYDROCEPHALUS
Management (cont’d)
 Be prepared for seizures and increased ICP.
 Use of feeding tubes and ventilators is common.
 Do not manipulate the VP shunt.
SPINA BIFIDA
Pathophysiology
 Neural tube fails to close fully as embryo develops
 Part of the nervous system remains outside the body.
SPINA BIFIDA

© Jones & Bartlett Learning

SPINA BIFIDA
Pathophysiology (cont’d)
 If an infection or chemical agent gains access, areas of the brain can be damaged.
 A decrease in oxygen can damage the brain.
SPINA BIFIDA
Assessment
 Range of complications
 None to complete loss of motor and sensory functions
 Hydrocephalus is common in children.
SPINA BIFIDA
Management
 The patient may be in need of multiple types of medical technology.
 In-hospital management is supportive.
 Multivitamins are standard during pregnancy.
CEREBRAL PALSY
Pathophysiology
 A developmental condition in which damage is done to the brain
 Definite cause is unclear.
 Will not get worse over time
CEREBRAL PALSY
Assessment
 Presentation begins as an infant.
 May involve:
 Walk with a scissors-like gait
 Slow, uncontrolled writhing movements
 Tremor
 Coordination difficulties
CEREBRAL PALSY
Management
 Prehospital management is supportive.
 In-hospital management is symptom based.
SUMMARY
Neurologic problems can be dangerous.
The central nervous system has two major structures: the brain and the spinal cord.
The peripheral nervous system consists of the somatic nervous system and the
autonomic nervous system.
Each portion of the brain is responsible for specific functions.
SUMMARY
Nerve cells (neurons) transmit signals along their axons and across synapses by means
of chemical neurotransmitters.
A variety of disease processes can cause neurologic dysfunction.
Intracranial pressure is determined by the volume of the intracranial contents.
The primary dangers of increased intracranial pressure are ischemia and brain
herniation.
SUMMARY
Investigating the neurologic patient’s chief complaint requires taking a history to
determine the mechanism of injury or nature of illness.
It is critical to determine when the patient was last seen normal because the amount
of time elapsed since the onset of symptoms will dictate the treatments available.
SUMMARY
Level of consciousness can be evaluated using:
 Glasgow Coma Scale and AVPU
 A test of corneal reflex or papillary response
 Evaluation of cranial nerve functioning
 Assessment of the patient’s orientation and alertness
 Assessment of the patient’s speech
 Evaluation of the patient’s movement
 Testing of the patient’s sensory perceptual abilities
 Testing of the blood glucose level
 Measurement of vital signs
SUMMARY
Following a set of standard care guidelines can help you address common neurologic
problems in a systematic way.
Stroke is a condition in which the blood supply to the brain is interrupted.
Stroke causes sudden-onset changes in neurologic status.
Time is brain.
SUMMARY
Transient ischemic attacks are episodes of cerebral ischemia that resolve within 24
hours, leaving no permanent damage.
A diminished level of consciousness is marked by increasing deficits in cognition and
speech and changes in movement and posture.
Seizures are caused by the sudden, erratic firing of neurons.
Seizures have a wide range of causes.
SUMMARY
Seizures are classified as either generalized or partial.
Generalized seizures are divided into tonic/clonic seizures, absence seizures, and
pseudoseizure.
Simple partial seizures involve either movement or sensations in one part of the body.
Complex partial seizures subtly diminish the level of consciousness.
SUMMARY
Status epilepticus is a seizure that lasts longer than 4 to 5 minutes or
consecutive seizures without consciousness returning between seizures.
Syncope is caused by a brief interruption in cerebral blood flow that
can be traced to cardiac rhythm disturbances, other cardiac causes, or
noncardiac causes.
Headaches can be classified as muscle tension, migraine, cluster, or sinus
headaches.
SUMMARY
Dementia is characterized by deterioration of memory, personality, language skills,
perception, reasoning, or judgment, with no loss of consciousness.
Tumors of the neurologic system affect the brain and spinal cord.
Demyelinating conditions attack the insulating sheath that surrounds and protects the
axon, so that nerve impulses can no longer travel smoothly.
SUMMARY
Multiple sclerosis is an autoimmune condition in which episodic attacks are followed
by periods of remission.
Amyotrophic lateral sclerosis (Lou Gehrig’s disease) is a disease that strikes the
voluntary motor neurons.
Parkinson’s disease damages the substantia nigra, the portion of the brain that
produces dopamine, which is needed for muscle contraction.
SUMMARY
Cranial nerve disorders have a range of signs and symptoms.
Dystonias are severe, abnormal muscle spasms that cause bizarre
contortions, repetitive motions, or postures.
Encephalitis and meningitis are central nervous system infections that
cause inflammation of the brain and meninges, respectively.
Abscesses indicate the presence of an infectious agent within the brain
or spinal cord.
SUMMARY
Polio is a viral infection that can cause long-term damage to the brain and brainstem,
leading to muscle weakness and paralysis.
Peripheral neuropathy is a group of conditions in which the nerves leaving the spinal
cord are damaged by trauma, toxins, tumors, autoimmune attack, and metabolic
disorders, or other processes.
SUMMARY
Normal-pressure hydrocephalus is a rare condition that occurs in older adults for
unknown reasons.
Cerebral palsy is a developmental condition characterized by damage to the frontal
lobe of the brain. Its cause is unclear.
CREDITS

Chapter opener: © Mark C. Ide

Backgrounds: Gold—Jones & Bartlett Learning. Courtesy of MIEMSS; Blue—
Courtesy of Rhonda Beck; Green—Courtesy of Rhonda Beck; Purple—
Courtesy of Rhonda Beck.
Unless otherwise indicated, all photographs and illustrations are under copyright
of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency
Medical Services Systems, or have been provided by the American Academy of
Orthopaedic Surgeons.