chapter 14: focused history and physical exam of the neuro

Principles of Patient Principles of Patient Assessment in EMS Assessment in EMS

By:By:Bob Elling, MPA, EMT-PBob Elling, MPA, EMT-P

&&Kirsten Elling, BS, EMT-PKirsten Elling, BS, EMT-P

Chapter 14 – Focused History Chapter 14 – Focused History & Physical Exam of the & Physical Exam of the

Patient with a Neurological Patient with a Neurological Problem Problem

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

ObjectivesObjectives

List the most common neurological List the most common neurological emergencies EMS providers emergencies EMS providers encounter.encounter.

Describe why the duration of Describe why the duration of symptoms is helpful in making a field symptoms is helpful in making a field impression of a neurological event.impression of a neurological event.

List some of the reasons why getting List some of the reasons why getting a focused history may be difficult in a a focused history may be difficult in a patient with a neurological problem.patient with a neurological problem.


Objectives Objectives (continued)(continued)

Give examples of clues the EMS Give examples of clues the EMS provider should look for in the provider should look for in the SAMPLE history of a patient with a SAMPLE history of a patient with a neurological problem.neurological problem.

List the six components of the List the six components of the neurological examination.neurological examination.

Describe the functions of the twelve Describe the functions of the twelve pairs of cranial nerves.pairs of cranial nerves.

Describe how to assess the cranial Describe how to assess the cranial nerves.nerves.


Objectives Objectives (continued)(continued)

Describe two ways to assess a patient’s Describe two ways to assess a patient’s coordination.coordination.

List the diagnostic tools that are useful in List the diagnostic tools that are useful in performing a neurological examination.performing a neurological examination.

Describe the two prehospital ministroke Describe the two prehospital ministroke tests developed to help in the tests developed to help in the assessment of a suspected stroke assessment of a suspected stroke patient.patient.

Explain how the mnemonic AEIOU-TIPS is Explain how the mnemonic AEIOU-TIPS is used in the assessment of the patient used in the assessment of the patient with AMS.with AMS.


Describe the three types of seizures.Describe the three types of seizures. List the two most common causes of List the two most common causes of

headache.headache. Describe the four general categories Describe the four general categories

of head injury.of head injury. Describe the three phases of brain Describe the three phases of brain

herniation syndrome.herniation syndrome.

Objectives (continued)Objectives (continued)


IntroductionIntroduction The nervous system is the most The nervous system is the most

complex of all body systems.complex of all body systems. The components of the nervous The components of the nervous

system can be easily assessed and system can be easily assessed and tested to form a reasonable field tested to form a reasonable field impression.impression.

The most common neurological The most common neurological emergencies include: stroke, AMS, emergencies include: stroke, AMS, seizure, headache, and traumatic seizure, headache, and traumatic brain injury.brain injury.


The Neurological PatientThe Neurological Patient Duration of onset is a helpful feature Duration of onset is a helpful feature

in making a field impressionin making a field impression Vascular pathologies tend to be Vascular pathologies tend to be

acute in onset (i.e. seconds to acute in onset (i.e. seconds to minutes)minutes) Some vascular causes may provide Some vascular causes may provide

a warning sign, such as a TIA, prior a warning sign, such as a TIA, prior to a CVAto a CVA


Changes occurring over 2 to 3 days Changes occurring over 2 to 3 days may be caused by dehydration, CNS may be caused by dehydration, CNS infection, subdural hematoma, infection, subdural hematoma, medications, or other toxic metabolic medications, or other toxic metabolic conditions.conditions.

Degenerative or chronic neurologic Degenerative or chronic neurologic diseases progressively worsen over diseases progressively worsen over weeks to years.weeks to years.

The Neurological PatientThe Neurological Patient


The Focused HistoryThe Focused History Obtaining the FH of a patient Obtaining the FH of a patient

experiencing a neurological experiencing a neurological emergency can be challenging.emergency can be challenging.

The patient may have difficulty The patient may have difficulty communicating.communicating. Unable to form words, speak clearly or Unable to form words, speak clearly or

say what he or she is thinkingsay what he or she is thinking Whenever possible verify information Whenever possible verify information

with family, caretakers, coworkers or with family, caretakers, coworkers or MDs.MDs.


OPQRST HistoryOPQRST History O – What were the circumstances when O – What were the circumstances when

this event began?this event began? P – Is there anything making the condition P – Is there anything making the condition

worse or better?worse or better? Q – What is the quality of neurologic Q – What is the quality of neurologic

symptoms (i.e. severe headache, or acute symptoms (i.e. severe headache, or acute parathesia)?parathesia)?

R – Is there any progression of symptoms. R – Is there any progression of symptoms. Have you attempted anything to improve Have you attempted anything to improve the condition?the condition?

S – Is this similar to prior episodes? Rate S – Is this similar to prior episodes? Rate on the scale of 1-10.on the scale of 1-10.

T – How long has this event been going on?T – How long has this event been going on?© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

SAMPLE HistorySAMPLE History S – Consider the associated symptoms S – Consider the associated symptoms

with a neurologic complaint:with a neurologic complaint: HeadacheHeadache Memory lossMemory loss ConfusionConfusion Motor disturbanceMotor disturbance Neck or back painNeck or back pain ParalysisParalysis ParathesiaParathesia ParesisParesis Speech disturbancesSpeech disturbances WeaknessWeakness Loss of bladder or bowel controlLoss of bladder or bowel control


SAMPLE History SAMPLE History (continued)(continued) A – Any allergies to medications?A – Any allergies to medications? M – What changes have there been to the M – What changes have there been to the

patient’s medication schedule recently?patient’s medication schedule recently? P – Any history of a condition that could P – Any history of a condition that could

cause a neurologic condition (i.e. cause a neurologic condition (i.e. hypertension)?hypertension)?

L – What was the last oral intake?L – What was the last oral intake? E – What may have precipitated the E – What may have precipitated the

incident (i.e. medication non-incident (i.e. medication non-compliance)?compliance)?


Causes of AMS Causes of AMS (AEIOU-TIPS)(AEIOU-TIPS) AlcoholAlcohol EpilepsyEpilepsy InfectionInfection OverdoseOverdose UremiaUremia TraumaTrauma InsulinInsulin PsychosisPsychosis StrokeStroke© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Physical ExamPhysical Exam The neurological exam evaluates 6 The neurological exam evaluates 6

components:components: Mental status (MS)Mental status (MS) Cranial nervesCranial nerves Motor responseMotor response Sensory responseSensory response CoordinationCoordination ReflexesReflexes


Assessing for symmetry is a key Assessing for symmetry is a key objective:objective: Asymmetry is abnormal till proven Asymmetry is abnormal till proven

otherwiseotherwise In some people asymmetry is normal. In some people asymmetry is normal.

Always ask “Is this normal for you?”Always ask “Is this normal for you?”

Physical ExamPhysical Exam


Mental StatusMental Status A reliable indicator of nervous A reliable indicator of nervous

system dysfunction is the finding of system dysfunction is the finding of subtle changes.subtle changes.

In the IA use AVPU for the mini-In the IA use AVPU for the mini-neurological exam followed by the neurological exam followed by the GCS.GCS.

AVPU is quick and easy to perform AVPU is quick and easy to perform and provides a gross estimation of and provides a gross estimation of the neurological status.the neurological status.


Mental Status Mental Status (continued)(continued) GCS is easy to perform and provides GCS is easy to perform and provides

a more quantitative measure of a more quantitative measure of dysfunction.dysfunction.

There is a pediatric version of the There is a pediatric version of the GCS (the modified coma score for GCS (the modified coma score for infants).infants).

Evaluation of MS includes the Evaluation of MS includes the patient’s affect, behavior, cognition patient’s affect, behavior, cognition and memory.and memory.


Recall, short, and long term memory Recall, short, and long term memory are tested by asking questions such are tested by asking questions such as:as: Recall – instruct the patient to remember Recall – instruct the patient to remember

the name of an object and then ask the the name of an object and then ask the name of the object at 5 minute intervals.name of the object at 5 minute intervals.

Short – What day of the week is it? When Short – What day of the week is it? When did you eat last?did you eat last?

Long – What is your date of birth? Social Long – What is your date of birth? Social security number? Address?security number? Address?

Mental Status (continued)Mental Status (continued)


Cranial Nerves: Pupils Cranial Nerves: Pupils Normally equally round and 3-5 mm in Normally equally round and 3-5 mm in

size. A difference of > 1 mm is abnormal.size. A difference of > 1 mm is abnormal. Aniscoria means unequal pupils and may Aniscoria means unequal pupils and may

indicate a CNS disease or traumatic indicate a CNS disease or traumatic injury.injury.

Pupils should constrict to light sources.Pupils should constrict to light sources. Light in one pupil should constrict both Light in one pupil should constrict both

(consensual light reflex CN-3).(consensual light reflex CN-3). Assess visual acuity by asking the patient Assess visual acuity by asking the patient

to read your name tag.to read your name tag.


Cranial Nerves: Pupils Cranial Nerves: Pupils (continued)(continued)

Accomodation is the ability of the Accomodation is the ability of the eyes to focus on various distances.eyes to focus on various distances. Normally the eyes move apart (diverge) Normally the eyes move apart (diverge)

to a parallel position (conjugate gaze) as to a parallel position (conjugate gaze) as they focus on a distant object. As an they focus on a distant object. As an object comes closer to the face the eyes object comes closer to the face the eyes should converge and pupils constrict.should converge and pupils constrict.

Ask the patient to focus on a distant Ask the patient to focus on a distant object and then on your finger in front of object and then on your finger in front of their face (CNS 2 & 3).their face (CNS 2 & 3).

Assess the field of vision by checking Assess the field of vision by checking the patient’s peripheral vision (CN 2).the patient’s peripheral vision (CN 2).



Assess EOMs to measure brainstem Assess EOMs to measure brainstem integrity (pons and midbrain).integrity (pons and midbrain). Assess the 6 cardinal positions of gaze.Assess the 6 cardinal positions of gaze. The inability to move one or both eyes The inability to move one or both eyes

indicates a neurological deficit (CN 3, 4, indicates a neurological deficit (CN 3, 4, 6).6).

Paralysis of a lateral gaze is an early Paralysis of a lateral gaze is an early sign of rising ICPsign of rising ICP

Paralysis of the upward gaze may Paralysis of the upward gaze may indicate an orbit fracture.indicate an orbit fracture.


Nystagmus is a fine motor twitching Nystagmus is a fine motor twitching of eyeball during extreme lateral of eyeball during extreme lateral gaze. It is normal but in other gaze. It is normal but in other positions it may be due to ETOH, MS, positions it may be due to ETOH, MS, inner ear problem or brain lesion.inner ear problem or brain lesion.



Cranial Nerves: Pupils/Face Cranial Nerves: Pupils/Face (continued)(continued)

PERRLA – pupils equally round, PERRLA – pupils equally round, reactive to light and accomodating.reactive to light and accomodating.

Assess facial movement/sensation by Assess facial movement/sensation by asking the patient to smile, show asking the patient to smile, show their teeth, frown and raise the their teeth, frown and raise the brows. Touch the forehead, cheeks brows. Touch the forehead, cheeks and chin.and chin. Unilateral drooping is abnormal and Unilateral drooping is abnormal and

associated with paralysis as in a CVA associated with paralysis as in a CVA (CN 7).(CN 7).


Cranial Nerves: Face Cranial Nerves: Face

Assess the palate by asking the Assess the palate by asking the patient to say “aah,” the soft palate patient to say “aah,” the soft palate should rise in the middle and the uvula should rise in the middle and the uvula midline (CN 10).midline (CN 10).

Ask the patient to stick out the tongue. Ask the patient to stick out the tongue. Midline position is normal (CN 12). Midline position is normal (CN 12).

Assess for an intact gag reflex (CN 9 Assess for an intact gag reflex (CN 9 and 10).and 10).


Cranial Nerves: Face Cranial Nerves: Face (continued)(continued)

Note any abnormal speech (i.e. Note any abnormal speech (i.e. aphasia, dsyphasia, dysarthria) or aphasia, dsyphasia, dysarthria) or difficulty swallowing (dysphagia), difficulty swallowing (dysphagia), chewing or drooling.chewing or drooling.

Assess CN 5 by asking the patient to Assess CN 5 by asking the patient to move the jaw from side-to-side while move the jaw from side-to-side while you place resistance with your you place resistance with your hands.hands.


A sudden hearing loss is a significant A sudden hearing loss is a significant finding involving CN 8.finding involving CN 8.

Assess CN 6 by testing strength any Assess CN 6 by testing strength any symmetry of shoulder shrug.symmetry of shoulder shrug.

Cranial Nerves: Face Cranial Nerves: Face (continued)(continued)


Motor ResponseMotor Response Assess equality of muscle strength, Assess equality of muscle strength,

tone, and symmetry in both upper tone, and symmetry in both upper and lower extremities.and lower extremities.

When pain or injury are present do When pain or injury are present do not test the affected extremity.not test the affected extremity.

Test upper extremities for grip Test upper extremities for grip strength and pronator drift.strength and pronator drift.


Test lower extremities by asking Test lower extremities by asking patient to push and pull their feet patient to push and pull their feet against resistance.against resistance.

Note any unilateral weakness.Note any unilateral weakness. When appropriate have the patient When appropriate have the patient

take a few steps to assess balance take a few steps to assess balance and gait.and gait.

Motor ResponseMotor Response


Sensory ResponseSensory Response This component of the neurological This component of the neurological

exam is useful in a patient who is exam is useful in a patient who is conscious or has a suspected spinal conscious or has a suspected spinal cord injury (SCI).cord injury (SCI).

Dermatomes are the areas on the Dermatomes are the areas on the surface of the body that are surface of the body that are innervated by affected nerve fibers innervated by affected nerve fibers from one spinal route.from one spinal route.

Assessing dermatomes is helpful to Assessing dermatomes is helpful to estimate a rough correlation to the estimate a rough correlation to the level of spine injury.level of spine injury.


Sensory Response Sensory Response (continued)(continued) For a patient with suspected SCI, For a patient with suspected SCI,

with loss of sensation or paralysis, with loss of sensation or paralysis, begin at the head and work down to begin at the head and work down to find the line of demarcation for loss find the line of demarcation for loss of sensation.of sensation.

For a non-SCI patient assess for For a non-SCI patient assess for destination between sharp and dull destination between sharp and dull touch on the skin of the face and touch on the skin of the face and extremities.extremities.


Ask the patient to close the eyes Ask the patient to close the eyes while you alternate between sharp while you alternate between sharp and dull touch.and dull touch.

In the unconscious patient assess for In the unconscious patient assess for deep pain response.deep pain response.

Sensory Response Sensory Response (continued)(continued)


Coordination and ReflexesCoordination and Reflexes Cerebellar function is concerned with Cerebellar function is concerned with

the control of muscular contractions the control of muscular contractions of the extremities.of the extremities.

Assess function by testing a patient’s Assess function by testing a patient’s balance, fine motor movements, and balance, fine motor movements, and coordination.coordination.

When appropriate observe a When appropriate observe a patient’s gait.patient’s gait.


Coordination and Reflexes Coordination and Reflexes (continued)(continued)

Examples of abnormal gait:Examples of abnormal gait: Ataxia – wobbly and unsteadyAtaxia – wobbly and unsteady Festination – uneven & hurried Festination – uneven & hurried

(Parkinsons)(Parkinsons) Spastic hemiparesis – unilateral Spastic hemiparesis – unilateral

weakness and foot draggingweakness and foot dragging Steppage – steps appear to be walking Steppage – steps appear to be walking

up stairs while on even surfaceup stairs while on even surface



Assess fine movements by asking the Assess fine movements by asking the patient to touch the nose with a patient to touch the nose with a finger while the eyes are closed.finger while the eyes are closed.

Assess reflexes on patients who are Assess reflexes on patients who are unconscious, unresponsive, or with a unconscious, unresponsive, or with a possible SCI.possible SCI.


The level of reflex response from The level of reflex response from good to bad:good to bad: Purposeful withdrawal from painPurposeful withdrawal from pain Absent gag reflexAbsent gag reflex Flexion (decorticate posturing)Flexion (decorticate posturing) Extension (decerebrate posturing)Extension (decerebrate posturing) No responseNo response




Assess motor response in the lower Assess motor response in the lower extremities by testing the plantar extremities by testing the plantar (Babinski) reflex:(Babinski) reflex: Using a capped pen draw a light stroke Using a capped pen draw a light stroke

up the lateral side of the sole of the foot up the lateral side of the sole of the foot and across the ball.and across the ball.

The normal response is plantar flexion of The normal response is plantar flexion of the toes and foot.the toes and foot.

The abnormal response is dorsi-flexion The abnormal response is dorsi-flexion of the big toe and fanning of all the toes.of the big toe and fanning of all the toes.

In children (<18 months) a positive In children (<18 months) a positive Babinski is normal.Babinski is normal.


Diagnostic Tools Diagnostic Tools The use of diagnostic tools in the The use of diagnostic tools in the

neurological exam includes:neurological exam includes: Glucometer or dexistripsGlucometer or dexistrips ThermometerThermometer ECG monitorECG monitor SpO-2SpO-2 EtCO-2EtCO-2


Neurologic Emergencies Neurologic Emergencies Cerebrovascular Accident (CVA)Cerebrovascular Accident (CVA)

CVA is an acute loss of blood flow to the CVA is an acute loss of blood flow to the brain. brain.

Transient ischemic attack (TIA) is an acute Transient ischemic attack (TIA) is an acute temporary loss of blood flow to the brain.temporary loss of blood flow to the brain.

AHA recognizes 2 prehospital mini stroke AHA recognizes 2 prehospital mini stroke tests to help in the assessment of a tests to help in the assessment of a suspected stroke patient: suspected stroke patient:

The Cincinnati Prehospital Stroke ScaleThe Cincinnati Prehospital Stroke Scale The Los Angles Prehospital Stroke Screen The Los Angles Prehospital Stroke Screen

(LAPSS)(LAPSS)


Altered Mental Status: AEIOU-Altered Mental Status: AEIOU-TIPS TIPS

Can range from a subtle confusion or Can range from a subtle confusion or agitation to unconsciousness and agitation to unconsciousness and coma.coma.

Try to exclude hypoxia, Try to exclude hypoxia, hypoglycemia and trauma first.hypoglycemia and trauma first.

Obtain VS as well as temperature Obtain VS as well as temperature and blood glucose (especially in the and blood glucose (especially in the young and elderly).young and elderly).


Seizure Seizure Is this the first or is there a history?Is this the first or is there a history? Is there a history of recent head Is there a history of recent head

trauma, illness or infection?trauma, illness or infection? Is the patient compliant with meds?Is the patient compliant with meds? Is this seizure different from previous Is this seizure different from previous

seizures?seizures? Consider variable causes for each Consider variable causes for each

age group?age group? Be prepared for another seizure.Be prepared for another seizure.


Seizure Seizure (continued)(continued) Three phases: preictal, ictal, and Three phases: preictal, ictal, and

postictal.postictal. After the seizure most patients will After the seizure most patients will

feel exhausted and initially confused feel exhausted and initially confused with progressive improvement over with progressive improvement over several minutes.several minutes.

Types of seizure include:Types of seizure include: PartialPartial GeneralizedGeneralized AbsenceAbsence


Seizure Seizure (continued)(continued) Partial seizures:Partial seizures:

Occur in a specific area of the brainOccur in a specific area of the brain Affect only specific area of the bodyAffect only specific area of the body Often present with an auraOften present with an aura


Generalized seizures:Generalized seizures: Involve the entire brain and may Involve the entire brain and may

include an aurainclude an aura Classified as: complete motor seizure, Classified as: complete motor seizure,

absence seizure, and atonic seizureabsence seizure, and atonic seizure Postictal confusion, fatigue, or Postictal confusion, fatigue, or

headacheheadache Loss of consciousness. Convulsive Loss of consciousness. Convulsive

activity – tongue biting, incontinenceactivity – tongue biting, incontinence

Seizure (continued) Seizure (continued)


Seizure Seizure (continued)(continued) Absence seizures:Absence seizures:

Formerly called petit malFormerly called petit mal Common in childrenCommon in children Daydreaming with convulsive activityDaydreaming with convulsive activity Usually no aura or postictal activity Usually no aura or postictal activity

periodperiod


Headache Headache Common neurological complaint.Common neurological complaint. Associated symptom of other Associated symptom of other

medical conditions.medical conditions. Most caused by: tension, muscle-Most caused by: tension, muscle-

contraction, and sinusitis.contraction, and sinusitis.


Other causes include:Other causes include: Vascular (including migraine)Vascular (including migraine) ClusterCluster MeningitisMeningitis Temporal arteritisTemporal arteritis Subarachnoid bleed or increased ICPSubarachnoid bleed or increased ICP Glaucoma or eyestrainGlaucoma or eyestrain Systemic problems (i.e. anemia, uremia, Systemic problems (i.e. anemia, uremia,

brain tumor, infection)brain tumor, infection)

Headache Headache


Headache Headache (continued)(continued) Is it acute, recurrent, or chronic.Is it acute, recurrent, or chronic. Types and Severity:Types and Severity:

Tension – due to stress and anxietyTension – due to stress and anxiety Sinus – begin in am and worsen Sinus – begin in am and worsen

throughout the day. Pressure increases throughout the day. Pressure increases with coughing and sneezingwith coughing and sneezing

Migraine – severe and throbbing Migraine – severe and throbbing followed by dull pain. Light sensitive, followed by dull pain. Light sensitive, nausea, vomiting and sometimes an nausea, vomiting and sometimes an aura. May last hours to daysaura. May last hours to days

Cluster – severe, stabbing and burning Cluster – severe, stabbing and burning pain recurring in patternspain recurring in patterns


Headache Headache (continued)(continued) Location of pain – does not always Location of pain – does not always

indicate the cause. indicate the cause. There are conditions that present There are conditions that present

with associated findings:with associated findings: Headache and hypertension – Headache and hypertension –

subarachnoid hemorrhagesubarachnoid hemorrhage Headache and fever – meningitis, Headache and fever – meningitis,

encephalitis, brain abcsess.encephalitis, brain abcsess. Obtain as much info on associated Obtain as much info on associated

findings to report to the ED. findings to report to the ED.


Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)

Open or closed?Open or closed? Consider the MOI. Consider the MOI.


Categories include:Categories include: Focal head injury – brain lesions such as: Focal head injury – brain lesions such as:

cerebral contusion, intracranial cerebral contusion, intracranial hemorrhage or epidural hematomahemorrhage or epidural hematoma

Diffuse axonal injuries – resulting from Diffuse axonal injuries – resulting from rapid acceleration/decelerationrapid acceleration/deceleration

Coup – develop directly beneath the Coup – develop directly beneath the point of impactpoint of impact

Contra-coup – develop on the opposite Contra-coup – develop on the opposite side of the point of impactside of the point of impact

Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)


Traumatic Brain Injury Traumatic Brain Injury (continued)(continued)

Deterioration of a mild injury to a Deterioration of a mild injury to a severe injury and death has a severe injury and death has a predictable pattern of signs and predictable pattern of signs and symptoms. symptoms.

Mild to severe TBIs cause:Mild to severe TBIs cause: AMSAMS Amnesia of the eventAmnesia of the event Confusion and disorientationConfusion and disorientation CombativenessCombativeness Focal neurological deficitsFocal neurological deficits


TBI: Effects of Rising TBI: Effects of Rising PressurePressure

On the hypothalamus - causes a On the hypothalamus - causes a vomiting reflex. vomiting reflex.

Mild injuries: on the brainstem - Mild injuries: on the brainstem - causes BP to rise.causes BP to rise.

Severe injuries: on the brainstem - Severe injuries: on the brainstem - causes vagal stimulation (bradycardia) causes vagal stimulation (bradycardia) and posturing (flexion or extension).and posturing (flexion or extension).

On the 3On the 3rdrd cranial nerve - causes cranial nerve - causes unequal and unreactive pupils. unequal and unreactive pupils.


TBI: Effects of Rising Pressure TBI: Effects of Rising Pressure (continued)(continued)

On the respiratory center – causes On the respiratory center – causes irregular respirations, C0-2 retention, irregular respirations, C0-2 retention, brain swelling, and hypoxemia in the brain swelling, and hypoxemia in the brain tissue.brain tissue.

The earliest indication of a TBI is the The earliest indication of a TBI is the MOI and presence of subtle changes MOI and presence of subtle changes in the mental status.in the mental status.

When bleeding is present When bleeding is present neurological deficits may indicate the neurological deficits may indicate the area of the brain that was involved. area of the brain that was involved.



Epidural hematoma – usually involves Epidural hematoma – usually involves a middle meningeal artery tear from a a middle meningeal artery tear from a blow to the temporal skull. Usually blow to the temporal skull. Usually involves a period of AMS followed by a involves a period of AMS followed by a lucid interval then rapidly lucid interval then rapidly deteriorating mental status.deteriorating mental status.

Subdural hematoma – ruptured Subdural hematoma – ruptured bridging veins between the cortex and bridging veins between the cortex and dura. Can be acute, chronic or dura. Can be acute, chronic or delayed.delayed.



Intracerebral hematoma – bleeding Intracerebral hematoma – bleeding within the brain tissue. Deficits reflect within the brain tissue. Deficits reflect the area involved. the area involved.

The skull is hard and non-expandable. The skull is hard and non-expandable. When bleeding and swelling progress When bleeding and swelling progress the ICP goes up and the brain shift the ICP goes up and the brain shift downward towards the foramen downward towards the foramen magnum.magnum.

Three phases to brain herniation:Three phases to brain herniation: EarlyEarly LateLate TerminalTerminal


Neurogenic ShockNeurogenic Shock

Fainting resulting from nervous Fainting resulting from nervous system disorders.system disorders.

Absence of sympathetic response Absence of sympathetic response results in:results in: Decreasing BPDecreasing BP Normal or slightly slow pulse rateNormal or slightly slow pulse rate Decreasing respiratory rateDecreasing respiratory rate


Causes of neurogenic shock:Causes of neurogenic shock: Injury or transection of the spine “spinal Injury or transection of the spine “spinal

shock”shock” CNS injuryCNS injury Anaphylactic reactionAnaphylactic reaction Insulin ODInsulin OD Septicemia Septicemia

Neurogenic ShockNeurogenic Shock


ConclusionConclusion

Key aspect is to determine if baseline Key aspect is to determine if baseline assessment findings are changing assessment findings are changing and in which direction.and in which direction.

You need to know what is “baseline” You need to know what is “baseline” for this patient to know what is for this patient to know what is “normal” or a change.“normal” or a change.

Many of the signs of nervous system Many of the signs of nervous system disorders are subtle changes in disorders are subtle changes in mental status. mental status.


chapter 14: focused history and physical exam of the neuro

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