nervous system emergencies nervous system a & p ä nervous system basics ä the body’s control...

Nervous System EmergenciesNervous System Emergencies

Nervous System A & PNervous System A & P

Nervous System BasicsNervous System Basics The body’s control systemThe body’s control system Exerts control through electrochemical impulses Exerts control through electrochemical impulses

transmitted through nervestransmitted through nerves Three subdivisionsThree subdivisions

Central nervous system (brain and spinal cord)Central nervous system (brain and spinal cord) Peripheral nervous system (cranial, peripheral nerves)Peripheral nervous system (cranial, peripheral nerves) Autonomic nervous system (sympathetic, Autonomic nervous system (sympathetic,

parasympathetic)parasympathetic)


A & P of CNS (A & P of CNS (brain and spinal cordbrain and spinal cord)) Neuron-nerve cell; fundamental component of Neuron-nerve cell; fundamental component of

the nervous systemthe nervous system Cell body contains nucleusCell body contains nucleus Dendrites carry nervous impulses to cell bodyDendrites carry nervous impulses to cell body Axons transmit nerve impulses away from cell bodyAxons transmit nerve impulses away from cell body


A & P of CNS (A & P of CNS (brain and spinal cordbrain and spinal cord) ) Transmission of impulses in the nervous systemTransmission of impulses in the nervous system

At rest, neuron is positively charged outside, At rest, neuron is positively charged outside, negatively charged insidenegatively charged inside

When stimulated, sodium enters cell, potassium When stimulated, sodium enters cell, potassium rapidly leaves cellrapidly leaves cell

Activity produces positive charge, called action Activity produces positive charge, called action potential, at entry sitepotential, at entry site

Nervous System A & P Overview Nervous System A & P Overview

A & P of CNS (A & P of CNS (brain and spinal cordbrain and spinal cord)) Transmission of impulses in the nervous system Transmission of impulses in the nervous system

((cont.cont.)) Action potential transmitted down neuron to meet Action potential transmitted down neuron to meet

other neurons at junctions called synapsesother neurons at junctions called synapses Axon releases neurotransmitter (acetylcholine or Axon releases neurotransmitter (acetylcholine or

norepinephrine) that transports impulses across norepinephrine) that transports impulses across synapse and stimulates connecting nervesynapse and stimulates connecting nerve

Nervous System A & P OverviewNervous System A & P Overview

Protective structures of the CNSProtective structures of the CNS Mostly protected by body structures (skull, Mostly protected by body structures (skull,

spinal column)spinal column) Also covered by membranes - meninges (pia, Also covered by membranes - meninges (pia,

arachnoid, dura)arachnoid, dura) Brain and spinal cord also bathed in Brain and spinal cord also bathed in

cerebrospinal fluid (CSF)cerebrospinal fluid (CSF)


The brainThe brain CerebrumCerebrum DiencephalonDiencephalon MesencephalonMesencephalon PonsPons Medulla OblongataMedulla Oblongata CerebellumCerebellum


Cerebrum Cerebrum Two hemispheres joined by corpus callosumTwo hemispheres joined by corpus callosum Governs all sensory and motor functionsGoverns all sensory and motor functions Responsible for language, learning, analysis, Responsible for language, learning, analysis,

memorymemory Cerebral cortex is outermost layerCerebral cortex is outermost layer


DiencephalonDiencephalon Superiormost portion of brain stemSuperiormost portion of brain stem Contains thalamus, hypothalamus, limbic Contains thalamus, hypothalamus, limbic

systemsystem Responsible for involuntary actionsResponsible for involuntary actions Major role in regulating autonomic nervous Major role in regulating autonomic nervous

systemsystem


MesencephalonMesencephalon Midbrain-located between mesencephalon and Midbrain-located between mesencephalon and

ponspons Responsible for motor coordination and eye Responsible for motor coordination and eye

movementmovement


PonsPons Located between midbrain and medullaLocated between midbrain and medulla Contains connections between the brain and Contains connections between the brain and

spinal cordspinal cord


Medulla OblongataMedulla Oblongata Located between pons and spinal cordLocated between pons and spinal cord Marks division between brain and spinal cordMarks division between brain and spinal cord Controls respirations, cardiac function , Controls respirations, cardiac function ,

vasomotor activityvasomotor activity


CerebellumCerebellum Located in posterior fossa of cranial cavityLocated in posterior fossa of cranial cavity Coordinates fine motor movement, posture, Coordinates fine motor movement, posture,

equilibrium, muscle toneequilibrium, muscle tone


Areas of SpecializationAreas of Specialization Speech-temporal lobeSpeech-temporal lobe Vision-occipital lobeVision-occipital lobe Personality-frontal lobesPersonality-frontal lobes Balance and coordination-cerebellumBalance and coordination-cerebellum Sensory-parietal lobesSensory-parietal lobes Motor-frontal lobesMotor-frontal lobes


Vascular supply to brainVascular supply to brain Supplied by two systems: carotid system and Supplied by two systems: carotid system and

vertebrobasilar systemvertebrobasilar system Both join at the circle of Willis before entering Both join at the circle of Willis before entering

brainbrain Interruption of one system will not seriously Interruption of one system will not seriously

affect brain perfusionaffect brain perfusion Venous drainage through venous sinuses and Venous drainage through venous sinuses and

internal jugular veinsinternal jugular veins


Spinal CordSpinal Cord 17-18 inches long17-18 inches long Leaves the brain through the foramen magnumLeaves the brain through the foramen magnum Conducts impulses to peripheral nervous Conducts impulses to peripheral nervous

systemsystem Conducts sensory impulses to the brain and has Conducts sensory impulses to the brain and has

reflex arc capabilityreflex arc capability


Spinal Cord (Spinal Cord (cont.cont.) ) Has 31 pairs of nerve fibersHas 31 pairs of nerve fibers

Dorsal roots contain afferent fibers (body to brain)Dorsal roots contain afferent fibers (body to brain) Ventral roots contain efferent fibers (brain to body)Ventral roots contain efferent fibers (brain to body)

Nerve fibers innovate corresponding body areas Nerve fibers innovate corresponding body areas called dermatonescalled dermatones


A & P of the peripheral nervous systemA & P of the peripheral nervous system Basic information Basic information

Consists of cranial and peripheral nervesConsists of cranial and peripheral nerves Has both voluntary and involuntary componentsHas both voluntary and involuntary components


A & P of the peripheral nervous systemA & P of the peripheral nervous system Categories of the peripheral nervesCategories of the peripheral nerves

Somatic motor-carry impulses to skeletal musclesSomatic motor-carry impulses to skeletal muscles Visceral sensory-transmit sensations from visceral Visceral sensory-transmit sensations from visceral

organs (e.g., full bladder need to defecate, etc.)organs (e.g., full bladder need to defecate, etc.) Somatic sensory-transmit sensations of touch, Somatic sensory-transmit sensations of touch,

pressure, pain, temperature, positionpressure, pain, temperature, position Visceral motor-supply nerves to visceral glands and Visceral motor-supply nerves to visceral glands and

organsorgans


Autonomic nervous systemAutonomic nervous system Responsible for unconscious control of body Responsible for unconscious control of body

functionsfunctions Made up of two antagonistic, but normally Made up of two antagonistic, but normally

balanced partsbalanced parts Sympathetic nervous system controls stress Sympathetic nervous system controls stress

responseresponse Parasympathetic nervous system controls custodial Parasympathetic nervous system controls custodial

(vegetative) functions(vegetative) functions

Assessment of the Neurological SystemAssessment of the Neurological System

Primary AssessmentPrimary Assessment First check for responsivenessFirst check for responsiveness Place emphasis on airway maintenance and Place emphasis on airway maintenance and

cervical spine stabilizationcervical spine stabilization With unconscious patients assume cervical With unconscious patients assume cervical

spinal injuryspinal injury Use modified jaw thrust maneuversUse modified jaw thrust maneuvers

Remain alert for possibility of respiratory arrestRemain alert for possibility of respiratory arrest

Assessment of the Nervous SystemAssessment of the Nervous System

Secondary AssessmentSecondary Assessment HistoryHistory

Determine trauma vs medical etiologyDetermine trauma vs medical etiology If traumaIf trauma

When did incident occurWhen did incident occur Mechanism of injuryMechanism of injury Any loss of consciousnessAny loss of consciousness Chief complaintChief complaint Complicating factorsComplicating factors


Secondary Assessment (cont.)Secondary Assessment (cont.) History (cont.)History (cont.)

If nontraumaIf nontrauma Chief complaint Chief complaint History of present illnessHistory of present illness Pertinent underlying medical problems (cardiac disease, Pertinent underlying medical problems (cardiac disease,

hypertension, diabetes, seizures)hypertension, diabetes, seizures) Environmental clues (medications, Medic-alert ID, Environmental clues (medications, Medic-alert ID,

alcohol or drug bottles)alcohol or drug bottles)


Head to toe surveyHead to toe survey PupilsPupils

Check eye movement and pupil reactionCheck eye movement and pupil reaction Early indicators of increasing ICPEarly indicators of increasing ICP Cardinal positions of gazeCardinal positions of gaze

Fixed, midsize pupils-midbrainFixed, midsize pupils-midbrain Pinpoint pupils, barely reactive-ponsPinpoint pupils, barely reactive-pons Unilateral fixed and dilated pupil-third nerveUnilateral fixed and dilated pupil-third nerve Fixed or asymmetric pupils-structural lesionsFixed or asymmetric pupils-structural lesions Nonreative pupils-toxic/metabolic statesNonreative pupils-toxic/metabolic states


Head to toe survey (Head to toe survey (cont.cont.)) Pupils (Pupils (cont.cont.))

Extraocular movements Extraocular movements Disconjugate gaze-structural brainstem lesionDisconjugate gaze-structural brainstem lesion Doll’s eyes-brainstem dysfunctionDoll’s eyes-brainstem dysfunction

Assessment of the Nervous System Assessment of the Nervous System

Head to toe survey (Head to toe survey (cont.cont.)) Respiratory derangements common with CNS Respiratory derangements common with CNS

illness or injuryillness or injury Cheyne Stokes respiration-period of apnea followed Cheyne Stokes respiration-period of apnea followed

by increasing depth and frequency of respirationsby increasing depth and frequency of respirations Central neurogenic hyperventilation-rapid, deep, Central neurogenic hyperventilation-rapid, deep,

noisy respirations; lesion in CNSnoisy respirations; lesion in CNS Ataxic respirations-ineffective thoracic muscular Ataxic respirations-ineffective thoracic muscular

coordination due to CNS damagecoordination due to CNS damage


Head to toe survey (Head to toe survey (contcont.).) Respiratory derangements common with CNS Respiratory derangements common with CNS

illness or injury (illness or injury (cont.cont.)) Apneustic respirations-prolonged inspiration Apneustic respirations-prolonged inspiration

unrelieved by expiration attempts; damage to upper unrelieved by expiration attempts; damage to upper ponspons

Diaphragmatic breathing-caused by intercostal Diaphragmatic breathing-caused by intercostal muscle dysfunctionmuscle dysfunction


Spinal Evaluation-document loss of motor Spinal Evaluation-document loss of motor function or sensationfunction or sensation Evaluate for pain and tendernessEvaluate for pain and tenderness Observe for bruisesObserve for bruises Observe for deformityObserve for deformity Check for motor, sensory and position in each Check for motor, sensory and position in each

extremity and bilateral grip strengthextremity and bilateral grip strength Determine response to painDetermine response to pain Note any incontinenceNote any incontinence


Vital signs that characterize CNS injuryVital signs that characterize CNS injury Increased blood pressureIncreased blood pressure Decreased pulseDecreased pulse Decreased respirationsDecreased respirations Increased temperatureIncreased temperature


Neurological Evaluation - provides baseline Neurological Evaluation - provides baseline neurological findings for later neurological findings for later comparison/contrastcomparison/contrast Determine level of consciousnessDetermine level of consciousness

AVPU during primary surveyAVPU during primary survey

Note sensation and motor function in extremitiesNote sensation and motor function in extremities Asymmetry-structural lesionsAsymmetry-structural lesions Abnormal posturingAbnormal posturing Flaccid paralysis-spinal cord injuryFlaccid paralysis-spinal cord injury


Glascow Coma ScaleGlascow Coma Scale Evaluates coma patient with CNS injury by Evaluates coma patient with CNS injury by

monitoringmonitoring Eye openingsEye openings Verbal responseVerbal response Motor responseMotor response


Altered mental status-hallmark of CNS Altered mental status-hallmark of CNS illness or injuryillness or injury Basic mechanisms that can produce altered Basic mechanisms that can produce altered

mental statusmental status Structural lesionsStructural lesions Toxic-metabolic statesToxic-metabolic states


Common causes of altered mental statusCommon causes of altered mental status Structural Structural

TraumaTrauma Brain tumorBrain tumor EpilepsyEpilepsy Intracranial hemorrhageIntracranial hemorrhage Other space-occupying lesionsOther space-occupying lesions


Common causes of altered mental statusCommon causes of altered mental status MetabolicMetabolic

AnoxiaAnoxia HypoglycemiaHypoglycemia Diabetic ketoacidosisDiabetic ketoacidosis Hepatic failureHepatic failure Renal failureRenal failure Thiamine deficiencyThiamine deficiency


Common causes of altered mental statusCommon causes of altered mental status DrugsDrugs

BarbituratesBarbiturates NarcoticsNarcotics HallucinogensHallucinogens DepressantsDepressants


Common causes of altered mental statusCommon causes of altered mental status CardiovascularCardiovascular

Hypertensive encephalopathyHypertensive encephalopathy ShockShock AnaphylaxisAnaphylaxis DysrhythmiasDysrhythmias Cardiac arrestCardiac arrest CVACVA


Common causes of altered mental statusCommon causes of altered mental status RespiratoryRespiratory

COPDCOPD Toxic gas inhalationToxic gas inhalation

InfectiousInfectious EncephalitisEncephalitis MeningitisMeningitis


Primary AssessmentPrimary Assessment Special attention to the airway and c-spineSpecial attention to the airway and c-spine Consider AEIOU TIPS mnemonicConsider AEIOU TIPS mnemonic Early intubationEarly intubation


Secondary AssessmentSecondary Assessment HistoryHistory

Length of alteration in mental statusLength of alteration in mental status OnsetOnset History of recent head traumaHistory of recent head trauma patient under medical carepatient under medical care Alcohol or drug useAlcohol or drug use Preceding symptoms or complaintsPreceding symptoms or complaints Any medicationsAny medications Medic-Alert tagsMedic-Alert tags


Secondary Assessment (Secondary Assessment (contcont.).) Physical exam-should include breathing, Physical exam-should include breathing,

response to stimuli, eye response, pupil response to stimuli, eye response, pupil response, being particularly alert in suspected response, being particularly alert in suspected CNS illness or injury casesCNS illness or injury cases Pupillary reflexes-fixed, dilated, or asymmetric Pupillary reflexes-fixed, dilated, or asymmetric

pupilspupils Extraocular movements-dysconjugate gazeExtraocular movements-dysconjugate gaze


Secondary Assessment (Secondary Assessment (contcont.).) Physical exam-should include breathing, response Physical exam-should include breathing, response

to stimuli, eye response, pupil response, being to stimuli, eye response, pupil response, being particularly alert in suspected CNS illness or particularly alert in suspected CNS illness or injury casesinjury cases Motor findings-asymmetry, decorticate or decebrate Motor findings-asymmetry, decorticate or decebrate

posturing, flaccid paralysisposturing, flaccid paralysis Respiratory patternsRespiratory patterns Vital signs-hypertension, bradycardia, unusual body Vital signs-hypertension, bradycardia, unusual body

temperaturetemperature


ManagementManagement Immobilization of the cervical spineImmobilization of the cervical spine Assure patency and adequate breathingAssure patency and adequate breathing Draw venous blood sample, check blood sugar Draw venous blood sample, check blood sugar

with glucometer or chem stripwith glucometer or chem strip IV 5% D5W at TKO rate; related NS or LR if IV 5% D5W at TKO rate; related NS or LR if

traumatrauma Cardiac monitorCardiac monitor


Drug considerationsDrug considerations 50mL of 50% dextrose (25 grams) IV to correct 50mL of 50% dextrose (25 grams) IV to correct

hypoglycemiahypoglycemia Naloxone 1-2 mg IV to reverse narcotic overdoseNaloxone 1-2 mg IV to reverse narcotic overdose Thiamine 100mg IV to correct thiamine Thiamine 100mg IV to correct thiamine

deficiency and allow glucose metabolismdeficiency and allow glucose metabolism Mannitol 25g IV to reduce ICPMannitol 25g IV to reduce ICP Decadron 4-24 mg IV to reduce cerebral edemaDecadron 4-24 mg IV to reduce cerebral edema


Management with chronic alcoholismManagement with chronic alcoholism Many have thiamine deficiencyMany have thiamine deficiency

Wernicke’s syndrome-memory loss, disorientationWernicke’s syndrome-memory loss, disorientation Korsakoff’s psychosis-disorientation,m muttering Korsakoff’s psychosis-disorientation,m muttering

delirium, insomnia, delusions painful extremities, delirium, insomnia, delusions painful extremities, bilateral foot drop, pain on pressure over long bilateral foot drop, pain on pressure over long nervesnerves

These patients should receive 100 mg Thiamine IV These patients should receive 100 mg Thiamine IV or IMor IM


Management with ICPManagement with ICP Hyperventilate patientHyperventilate patient Decadron 4-24 mg IV to reduce cerebral edemaDecadron 4-24 mg IV to reduce cerebral edema Mannitol 25g IV to cause an osmotic diuresisMannitol 25g IV to cause an osmotic diuresis


Seizures Seizures Pathophysiology of seizuresPathophysiology of seizures

Massive electrical discharge of one or more groups Massive electrical discharge of one or more groups of neurons in the brainof neurons in the brain

Can be general or partialCan be general or partial Generalized seizures-grand mal and petit malGeneralized seizures-grand mal and petit mal Partial seizures-simple or complex (psychomotor)Partial seizures-simple or complex (psychomotor)


Seizures (Seizures (contcont.).) Causes of seizuresCauses of seizures

Stressors such as hypoxia, sudden elevation in Stressors such as hypoxia, sudden elevation in temperature, or hypoglycemia in healthy personstemperature, or hypoglycemia in healthy persons

Structural diseases such as tumors, head trauma, Structural diseases such as tumors, head trauma, eclampsia, vascular disorderseclampsia, vascular disorders

Idiopathic epilepsy is the most common causeIdiopathic epilepsy is the most common cause


Seizures (Seizures (contcont.).) Types of SeizuresTypes of Seizures

Grand Mal-generalized motor seizureGrand Mal-generalized motor seizure Produces loss of consciousness from brain hypoxiaProduces loss of consciousness from brain hypoxia Causes uncontrollable tonic/clonic movements of Causes uncontrollable tonic/clonic movements of

extremitiesextremities Disrupts respirations, producing cyanosisDisrupts respirations, producing cyanosis Often lead to frothing, incontinence, mental confusionOften lead to frothing, incontinence, mental confusion Coma or drowsiness follows (postical period)Coma or drowsiness follows (postical period)


Seizures (Seizures (contcont.).) Grand-mal (Grand-mal (progressionprogression))

Aura-subjective sensation preceding seizureAura-subjective sensation preceding seizure May be psychic (déjà vu)May be psychic (déjà vu) May be sensory (a noise, sight, sound, odor)May be sensory (a noise, sight, sound, odor)

Loss of consciousnessLoss of consciousness Tonic phase-continuous motor tension and Tonic phase-continuous motor tension and

contraction of musclescontraction of muscles


Seizures (Seizures (contcont.).) Grand-mal (Grand-mal (progressionprogression contcont.).)

Hypertonic phase-extreme muscular rigidity, Hypertonic phase-extreme muscular rigidity, hyperextension of the backhyperextension of the back

Clonic phase-extreme muscular rigidClonic phase-extreme muscular rigid


Seizures (Seizures (contcont.).) Grand-mal (Grand-mal (progressionprogression contcont.).)

Post-seizure comaPost-seizure coma Postictal period-patient awakens confused, fatigued Postictal period-patient awakens confused, fatigued

with some neurological deficitswith some neurological deficits


Seizures (Seizures (contcont.).) Focal motor seizuresFocal motor seizures

Characterized by dysfunction of one area of the Characterized by dysfunction of one area of the bodybody

Caused by electrical discharge form one part of the Caused by electrical discharge form one part of the brainbrain

Begin as localized tonic/clonic movements; can Begin as localized tonic/clonic movements; can spread and appear s generalizedspread and appear s generalized


Seizures (Seizures (contcont.).) Psychomotor (temporal lobe) seizuresPsychomotor (temporal lobe) seizures

Characterized by distinctive pre-seizure auraCharacterized by distinctive pre-seizure aura Focal seizures lasting 1-2 minutesFocal seizures lasting 1-2 minutes Patient experiences loss of contact with Patient experiences loss of contact with

surroundingssurroundings Patient may be confused, purposeless, or may show Patient may be confused, purposeless, or may show

change in personality or rage abruptlychange in personality or rage abruptly


Seizures (Seizures (contcont.).) Petit mal seizuresPetit mal seizures

Generalized seizures with 10-30 second loss of Generalized seizures with 10-30 second loss of consciousnessconsciousness

Patient may stare and flutter eyelidsPatient may stare and flutter eyelids Observers may be unaware of seizureObservers may be unaware of seizure


Seizures (Seizures (contcont.).) Hysterical seizuresHysterical seizures

Psychological disordersPsychological disorders Patient presents with sharp and bizarre movementsPatient presents with sharp and bizarre movements Curt commands can curtail seizureCurt commands can curtail seizure No postical periodNo postical period Use of aromatic ammonia may differentiate Use of aromatic ammonia may differentiate

hysterical from true seizurehysterical from true seizure


AssessmentAssessment rule out other causes of comarule out other causes of coma Obtain history including:Obtain history including:

History of seizureHistory of seizure Alcohol/drug abuseAlcohol/drug abuse Current medicationsCurrent medications Recent history of head traumaRecent history of head trauma Description of seizureDescription of seizure Past medical history (diabetes, cardiac, strokes)Past medical history (diabetes, cardiac, strokes)

Differentiate true seizure vs. syncopeDifferentiate true seizure vs. syncope


ManagementManagement Protect patient from self-harm; do not restrainProtect patient from self-harm; do not restrain Maintain airwayMaintain airway Administer oxygenAdminister oxygen Establish IV accessEstablish IV access Determine blood glucose; D50W if neededDetermine blood glucose; D50W if needed Protect body temperatureProtect body temperature position patient on side after tonic/clonic phaseposition patient on side after tonic/clonic phase


Management (Management (contcont.).) Suction if required Suction if required Monitor cardiac rhythmMonitor cardiac rhythm Provide quiet rest, reassuring atmosphereProvide quiet rest, reassuring atmosphere Transport in supine or lateral recumbent Transport in supine or lateral recumbent

positionposition


Status EpilepticusStatus Epilepticus DescriptionDescription

Series of two or more seizures without lucid periodSeries of two or more seizures without lucid period Most common cause is failure to take anticonvulsant Most common cause is failure to take anticonvulsant

medicationsmedications Can lead to brain injury from anoxiaCan lead to brain injury from anoxia


Status Epilepticus (Status Epilepticus (contcont.).) ManagementManagement

Establish and protect airwayEstablish and protect airway Assist ventilations with 100% oxygenAssist ventilations with 100% oxygen Establish IV access with NS TKOEstablish IV access with NS TKO Monitor cardiac rhythmMonitor cardiac rhythm Administer 50% dextrose 25gm IVAdminister 50% dextrose 25gm IV Administer diazepam 5-10 mg IVAdminister diazepam 5-10 mg IV


Stroke (cerebrovascular accident - CVA)Stroke (cerebrovascular accident - CVA) PathophysiologyPathophysiology

injury or death to brain tissue from interruption of injury or death to brain tissue from interruption of bloodblood

Can by caused by ischemic or hemorrhagic lesions Can by caused by ischemic or hemorrhagic lesions commonly secondary to atherosclerosis or commonly secondary to atherosclerosis or hypertensionhypertension

Sudden loss of consciousness followed by paralysis Sudden loss of consciousness followed by paralysis which may be caused by hemorrhage, embolism or which may be caused by hemorrhage, embolism or thrombusthrombus


Strokes (Strokes (contcont.).) Categories of strokeCategories of stroke

InfarctionInfarction Inadequate blood supply to limited prtion of the brainInadequate blood supply to limited prtion of the brain caused by embolism or blood vessel occlusion usually due caused by embolism or blood vessel occlusion usually due

to thrombusto thrombus

HemorrhageHemorrhage Intracerebral or subarachnoid bleedingIntracerebral or subarachnoid bleeding Marked by sudden onset of headache and stiff neckMarked by sudden onset of headache and stiff neck Can cause increased intracranial pressureCan cause increased intracranial pressure


Strokes (Strokes (contcont.).) Clinical presentation of a strokeClinical presentation of a stroke

Symptoms depend on area of brain injuredSymptoms depend on area of brain injured Motor, speech, and sensory centers most commonly Motor, speech, and sensory centers most commonly

affected affected Onset of symptoms is acute and may include:Onset of symptoms is acute and may include:

UnconsciousnessUnconsciousness Stertorous breathingStertorous breathing Unequal pupilsUnequal pupils Unilateral paralysisUnilateral paralysis Speech disturbancesSpeech disturbances


Strokes (Strokes (contcont.).) Distinguishing CVA from transient ischemic Distinguishing CVA from transient ischemic

attacks (TIA’s)attacks (TIA’s) Temporary stroke symptomsTemporary stroke symptoms Usually caused by small emboliUsually caused by small emboli Can last several minutes to hoursCan last several minutes to hours No evidence of neurological deficient after attackNo evidence of neurological deficient after attack Abrupt onset with symptoms depending on area of Abrupt onset with symptoms depending on area of

brain affectedbrain affected


Strokes (Strokes (contcont.).) SymptomsSymptoms

Monocular blindnessMonocular blindness HemiplegiaHemiplegia Inability to recognize by touchInability to recognize by touch StaggeringStaggering Difficulty in swallowing, aphasiaDifficulty in swallowing, aphasia HemiparesisHemiparesis DizzinessDizziness Numbness, paresthesiaNumbness, paresthesia


Strokes (Strokes (contcont.).) History - Determine:History - Determine:

Previous neurological symptomsPrevious neurological symptoms Initial symptoms and their progressionInitial symptoms and their progression Chanbes in mental status Precipitating factorsChanbes in mental status Precipitating factors DizzinessDizziness PalpitationsPalpitations History of hypertension, cardiac disease, sickle cell History of hypertension, cardiac disease, sickle cell

disease, previous TIA or strokedisease, previous TIA or stroke


Strokes (Strokes (contcont.).) Physical Exam - Be alert for:Physical Exam - Be alert for:

Hemiparesis, hemiplegiaHemiparesis, hemiplegia Unilateral facial droopUnilateral facial droop Speech disturbancesSpeech disturbances Gait problemsGait problems Altered mental statusAltered mental status Vision problemsVision problems


Strokes (Strokes (contcont.).) Management of CVA and TIAManagement of CVA and TIA

Maintain patient supine with 15 degree head Maintain patient supine with 15 degree head elevation to maximize venous drainageelevation to maximize venous drainage

Maintain c-spine integrity if trauma suspectedMaintain c-spine integrity if trauma suspected Maintain a patent airway, assisting ventilation PRNMaintain a patent airway, assisting ventilation PRN Administer oxygen, hyperventilation if patient Administer oxygen, hyperventilation if patient

unresponsiveunresponsive Draw venous blood sample and test for blood sugarDraw venous blood sample and test for blood sugar


Strokes (Strokes (contcont.).) ManagementManagement

Start IV with NS or LR TKOStart IV with NS or LR TKO Monitor cardiac rhythmMonitor cardiac rhythm If patient hypoglycemic, give D50WIf patient hypoglycemic, give D50W Protect paralyzed extremitiesProtect paralyzed extremities Reassure patient and transport quietly to hospitalReassure patient and transport quietly to hospital


Judy Dyke, RN, NREMT-PJudy Dyke, RN, NREMT-P

Rogers State UniversityRogers State University

Paramedic Technology ProgramParamedic Technology Program

nervous system emergencies nervous system a & p ä nervous system basics ä the body’s control...

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