NeurologicalEmergencies

Headaches Causes �  Whenpainreceptorsfiredueto:

�  Traction�  Pressure�  Displacement�  Inflammation�  Dilation

Headachescont.PrimaryHA SecondaryHA�  Noorganiccause�  Includes:migraines,tension,cluster

�  50%oftheseareMigraines

�  Associationw/anOrganiccause�  Tumor�  Aneurysm�  Meningitis�  TemporalArteritis

Headaches

Headaches RedFlags�  SuddenOnset(Peaking<1min.)�  ChangefrompriorHA�  Concurrentevidenceofinfection�  AlteredMentalStatus�  Age>50(regardlessofpriorHA’s)�  Immunosuppression�  FocalNeurologicalDeficits�  StiffNeck�  ToxicAppearance

Migraines

� CanbewithorwithoutAura� Unilateral� Pulsating� AssociatedwithN&V� Photo/Phonophobia

TemporalArteri6sAKA“GiantCellArteritis”�  InflammatoryProcess�  Freq.assoc.w/lupus,RA,orInfections

�  Unilateral,severepain,constant

�  ClassicFinding:Tenderovertemporalartery

�  Mayleadtoblindnessd/tbloodsupplytotheopticnerve

�  Diagnostics:SedRate,Biopsyforconfirmation

�  Tx:Highdosesteroids,analgesics,needvascular/neurologistconsultandadmit.

Headachescont.CTindications: LumbarPuncture�  SuddenOnset�  Onsetwithexertion/cough�  FocalNeurologicalDeficits�  StiffNeck�  NewOnset�  Immunocompromised�  Changein“Usual”HApattern

�  IfsuspectbleeddespitenormalCT

�  Meningitis:cellcountelevated,decreaseinglucose

�  Intra-cranialHTN:Cellcountnormal,proteinnormal

�  SAH:Bloodinsubarachnoidspace

HeadachesInterventions Medications�  Environmental

�  Decreaselights/sounds�  IVAccess

�  FluidBolus�  MedicationAdministration

�  Ergots:(Imitrex)�  MostUsefulwithinhoursofonset.Caution

withknownCAD.�  Compazine

�  Indicatedformigraine.�  Givewithantihistaminetoreducedystonias

�  Toradol�  Cautioninrenalimpairment

�  Zofran�  Reglan

�  PossDystonia,Sedation�  Phenegran

�  Movingawayfromit’suse.ConcernsaboutIVuse.Possiblyaddicting.

�  Euphoriapossible�  OpiateNarcotics

�  Maskconditions.Freq.Narcoticuse.Causeshypotension,depressedLOC

StrokeInterruptioninvascularsupply

�  Ischemic&HemorrhagicTypes�  50%ofallstrokesfatal�  50%ofsurvivorshavepermanentdeficits�  ThirdleadingCauseofDeath

StrokeIschemic

Hemorrhagic

� Atherosclerosis� Plaques� Emboli� VesselSpasm

� BLEED� SAHorICH

CVAVS.TIAStroke/CVA

TIA

�  NoO2�  ClotintheBrainstoppingtheoxygen

�  PERMANENT

�  LowO2�  Narrowbloodvessels

�  Vasoconstriction�  PlaqueSELF-LIMITING

Acutestrokeinyoungerpa6ents� Arterial

� Dissection(spontaneous,traumatic)�  Fibromusculardysplasia,Marfan’s,vasculitis�  Vasoactivedrugs:cocaine,amphetamines

� Paradoxicalcardiacembolus(PFO)� Hypercoagulablestates

StrokeGoals� Preventfurtherdamage� Possiblereversalofischemia

� Re-establishvascularsupply

� **GoldenHour� DoortoNeedle<60min

Acutestrokesymptoms� Hemiparesisorisolatedlimbweakness

� Hemisensorydeficit� Monocularorbinocular(typicallyhomonymous)visionloss

�  Brainstemdeficits(diplopia,dysphagia,deafness,crossedsensoryormotorsigns)

�  Ataxiaoflimbsorgait�  Corticalsigns(aphasia,neglect,apraxia…)

StrokeInterventions

�  GCS<8=intubate� Hi-flowO2�  RapidIVaccess�  Cautiousfluidadministration

�  Position:HOBElev30-40degreesifnotcontra-indicated

StrokeMedications�  RSI�  Anti-hypertensives

�  MaintainSBP<185�  MaintainDBP<110

�  Fibrinolytics�  TPA,Alteplase�  Ideallywithin3hrsofonset.Possiblyconsideredupto4-6hours.

�  Givenasarapidbolus,therestover60min

�  Mustmeetqualifyingcriteria�  Considerrisk/benefitandfamilyconsultation.

Demen6a� OrganicDisorder� Decreasedcognitivefunction

�  LOCremainsunchanged� Memorymostcommonlyaffected

Demen6aDisposition/Education

�  Ifacutechangeornewonset:Admit.�  Ifd/chome:Considerptsafetyinnormalenvironment.�  Primarycarefollowupimportant.�  Considerfamily’sabilitytocareforpt.

VPShuntVentriculo-PeritonealShunts�  PlacedtorelieveincreasedICPfromhydrocephalus

�  DivertsexcessCSFfromVentricletoPeritonealCavity

�  CommonComplications:�  Infection&Malfunction

VPShuntAssessment EXAM�  Typeofshunt�  Whenwasitplaced�  Priorproblems�  Reasonitwasplaced�  Neurochanges�  Fever�  N&V

�  LOC,Behavior,Lethargy,Inconsolable?

�  Fever?�  AbdomenDistended?�  Fontanelles:TenseorBulging?

�  Abdomen:Tender(Infection?)

VPShuntDiagnostics Interventions

�  CBC(Infection)�  Chemistries/Glucose�  Xrays:ShuntSeries-Skull,CXR,KUB

�  CTofHead,Abdomen�  LP:Ifinfectionquestionable

�  Carefulwithfluids�  Antbiotics:Infection�  Anti-emetics:N&V

SeizuresSuddenDischargeofNeuronalImpulses� Temporarilyimpairsmovement,sensation,orcognition

� WithorWithoutALossofConsciousness

SeizuresCauses AtRiskGroups

�  Electrolyteimbalances� Metabolic(Fever,Hyperglycemia,Stress,Fatigue)

�  NerveCellStructureChanges� Hypoxia�  Tumors�  Trauma

� HxofHeadInjury�  Stroke�  CNSInfection�  DegenerativeCNSConditions

SeizuresSTATUSEPILEPTICUS�  Aseriesofseizuresunrelenting�  Diaphragm/Intercostalscan’t

relax�  Emergencyduetoriskfor

Hypoxia�  NeuronalDischargewill

continueaftertxbutbeMASKED

�  NeuronalCellularChanges/DestructionwillContinue

�  HighDosesofBenzosandNeuroleptics!!

�  **NOPARALYTICS!

SeizuresPSEUDOSEIZURES

�  Canbeinterruptedbyvocal/tactilestimuli�  Characterizedbyabruptreturnofconsciousnesspossiblyfollowedby“LossofConsciousness”

�  SuddenlossofTone�  ButprotectiveMechanismsremainintact

SeizuresInterventions�  SupportABC’s�  SupplementalO2�  PROTECTPATIENT

�  STATUSEPILEPTICUS�  SUCTIONPRN�  RISKFORASPIRATION�  RSIIFRESPIRATORYCOMPROMISE�  IVACCESS�  CARDIAC,PULSEOXMONITORING

29

Guillain-Barre Syndrome �  An autoimmune attack of the peripheral nerve myelin. The

result is acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing: �  ascending weakness with dyskinesia (inability to execute

voluntary movements) �  hyporeflexia (subnormal or absent reflexes) �  paresthesias (numbness).

�  Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. It is produced by Schwann cells that are spared, allowing for remyelination in the recovery phase of the disease

30

Guillian Barre Syndrome �  Causes

�  Respiratory or gastrointestinal infection (Campylobacter jejuni) �  Vaccination �  Pregnancy �  Surgery The antecedent event usually occurs 2 weeks before symptoms begin. Weakness usually begins in the legs and progresses upward for about 1 month.

Treatment� Telemetry� Respiratoryparameters� ICUmonitoring� Corticosteroidshavenotbeenshowntobebeneficial

� ExtremitySplinting

31

Intra-CranialPressure

� ManagingsecondaryproblemsrelatedtoincreasingICPisparamount

� ThegoalistomaintainaphysiologicalCerebralPerfusionPressure

� ManyheadinjuriescanleadtoIncreasingICP

Intra-CranialPressureCPP CPPCompensation�  Pressureexertedtoperfusecerebraltissues

�  Normal70-100MMHG�  Calculated=MAP–ICP�  IE:TheaverageSBPminustheresistance(ICP)

�  CompensatoryMechanismsstrivetokeepCPPatPhysiologicallevels

�  Initially,afairamountofchangeiscompensatedandtolerated

�  Ascompensatoryresourcesaredepletedarapiddeclineoccurs

�  InlateincreasingICP:smallchangesinpressurecancausebigchangesinvolume

KeepingICPDown�  IncreasetheMAP

�  Fluids�  Blood�  Pressors

�  DecreasetheIntracranialVolume� Diuretics�  ElevateHOB

�  DecreaseVasodilation�  CerebralIschemiacausesPHchanges

�  IncreasingConcentrationsofCO2causesvasodialtion(BAD)

ICP&Hyperven6la6on???

�  ItisnotHYPEROXYGENATION

�  ItisanincreaseintheMINUTEVENTILATION

�  ConsiderHyperventilationIfnoclinicalimprovementwith�  Sedation�  Diuretics�  CSFDrainage�  Positioning�  MaintainNormothermia�  Prevention/TxSeizures

ICPHerniationSyndrome� Whenvolumecan’tbecompensatedforanymore,riskofherniationoccurs.

� Herniationdirectlyaffectsbrainstem&Vitallifefunctions�  Cranialnervefunctionsaffected

�  LOC�  Pupillary� Motor�  VitalSignChanges

Cushing’sResponse/TriadIndicatesImpendingHerniationThreeclinicalCriteria

1.  Hypertension2.  Bradycardia

Somesaythethirdoneis….3.Irregularrespirations

Or3.WideningPulsePressure

Or3.PupillaryChanges

IncreasingICPEarlyFindings LateFindings�  LOC,Behavior,Anxiety,Restlessness,Agitation

�  Decreasingresponsiveness�  SluggishPupillaryresponsetolight

�  Motor:Pronatordrift,decreasingstrength

�  Vitals:Occasionaltachycardia,someHTNseen

�  Fixedordilatedpupils�  Hemiparesis�  Posturing

�  Decerebrete�  Decorticate

�  Cushing’sresponse

SpinalCordInjuriesInsulttospinalcordresultinginachange,inthenormalmotor,sensoryorautonomicfunction.Thischangeiseithertemporaryorpermanent.

Mechanisms:i)  Directtraumaii)  Compressionbybonefragments/haematoma/

discmaterialiii)  Ischemiafromdamage/impingementonthe

spinalarteries

Wheredoesthespinalcordend?

31pairsofspinalnerves: 8cervical 12thoracic 5lumbar 5sacral 1coccygeal

SpinalCord

SpinalCordInjuryClassifica6onInjuryeither:1)  Complete

2)  Incomplete

Complete:i)  Lossofvoluntarymovementofpartsinnervatedby

segment,thisisirreversibleii)  Lossofsensationiii)  Spinalshock

Incomplete:i)  Somefunctionispresentbelowsiteofinjuryii)  Morefavourableprognosisoveralliii)  Arerecognisablepatternsofinjury,althoughthey

arerarelypureandvariationsoccur

InjurydefinedbyASIAImpairmentScaleASIA–AmericanSpinalInjuryAssociation:A–Complete:nosensoryormotorfunctionpreservedinsacralsegmentsS4–S5

B–Incomplete:sensory,butnomotorfunctioninsacralsegments

C–Incomplete:motorfunctionpreservedbelowlevelandpowergraded<3

D–Incomplete:motorfunctionpreservedbelowlevelandpowergraded3ormore

E–Normal:sensoryandmotorfunctionnormal

MuscleStrengthGrading:�  5–Normalstrength�  4–Fullrangeofmotion,butlessthan

normalstrengthagainstresistance�  3–Fullrangeofmotionagainstgravity�  2–Movementwithgravityeliminated�  1–Flickerofmovement�  0–Totalparalysis

SpinalShockvsNeurogenicShockSpinalShock:�  Transientreflexdepressionofcordfunctionbelowlevelofinjury

�  Initiallyhypertensionduetoreleaseofcatecholamines�  Followedbyhypotension�  Flaccidparalysis�  Bowelandbladderinvolved�  Sometimespriaprismdevelops�  Symptomslastseveralhourstodays

Neurogenicshock:� Triadofi)hypotension ii)bradycardia iii)hypothermia

� MorecommonlyininjuriesaboveT6�  SecondarytodisruptionofsympatheticoutflowfromT1–L2

� Lossofvasomotortone–poolingofblood� Lossofcardiacsympathetictone–bradycardia� Bloodpressurewillnotberestoredbyfluidinfusionalone

� Massivefluidadministrationmayleadtooverloadandpulmonaryedema

� Vasopressorsmaybeindicated� Atropineusedtotreatbradycardia

Typesofincompleteinjuriesi)  CentralCordSyndrome

ii)  AnteriorCordSyndrome

iii)  PosteriorCordSyndrome

iv)  Brown–SequardSyndrome

v)  CaudaEquinaSyndrome

i)  CentralCordSyndrome:�  Typicallyinolderpatients�  Hyperextensioninjury�  Compressionofthecordanteriorlybyosteophytesand

posteriorlybyligamentumflavum

�  Alsoassociatedwithfracturedislocationandcompressionfractures

� Morecentrallysituatedcervicaltractstendtobemoreinvolvedhenceflaccidweaknessofarms>legs

�  Perianalsensation&somelowerextremitymovementandsensationmaybepreserved

ii)AnteriorCordSyndrome:� Duetoflexion/rotation� Anteriordislocation/compressionfractureofavertebralbodyencroachingtheventralcanal

� Corticospinalandspinothalamictractsaredamagedeitherbydirecttraumaorischemiaofbloodsupply(anteriorspinalarteries)

Clinically:�  Lossofpower� Decreaseinpainandsensationbelowlesion� Dorsalcolumnsremainintact

ii)PosteriorCordSyndrome:Hyperextensioninjurieswithfracturesoftheposteriorelementsofthevertebrae Clinically:

�  Proprioceptionaffected–ataxiaandfalteringgait�  Usuallygoodpowerandsensation

iv)Brown–SequardSyndrome:� Hemi-sectionofthecord�  Eitherduetopenetratinginjuries:i)stabwoundsii)gunshotwounds

�  FracturesoflateralmassofvertebraeClinically:�  Paralysisonaffectedside(corticospinal)�  Lossofproprioceptionandfinediscrimination(dorsalcolumns)

�  Painandtemperaturelossontheoppositesidebelowthelesion(spinothalamic)

v)CaudaEquinaSyndrome:�  Duetobonycompressionordiscprotrusions

inlumbarorsacralregionClinically� Nonspecificsymptoms–backpain -bowelandbladderdysfunction -legnumbnessandweakness -saddleparesthesia

REVIEW

�  Whichofthefollowingisanearlysignofincreasingintracranialpressureinapatientwithaheadinjury?

1.  Bradycardiaandprematureventricularescapebeats2.  Unilateralfixedanddilatedpupil3.  Nausea&Vomiting4.  Extensionofupperextremitieswithstimuli

Answer

�  Whichofthefollowingisanearlysignofincreasingintracranialpressureinapatientwithaheadinjury?

1.  Bradycardiaandprematureventricularescapebeats2.  Unilateralfixedanddilatedpupil3.  Nausea&Vomiting4.  Extensionofupperextremitieswithstimuli

REVIEW

�  Whichtypeofheadacheisassociatedwithhavinganaura,signalingthestartofaheadache?

1.  Cluster2.  Migraine3.  Tension4.  Temporalarteritis

Answer

�  Whichtypeofheadacheisassociatedwithhavinganaura,signalingthestartofaheadache?

1.  Cluster2.  Migraine3.  Tension4.  Temporalarteritis

REVIEW

�  Whencaringforapatientduringaclonic-tonicseizure,whichnursingactionhasthefirstpriority?

1.  Establishandmaintainapatentairway2.  Insertapaddedtonguebladebetweenthepatient’steeth3. Padthesiderails4. Administeroxygen

Answer

�  Whencaringforapatientduringaclonic-tonicseizure,whichnursingactionhasthefirstpriority?

1.  Establishandmaintainapatentairway2.  Insertapaddedtonguebladebetweenthepatient’steeth3. Padthesiderails4. Administeroxygen

REVIEW

�  Autonomicdysreflexiainspinalcordinjury(SCI)ischaracterizedbywhichofthefollowingsymptoms?

1.  Pupillaryconstriction2.  Tachycardia3.  Hypertension4.  Sweatingbelowthelevelofthelesion

Answer

�  Autonomicdysreflexiainspinalcordinjury(SCI)ischaracterizedbywhichofthefollowingsymptoms?

1.  Pupillaryconstriction2.  Tachycardia3.  Hypertension4.  Sweatingbelowthelevelofthelesion

REVIEW

Anelderlypatienthasahistoryoffallingathomeandadeclineinmentationoverthelast2weeks.Thepatientisconfusedtotimeandlocation.Bloodglucoseis104mg/dL.Thenursewouldsuspecta(n):1.  Diffuseaxonalinjury2.  Subarachnoidhemorrhage3.  Epiduralhematoma4.  Subduralhematoma

Answer

Anelderlypatienthasahistoryoffallingathomeandadeclineinmentationoverthelast2weeks.Thepatientisconfusedtotimeandlocation.Bloodglucoseis104mg/dL.Thenursewouldsuspecta(n):1.  Diffuseaxonalinjury2.  Subarachnoidhemorrhage3.  Epiduralhematoma4.  Subduralhematoma

REVIEW

Apatientwithagunshotwoundtothebackisawakeandreportsthathehasfeelingtotherightsideofhisbody,butnottheleft,andcanmovehisleftside,butnottheright.Hisconditioniscalled:1.  Anteriorcordsyndrome2.  Brown-Sequardsyndrome3.  Centralcordsyndrome4.  Autonomicdysreflexia

Answer

Apatientwithagunshotwoundtothebackisawakeandreportsthathehasfeelingtotherightsideofhisbody,butnottheleft,andcanmovehisleftside,butnottheright.Hisconditioniscalled:1.  Anteriorcordsyndrome2.  Brown-Sequardsyndrome3.  Centralcordsyndrome4.  Autonomicdysreflexia