Chapter 18 - Neurologic

Anatomy & Physiology

Brainstem

- Controls the basic functions of

the body; breathing, blood
pressure, swallowing, pupil
constriction

Cerebellum

- Controls muscle and body

coordination; standing on one foot,
walking, writing, picking things up,
playing instruments, etc

Cerebrum

-​ Divided into right and left cerebral hemispheres, which control actions on the
opposite side of the body
-​ Front part controls emotion and thought
-​ Middle part controls sensation and movement
-​ Back part processes sight
-​ Speech is usually controlled on the left side, near the middle

Nerves

-​ Send messages to and from brain

-​ 12 pairs of cranial nerves run from the brain to parts of the body
-​ The remaining nerves join the spinal cord and exit at the foramen magnum
-​ Each vertebrae has two spinal nerves that branch out from the spinal cord

The brain is most sensitive to changes in oxygen, glucose, or temperature

Vocab

Ischemia - reduction in blood supply

Thrombosis - a clot that forms at the sight of the blockage

Embolus - a clot that forms in a different area and travels to the site of the blockage

Infarction - death of tissue

Neglect - patients who are oblivious to their problem

Dura - covering of the brain next to the skull

Aura - warning sign prior to the seizure

Postictal State - occurs after a seizure where the patient is unresponsive at first and
gradually regains consciousness. A postictal state will have rapid, deep respirations and
tachycardia

Hemiparesis - weakness on one side of the body

Delirium - new symptom of any number of causes, signs and symptoms include confusion
and disorientation, disorganized thoughts, inattention, memory loss, striking changes in
personality and affect, hallucinations, delusions, or a decreased level of consciousness

Headache

Headache treatment is supportive, and can include creating a dark and quiet environment or
giving oxygen

Tension Headache
-​ Caused by muscle contractions in the head and neck, attributed to stress
-​ Squeezing, dull or achy pain

Sinus Headache

-​ Caused by pressure that is the result of fluid accumulation in the sinus cavities.
-​ Patients may also have cold-like signs and symptoms of nasal congestion, cough,
and fever if they have a sinus infection.
 -​ Patients may report increased pain when they bend over or when their heads are
moved forward.

Migraine

-​ Caused by changes in blood vessel size at base of brain

-​ More common in women
-​ Pounding, throbbing, or pulsating pain, nausea, vomiting, partial vision loss

Headache Red Flags

-​ Sudden onset of symptoms

-​ Headache described by the patient as “the worst headache of my life”
-​ Explosive/thunderclap pain
-​ Altered mental status
-​ Age older than 50 years
-​ Depressed immune system (known to be at higher risk for infection)
-​ Neurologic deficits
-​ Neck stiffness/pain
-​ Fever
-​ Changes in vision
-​ One-sided paralysis or weakness

Headache red flags can be caused by hemorrhagic stroke, brain tumor, or meningitis

Stroke

Cerebrovascular accident/stroke - interruption of blood flow to an area in the brain,

resulting in loss of brain function

Treat stroke patients quickly, maintain XABCs, suction as needed, be cautious with oxygen
if not indicated for respiratory distress or hypoxia but err on the side of giving oxygen,
provide emotional support and communicate with patients, even though they might not
communicate back. Provide rapid transport to a stroke center for fibrinolytic therapy (blood
clot-dissolving drugs) and mechanical clot removal in ischemic strokes.
 -​ Ischemic Stroke
-​ 87% of strokes
-​ Result of a blood clot that blocks blood flow to the brain inside a vessel
-​ Caused by embolism, thrombosis, or atherosclerosis
-​ Dramatic signs and symptoms include loss of movement on opposite side of
body, but symptoms vary based on location of clot
-​ Hemorrhagic Stroke
-​ 13% of strokes
-​ Result of a ruptured blood vessel which forms a clot, compressing brain
tissue
-​ Common in people with high stress or hypertension
-​ Transient Ischemic Attack
-​ Mini stroke event
-​ Symptoms resolve in up to 24 hours and have no death of tissue
-​ TIA’s are still urgent as they may happen soon before a stroke

Stroke Symptoms

-​ Left Hemisphere Stroke: aphasia, paralysis of the right side of the body
-​ Right Hemisphere Stroke: trouble moving muscles on the left side of the body,
slurred words, signs of neglect, vision
-​ General Signs of Stroke:
-​ Facial drooping
-​ Sudden weakness, numbness or paralysis in the face, arm, leg, or one side of
the body
-​ Place the patient’s affected or paralyzed extremity in a secure and
safe position during patient movement and transport. Decreased or
absent movement and sensation on one side of the body
-​ Lack of muscle coordination (ataxia) or loss of balance
-​ Sudden vision loss in one eye; blurred or double vision or abnormal eye
movements
-​ Difficulty understanding language
-​ Some patients who have had a stroke may be unable to communicate,
but they can often understand what is being said around them
 -​ Difficulty swallowing, Decreased LOC, Sudden and severe headache,
Dizziness, Weakness, Restlessness, Tongue deviation, Coma

Stroke symptoms can also be caused by hypoglycemia, a postictal state, or cerebral

hemorrhage

Cincinnati Prehospital Stroke Scale

Normal Response Abnormal Response

Facial droop (Ask patient to Both sides of the face move One side of the face does
show teeth or smile.) equally well. not move as well as the
other (droops).

Arm drift (Ask patient to Both arms move the same, One arm does not move, or
close eyes and hold both or neither arm moves. (The one arm drifts down
arms out with palms up.) latter response requires a compared with the other
retest because it may side.
indicate the patient did not
understand the
instructions.)

Speech (Ask patient to say, Patient uses correct words Patient slurs words,
“You can’t teach an old dog with no slurring. uses inappropriate
new tricks.”) words, or is unable to
speak

Los Angeles Prehospital Stroke Screen

Criterion Yes Unknown No

1.​ Older than 45 y

2.​ History of Seizures

3.​ Symptoms <24 hrs

4.​ At baseline, pt is not wheelchair or bedridden

5.​ Blood glucose between 60 and 400

6.​ See Cincinnati Scale

Be Fast Stroke Assessment

 Balance Did the patient experience a sudden loss of balance or inability to
walk?

Eyes Is there a change in vision? Loss of vision, double vision, or no

side or top vision?

Facial Droop Does one side of the patient’s face droop when he or she smiles?

Arm Drift Does the patient demonstrate weakness or the inability to move
one of the arms?

Speech Is the patient slurring words or using words that do not make
sense?

Time When did the symptoms first appear? Do not delay transport to
an appropriate stroke facility.

3-Item Stroke Severity Scale (LAG)

LOC Normal 0
Mild dysfunction 1
Severe dysfunction (unconscious) 2

Arm Drift Normal function 0

Mild dysfunction 1
Severe dysfunction (flaccid) 2

Gaze Normal gaze (follows pen/finger to left and right sides) 0

Mild dysfunction 1
Severe dysfunction (fixed gaze) 2

Total score >4 means stroke is likely

Cerebral Hemorrhage

Cerebral hemorrhage - Bleeding in the brain/collection of blood near the skull that presses
on the brain, usually occur as a result of trauma

-​ Subdural - rapid bleeding, high blood pressure

-​ Epidural - rapid bleeding, high blood pressure

Seizure

Seizure - neurologic episode caused by a surge of electrical activity in the brain that takes
the form of convulsions, uncoordinated muscle activity and possible altered LOC
Treat seizures by protecting them from harm, maintain a clear airway by suctioning as
necessary, and administer oxygen as quickly as possible. If head or neck trauma is
suspected, provide spinal motion restriction and never restrain a patient. Use soft materials
for padding

-​ Generalized Seizures: involves both hemispheres, possibly tachycardia,

hyperventilation, sweating, intense salivation. Lasts less than 5 minutes and followed
by a postictal state
-​ Generalized motor/tonic clonic: unconsciousness, generalized seizure
with severe twitching of all muscles that lasts several minutes
-​ Tonic phase - period of extreme muscle rigidity
-​ Clonic phase - constant muscle retraction of trembling, tongue
biting, incontinence
-​ Generalized onset-absence: brief lapse of consciousness, blank stare
and lack of response with no motor changes
-​ Focal Seizures: involving one part of the brain
-​ Focal onset-aware: no LOC change, numbness, weakness, or dizziness,
change in senses, possible slight muscle twitching or paralysis
-​ Focal onset impaired awareness: altered LOC, lip smacking, eye
blinking, isolated convulsions or jerking, changes in senses,
hallucinations, fear, repetitive physical behavior
-​ Caused in the temporal lobe

Status Epilepticus - seizures that continue every few minutes without the person regaining
consciousness or that last longer than 30 minutes

Treat status epilepticus with suction, bag mask ventilations, and rendezvous with ALS if
possible

Seizures can be caused by:

-​ Congenital origin (epilepsy), Structural Origin (tumor, infection, scar tissue, head
trauma, stroke), Metabolic (hypoxia, abnormal blood chemical values, hypoglycemia,
poisoning/OD, withdrawal), Febrile (sudden high fever)

Drugs that help with seizures:

 -​ Levetiracetam (Keppra), Phenytoin (Dilantin), Phenobarbital, Carbamazepine
(Tegretol), Valproate (Depakote), Topiramate (Topamax), Clonazepam (Klonopin)

Altered Mental Status

Altered mental status - patient is not thinking clearly or is incapable of being awakened

Treat altered mental status by determining MOI/NOI, provide spinal motion restriction,
maintain XABC’s, and transport rapidly

Can be caused by

-​ AEIOU TIPS
-​ A: Alcohol
-​ E: Epilepsy, endocrine, electrolytes
-​ I: Insulin
-​ Hypoglycemia
-​ Patient with hypoglycemia will almost always have an altered
LOC and hemiparesis
-​ May experience seizures, return to normal LOC will not happen
-​ O: Opiates and drugs
-​ U: Uremia
-​ T: Trauma, temperature
-​ P: Poisoning, psychogenic causes
-​ S: Shock, stroke, seizure, syncope, space-occupying lesion, subarachnoid
hemorrhage