723 Neuromuscular System

nervous system red flags general

• Dizziness

• Drop attacks (sudden falling to the ground without loss of consciousness)

• Diplopia

• Dysarthria

• Dysphagia

• Ataxia

• Nausea

• Numbness

• Nystagmus

nervous system red flags sensory changes

• loss of sensation

• numbness/tingling

• saddle anesthesia or paresthesia

nervous system red flags motor changes

• Weakness

• Bilateral weakness

• Gait difficulty

nervous system red flags reflex changes

• Hyporeflexia (Lower motor neuron/PNS issue)

• Hyperreflexia (Upper motor neuron/CNS issue)

nervous system red flags other changes

• Sudden or new onset headaches

• Changes in speech, vision, hearing, sense of smell

• Memory changes or confusion

• Seizures

• Tremors

• Changes in coordination

musculoskeletal system red flags

• night pain

• pain at rest

• recent trauma or motor vehicle collision

• prolonged use of corticosteroids

Bell’s Palsy

is a compromise of cranial nerve VII leading to facial drooping. Patient will lose function of the upper and lower parts of the face meaning they cannot control their mouth or their eyebrows.

nervous system emergency conditions

• Stoke

  • Hemorrhagic or ischemic

• Seizure

  • If patient has a history of seizures, seizure >5min is an emergency

  • If no history of seizures, any seizure regardless if length is an emergency

• Acute/Sudden Cranial Nerve Changes

  • Dysphagia, dysarthria, vision changes, facial or sensory weakness, hearing loss, vertigo

• Cauda Equina Syndrome (bundle of nerve roots at the bottom of the spine become compressed)

  • Compression of L1-S2

  • LE weakness, bowel or bladder changes, hyporeflexia of LE reflexes

nervous system emergency situations

• Loss of consciousness or difficult to arouse

• Extreme confusion

• Acute infection

• Rapid onset of focal neurological deficits

  • Weakness, numbness, tingling

  • Blurred or decreased vision

  • Loss of speech or trouble understanding speech

  • Headache (“worst headache of my life”)

  • Dizziness, loss of balance

• Evidence of spinal column instability (decline in motor or sensory status with position change and/or bilateral UE paresthesia with neck flexion)

nervous system urgent conditions

• Myelopathy: compression of spinal cord, usually cervical or thoracic

• If the patient has a history of seizure disorder

• Suspicion of undiagnosed neurological disorder

• Disc herniation causing neurologic compromise at the nerve root

nervous system urgent situations

• Progressive neurological signs in a known neurological diagnosis that is not degenerative

• Evidence of lower motor neuron disease not previously diagnosed

• New onset of involuntary movements or tremor

• Changes in autonomic status (HR, RR, BP, temp, etc)

• Constant headache worsens overtime

• Patient report of transient ischemic attack symptoms

• Gradual/progressive onset of cranial nerve signs/symptoms

• Vertebral artery insufficiency

• Neurological signs inconsistent with the current diagnosis

• Changes in personality or cognitive status

musculoskeletal system emergency situations

• Fracture of dislocation causing neurologic or vascular changes/compromise

• Upper cervical ligamentous instability causing neurologic symptoms

• Suspicion of cervical spine fracture  

musculoskeletal system emergency situation

• Fracture or dislocation not causing neurological or vascular compromise

• Suspicion of severely compromised soft tissue

what to do in emergency situations

call 911 or follow facility policy (AKA call a code)

what to do in urgent situations

decide who to refer to… who can see them soon enough

fibers controlling the lower face..

travel from cortex to brainstem and cross over to the contralateral facial nerve

fibers controlling the upper face..

travel from the cortex to brainstem, then cross over AND stay ipsilateral, contributing to both the contralateral and ipsilateral facial nerve

when damage occurs to the motor cortex (as in stroke)…

the patient retains function of the eye/upper half of the face because of the contra and ipsilateral innervation. Patient can still raise eyebrows symmetrically but cannot smile symmetrically

When damage occurs in the PNS to the facial nerve (Bell’s palsy)..

the patient loses function of the upper AND lower halves of the face. The patient cannot raise the eyebrows or smile symmetrically

upper motor neuron issue symptoms

• diminished diffuse sensation for dermatomes

• general myotome weakness

• hyperreflexia

• positive UMN tests

lower motor neuron issue symptoms

• diminished sensation following dermatome pattern

• myotome weakness consistent with spinal level

• hyporeflexia

• negative UMN tests