Neurology Flashcards

Mental Status Examination

• Mental status is assessed throughout the interaction with a patient by evaluating:
  • Alertness
  • Orientation
  • Cognitive abilities
  • Mood
• Mental status defined:
  • Total expression of emotional responses
  • Mood
  • Cognitive functioning (ability to think, reason, and make judgments)
  • Personality

Observation of the Patient

• Appearance and Behavior:
  • Grooming: Appropriateness for age, season, and uniform wear.
    • Poor hygiene in a previously well-groomed individual may indicate depression.
  • Emotional Status
  • Body Language: Note eye contact.
• Emotional Stability:
  • Mood and Feelings: Ask about feeling down, depressed, or hopeless over the past two weeks, and about loss of interest or pleasure in doing things.
    • Positive responses indicate further evaluation.
  • Emotional status: Observe behavior for cooperativeness, friendliness, and appropriate concern for topics discussed.
• Cognitive Abilities:
  • Patient consciousness: Orientation to person, place, and time; appropriate responses.
  • Memory: Evaluate immediate memory with a list of five words, then delayed recall a few minutes later without prompting.
• Speech and Language:
  • Voice Quality: Inflections, clarity, strength, and ability to increase in volume.
  • Rate of Speech: Assess for excessively fast, slow, normal pace, or hesitations.
  • Speech: Should be fluent with clear expression of thoughts.
  • Articulation
  • Comprehension
  • Coherence
  • Aphasia

Pre-Hospital Skull Fractures and Brain Injuries Assessment

• Evaluate Airway, Breathing, and Circulation (ABCs).
• Assess AVPU (Alert, Verbal, Pain, Unresponsive).
• Signs and Symptoms of Skull Fractures and Brain Injuries:
  • Visible bone fragments and possibly brain tissue.
  • Altered mental status.
  • Deep laceration, severe bruise, or hematoma to the scalp or forehead.
  • Depressions or deformity of the skull, large swellings, or unusual cranium shape.
  • Severe pain at the site of head injury.
  • "Battle's sign" (late sign).
  • Pupils unequal or nonreactive to light.
  • "Raccoon eyes", black eyes, or discoloration under both eyes (late sign).
  • One eye appears sunken.
  • Bleeding from the ear and/or nose.
  • Clear fluid from ears and/or nose (CSF).
  • Personality change (major sign).
  • Increased blood pressure and decreased pulse rate (Cushing's reflex).
  • Irregular breathing patterns.
  • Temperature increase (late sign).
  • Blurred or multiple-image vision.
  • Impaired hearing or ringing in the ears.
  • Equilibrium problems.
  • Forceful or projectile vomiting.
  • Decorticate or decerebrate posturing.
  • Paralysis or disability on one side of the body.
  • Seizures.
  • Deteriorating vital signs.
  • Head injury with shock: look for blood loss elsewhere (except in infants).
  • Assume skull or brain injury based on mechanism and location of injury.

Treatment

1. Take appropriate Standard Precautions.
2. Consider spine injury; provide manual stabilization if indicated.
3. Open and maintain the airway.
4. Monitor the unconscious patient for changes in breathing; avoid hyperventilation.
5. Apply rigid cervical collar, immobilize the neck and spine; determine method of extrication if appropriate.
6. Control Bleeding; avoid direct pressure if bone fragments, depression, or exposed brain is present; do not stop CSF flow from ears or nose.
7. Keep the patient at rest.
8. Talk to the conscious patient, providing emotional support.
9. Dress and bandage open wounds; stabilize penetrating objects.
10. Manage the patient for shock, even if signs are not present.
11. Be prepared for vomiting; have suction unit ready.
12. Transport the patient promptly.
    • Monitor vital signs every 5 minutes enroute to the hospital.
    • Assess patient's response to questions:
      • Does he/she know where they are?
      • What is there current place of location?
      • What time of day/What day is it?
13. Assess patient's eyes for size, shape, equality, and reactivity.
14. Assess patient's respiratory system for any abnormalities.
15. Assess patient's vital signs for any abnormalities.

Seizure Assessment

1. Place patient on the floor or ground; position on side (if no spine injury).
2. Loosen restrictive clothing.
3. Remove objects that may harm the patient.
4. Protect the patient from injury, but do not try to hold the patient.
5. Protect the patient's airway.
6. If patient is cyanotic, ensure an open airway and provide artificial ventilations with supplemental oxygen.
7. Treat any injuries sustained during the seizure.
8. Transport to a medical facility.
9. Monitor vital signs and respirations during transport.

Military Acute Concussion Evaluation (MACE 2)

• MACE 2 Exam: Conducted on any patient with a suspected concussion or TBI immediately following the injury event or as soon as possible.
  • Screening tool for assessing concussion in the deployed setting.
  • Takes approximately 10 minutes to administer by a skilled medic/corpsman or a provider.
  • MACE 2 alone doesn't diagnose concussion.
  • Assists in obtaining the event that later helps providers determine how to proceed with the cognitive screening, symptom screening and neurological evaluation.
  • All findings, whether positive or negative should be presented to the medical provider for further diagnosis or treatment.

Concussion

Description of Incident.

• Alteration of Consciousness or Memory.
• Symptoms.
• History?
• Orientation?
• Immediate Memory
• Speech Fluency?
• Word Finding?
• Grip Strength
• Pronator Drift.
• Single Leg Stance.
• Tandem Gait.
• Pupil Response.
• Eye Tracking
• Concentration
• Delayed Recall
• Vestibular/Ocular-Motor Screening (VOMS) for Concussion Instructions
• Neurological Conditions

Pathophysiology/Mechanism of Injury/Nature of Illness

• A blow causes acceleration-deceleration and rotational forces that may stretch, compress, or shear nerve fibers as the brain moves within the skull, and disrupts the brain chemicals responsible for brain functioning; often caused by sports injuries.

Pre-Hospital/Inpatient/Outpatient Considerations

Subjective/Injuries/Illness

• Headache
• Dazed or dizzy
• Nausea or vomiting
• Blurred vision
• Ringing in ears
• Amnesia
• Restless or irritable
• May or may not have lost consciousness

Objective Data/Signs/Symptoms

• What was the person doing at the time of the event?
• Exactly what does the person remember from the event?
• How long were they unconscious? If needed, utilize bystanders for that information.
• Possible symptoms that you may see:
  • Dazed expression
  • Slow motor and verbal responses, slurred speech
  • Emotional liability
  • Hypersensitivity to stimuli
  • Deficits in coordination, cognition, memory, and attention
  • Coma (sign of a more severe injury)
  • Symptoms may disappear within 15 minutes or persist for several weeks

Assessment

• Concussion

Plan/Treatment

• Immobilize and evaluate the cervical spine, if indicated.
• Perform serial observations of level of consciousness.
• Administer nonnarcotic analgesics for headache.
• Admit the patient to the hospital for observation if the following are present:
  • Level of consciousness does not quickly return to normal.
  • Severe vomiting
  • Skull fracture
• Discharge the patient home if a family member or friend can reliably follow careful verbal and written aftercare instructions.
• It is important to make the patient aware of the possibility of post concussive symptoms so they can seek follow-up and treatment.

Seizures

Pathophysiology/Mechanism of Injury/Nature of Illness

• When normal functions of the brain are upset by injury, infection, or disease, the brain's electrical activity can become irregular. This irregularity can bring about a sudden change in sensation, behavior, or movement, called an seizure. A seizure itself is not a disease in itself, but, rather a sign of some underlying defect, injury or disease.

Pre-Hospital/Inpatient/Outpatient Considerations

Subjective Data/Injuries/Illness

• History of prior seizure
• Premonition or aura (headache, mood change, anxiety, irritability, lethargy, changes in appetite, dizziness, and lightheadedness)
• Body is stiff and rigid, followed by rhythmic jerking movements
• Eyes roll upward
• Drooling
• Loss of bladder or bowel control

Objective Data/Signs/Symptoms

• Tonic phase: body becomes rigid, for no more than 30 seconds. Breathing may stop, patient may bite their tongue, and bowel and bladder control could stop.
• Clonic phase: body jerks about violently usually for no more than 1-2 minutes, patient may foam at the mouth and drool, while their face and lips often become cyanotic.
• Postictal state: coma followed by confusion and lethargy.
• Common EEG findings of spikes and waves.

Assessment

• Seizures

Plan/Treatment

• If you are present when a convulsion seizure occurs
  • Administer oxygen as needed to maintain saturation.
  • Maintain airway, breathing, and circulation.
  • Safeguard the patient from injury.
  • Turn patient on side and suction oropharynx as needed.
  • Protect the head.
  • Side rails up at all times.
  • Pad side rails with blankets.
• Once the convulsive seizure has ended
  • Most seizures spontaneously resolve. Administer benzodiazepines (e.g., diazepam [Valium], lorazepam [Ativan]) intravenously to control unresolved seizure activity, as ordered. Intravenously administer anticonvulsants, such as phenytoin (Dilantin) or phenobarbital, once seizures have been controlled, as ordered.
  • Obtain and send therapeutic drug level samples for any anticonvulsant agents that may have been prescribed for the patient.
  • Treat any injuries sustained.

Meningitis

Pathophysiology/Mechanism of Injury/Nature of Illness

• The bacterial, viral, or fungal organism often colonizes in the upper respiratory tract, invades the bloodstream, and then crosses the blood-brain barrier to infect the cerebrospinal fluid and meninges.

Pre-Hospital/Inpatient/Outpatient Considerations

Subjective Data/Injuries/Illness

• Fever, chills
• Headache, stiff neck
• Lethargy, malaise
• Vomiting
• Irritability
• Seizures

Objective Data/Signs/Symptoms

• Altered mental status, confusion
• Nuchal rigidity
• Fever
• Brudzinski (on passive flexion of the leg, a similar movement occurs, or involuntary flexion of the knees and hips following flexion of the neck while supine) and Kernig (Involuntary contraction of the hamstring muscles sue to irritation of the nerve roots supplying them) signs may be positive
• Petechiae and purpura with meningococcal meningitis
• Lumbar puncture and cerebrospinal fluid culture confirm the diagnosis

Assessment

• Meningitis

Plan/Treatment

• Initiate respiratory isolation.
• Maintain airway, breathing, and circulation.
• Administer supplemental oxygen.
• Obtain vascular access and administer the following:
  • Fluid boluses (20 mL/kg) for hypotension and poor perfusion
  • Antibiotics
  • Antipyretics
  • Analgesics
• Administration of dexamethasone for suspected H. influenza meningitis has not been proven to be a beneficial adjunct in improving outcomes.
• Perform ongoing neurologic assessments and document Glasgow Coma Scale score.
• Consider placing a gastric tube and indwelling urinary catheter.
• Institute seizure precautions.

Stroke

Pathophysiology/Mechanism of Injury/Nature of Illness

• Ischemic strokes (most common cause) occur when a thrombus or embolism interrupts the blood supply, oxygen, and nutrients to the brain, and brain cells die.
• Intracerebral or subarachnoid bleeding causes about 15% of hemorrhagic strokes, often within the distribution of the anterior circulation of the brain; brain cells die due to the bleeding into or around the brain.

Pre-Hospital/Inpatient/Outpatient Considerations

Subjective Data/Injuries/Illness

• Sudden numbness or weakness, especially on one side of the body.
• Sudden confusion or trouble speaking or understanding speech.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble with walking, dizziness, or loss of balance or coordination.
• Sudden severe headache with no known cause.

Objective Data/Signs/Symptoms

• Signs vary by part of the brain affected.
• Elevated blood pressure
• Altered level of consciousness.
• Difficulty managing secretions.
• Weakness or paralysis of extremities or facial muscles on one or both sides of the body.
• Aphasia, receptive or expressive.
• Articulation impairment.
• Impaired horizontal gaze or hemianopia.
• Brain imaging with CT and MRI diagnose the type of stroke.
• You can also utilize the Cincinnati Pre-Hospital Stroke Scale to gauge if the patient has had a stroke. If the patient meets one of the following criteria, the likelihood of stroke is approximately 70%. The scale is based off from three criteria, listed below:
  • Facial Droop (Ask the patient to grimace or smile.)
    • Normal - Both sides of the face move equally
    • Abnormal - One side of the face does not move at all.
  • Arm Drift (Ask the patient to extend arms out in front of them.)
    • Normal-Both arms move equally or not at all.
    • Abnormal - One arm drifts compared to the other.
  • Speech (Have the patient say "You can't teach an old dog new tricks.")
    • Patient uses correct words with no slurring.
    • Slurred or inappropriate words or mute

Assessment

• Stroke

Plan/Treatment

• Administer supplemental oxygen if oxygen saturation via pulse oximetry is less than 92%.
• Consider advanced airway as needed.
• Obtain second intravenous (IV) line with normal saline solution.
• Initiate continuous cardiac monitoring.
• Treat hypoglycemia: do not treat hyperglycemia unless serum glucose is over 185 mg/dL.
• Maintain normal body temperature; treat fever greater than 37.5° C (99.5° F).
• Keep patient "nothing by mouth" (NPO) until he or she can be screened for dysphagia.
• Continuously reassess the patient's neurologic status.

Bell's Palsy

Pathophysiology Mechanism of Injury/Nature of Illness

• May be caused by an acute inflammation of the facial nerve (cranial nerve VII), such as a viral infection with herpes simplex, which leads to ischemia and demyelination.
• Other potential causes include central nervous system lesions (e.g., multiple sclerosis, stroke, or tumor) or structural lesions in the ear or parotid gland.
• Occurs more commonly in patients with diabetes mellitus.

Pre-Hospital/Inpatient/Outpatient Considerations

Subjective Data/Injuries/Illness

• Rapidly progressive muscle weakness on one side of face (over 2 to 3 days).
• Feeling of facial numbness.

Objective Data/Signs/Symptoms

• Facial creases and nasolabial fold disappear on affected side.
• Eyelid will not close on affected side and lower lid sags; leads to eye imitation; eye may tear excessively.
• Food and saliva may pool in affected side of mouth.
• Facial sensation is intact.

Assessment

• (Dx) Bell's Palsy

Plan/Treatment

• Antiviral medications and corticosteroids may shorten the disease course.
• Analgesics for pain.
• Eye care: artificial tears during the day, lubricants for nighttime eye protection.
• Consider facial massage to prevent contracture or paralyzed muscles.

Peripheral Neuropathy

Pathophysiology

• Other causes include altered lipid metabolism, vitamin B12 or folate deficiency; neuropathy associated with Lyme disease, HIV infection, and diabetic polyneuropathy are believed to have an autoimmune etiology.
• Impaired blood flow, vasoconstriction, and chronic ischemic changes within the peripheral neuronal fibers lead to the sensory and autonomic nerve function deficits.

Pre-Hospital/Inpatient/Outpatient Considerations

Subjective Data/Injuries/Illness

• Gradual onset of numbness, tingling, burning, and cramping, most commonly in the hands and feet.
• Night pain in one or both feet.
• Early signs may be unusual sensations of walking on cotton, floors feeling strange, or inability to distinguish between coins by feel.
• Sensation of burning accompanied by hyperalgesia and allodynia (all sensation is painful).

Objective Data/Signs/Symptoms

• Reduced sensation in the foot with the monofilament; loss of pain or sharp touch sensation to the mid-calf level.
• Distal pulses may be present or diminished.
• Diminished or absent ankle and knee reflexes.
• Decreased or no vibratory sensation below the knees; temperature sensation may be less impaired.
• Distal muscle weakness, inability to stand on toes or heels.
• Skin ulceration or injuries to extremities the patient does not feel.

Assessment

• (Dx) Bell's Palsy

Plan/Treatment

• Nonpharmacological treatment of painful peripheral neuropathy is aimed at
  improvement of glycemic control; avoidance of alcohol; physical therapy; use of
  relaxation, acupuncture, or biofeedback techniques; or referral to a pain control clinic.
• Improvement in glycemic control may result in a temporary worsening of painful neuropathic symptoms, but pain will abate with the maintenance of good blood glucose levels.
• Topical treatments include capsaicin and lidocaine patches

De-Escalation of an Unstable Patient

Unstable Patient Recognition

• Aggressive or disruptive behavior may be caused by trauma to the brain and nervous system, metabolic disorders, stress, alcohol, other drugs, or psychological disorders.
• You may know your patient is aggressive from information you receive from dispatch, clues from the scene, or neighbors, family members, and bystanders.
• The patient's stance (tense muscles, fists clenched, or quick irregular movements) or his position in the room may give you an early warning of possible violence.
• Occasionally a calm patient may suddenly turn aggressive.
• If a patient acts as if he may hurt himself or others, take the following precautions:
• Do not isolate yourself from your partner or other sources of help; make sure you have an escape route.
• Do not take any action that may be considered threatening by the patient.
• Always be on the watch for weapons; stay out of kitchens and move to a safe area, if necessary, until law enforcement controls the scene.

Unstable Patient Assessment

• Your assessment may not go beyond the primary assessment phase until the patient is appropriately calmed or restrained.
• Most of your time may be spent trying to calm the patient and ensuring everyone's safety.
• Signs of an aggressive or hostile patient
  • Responds to people inappropriately
  • Tries to hurt himself or others
  • May have a rapid pulse and breathing
  • Usually displays rapid speech and rapid physical movements
  • May appear anxious, nervous, "panicky"

Treatment of an Unstable Patient

• Treatment begins with the initial encounter; request assistance from law enforcement, if necessary, and take Standard Precautions.
• Seek advice from medical provider if the patient's behavior prevents normal assessment and care procedures.
• As part of reassessment, watch for sudden changes in the patient's behavior; complete reassessments upon any change in mental status
• Seek assistance from law enforcement, as well as from medical direction, if restraint seems necessary.

Patient Restraints

Restraint Use

• Reasonable force is the force necessary to keep a patient from himself or others.
• Reasonableness is determined by looking at all circumstances involved:
  • Patient's strength and size
  • Types of abnormal behavior
  • Mental status
  • Available methods of restraint
• You must avoid actions that can cause injury to the patient.
• HM's cannot legally restrain a behavioral emergency patient, move the patient against his will, or force a patient to accept emergency care.
• The restraint and forcible moving of patients is usually within the jurisdiction of the medical provider or law enforcement.
• If a provider orders restraints, they must perform or assist with these procedures as necessary; follow local protocol.
• At times, a patient with a medical or traumatic emergency may display violent behavior to the extent that restraint is necessary before the patient can receive the medical treatment he needs.
• Determining whether a particular patient has a medical or traumatic emergency that is causing abnormal behavior can be difficult; consider whether the patient is capable of giving or refusing informed consent, consult with a medical provider, and administer care without endangering yourself.
• Never try to assist in restraining a patient unless you have sufficient personnel.
• If you help the nurse or physician restrain a patient, make certain the restraints are humane.
• Restraints for the wrists and ankles can be made from gauze roller bandages.
• Be alert for excited delirium; monitor the patient constantly.
• Do not remove soft restraints, even if the patient appears to be acting rationally.

Guidelines for when a patient must be restrained:

• ONLY A PROVIDER CAN ORDER RESTRAINTS!
• Be sure to have adequate help.
• Plan your activities; have a well-delineated plan of action before initiating restraint
• Estimate the range of motion of the patient's arms and legs and stay beyond range until ready.
• Once the decision to restrain the patient has been reached, act quickly.
• Approach with a minimum of four persons, one assigned to each limb, all to act at the same time.
• Secure all four limbs with restraints approved by medical provider.
• Position the patient face up,
• Position dictated by restraining process itself, patient's condition, and local protocols.
• Never restrain the patient in any manner that will impair breathing or cause positional asphyxia.
• Monitor all restrained patients carefully.
• Use multiple straps or other restraints to ensure that the patient is adequately secured.
• If the patient is spitting on rescuers, place a surgical mask on the patient if he has no breathing difficulty or likelihood of vomiting (and if protocol permits); have rescuers wear protective masks, eye ear, and clothing
• Reassess the patient's distal circulation frequently and adjust restraints as safe and necessary.
• Use sufficient force, but avoid unnecessary force.
• Document the reasons why the patient was restrained and the technique of the restraint.

Document Neurology Encounter in a SOAP Note

• Documentation on SOAP note classroom activity based on case study.
• HM1 Robert R. Ingram is a 32-year-old male who comes into the Battalion Aid complaining of having trouble with his sense of balance. He states that since waking up this morning his right hand also seems to be jittery and uncontrollable. You notice that is posture is becoming stooped and when you ask him a question, his reaction and response is slow.