Emergency Nursing Course

2. Emergency Nursing Course Neurological Emergencies Dr. Fu Tat Lee (李富達醫生) Princess Margaret Hospital (瑪嘉烈醫院)

3. Outline • Neurological assessment • Stroke • Seizure • Acute generalized weakness • Headache

4. Neurological assessment • What is it? • Where is it?

7. The Neurological Assessment • History should direct the neurological examination to the most relevant areas. • Symptoms may occur before signs can be detected. • In the absence of symptoms, any signs are less likely to be important.

8. The Neurological Assessment • Look for asymmetrical abnormalities • Tendon reflexes can be absent in health but may indicate an abnormality in the sensory or motor system • An EXTENSOR PLANTAR REFLEX which is reproducible is never normal (except in infants)

9. The Neurological Assessment A. Mental Status Glasgow Coma Scale eye opening motor response verbal response B. Cranial nerves (1st - 12th) C. Upper & lower limbs - motor - sensory - coordination - reflexes

10. Decorticate posture Decerebrate posture

12. Neurological Examination Cranial nerves (1) 1st (olfactory) nerve - anosmia (loss of smell)

13. 2nd (optic) nerve - visual acuity - visual field

14. Homonymous hemianopia

15. Bitemporal hemianopia

16. 3rd (Oculomotor), 4th (Trochlear) and 6th (Abducent) nerves - eye movements, upper eyelid & pupil size

19. 5th (Trigeminal) nerve Motor: Masseter Sensory: ophthalmic, maxillary & mandibular divisions

20. VII nerve (Facial nerve)

21. Lower Motor Neuron lesion of VII nerve palsy

23. Bell’s palsy • 1st described by Dr Charles Bell in 1882 • Lower Motor neuron lesion of 7th nerve • idiopathic etiology - Dx on i) no identifiable cause (viral/post viral Sx) ii) peripheral

24. Symptoms • Pain • Tearing • Drooling • Hypersensitivity to sound • Impairment of taste

26. DDx: Central 7th nerve palsy - sparing ipsilateral frontalis muscle

27. Other causes of LMN lesion of VII nerve: Acoustic neuroma Parotid gland tumour Ramsey Hunt Syndrome: facial nerve palsy due to Herpes Zoster vesicles at the external auditory canal and ear.

29. Bell’s palsy Treatment : - Prednisolone 60 mg daily for 5 days - ? Acyclovir - physiotherapy - eyedrops and cover - refer medical or ENT if fail to recover Prognosis : 80% recover completely within 3 months

30. 8th (Acoustic) nerve - balance - deafness Weber & Rinnie Test to distinguish conductive deafness from sensory deafness

31. Rinnie test Weber test

32. 9th Glossopharyngeal nerve Muscles for swallowing

34. 10th Vagus nerve • Smooth muscles of GI & respiratory tract • Pacemaker • Muscles of heart, pharynx & Larynx gag reflex (sensory 9th) (motor 10th)

35. 11th (accessory) nerve - sternomastoid & trapezius muscle

36. 12th (hypoglossal) nerve - tongue

37. Neurological Examination Upper & Lower limbs assessment Motor • Posture, Muscle wasting, Fasciculation • Muscle Tone: Hypertonic or Hypotonic • Muscle power : • Grading : 0 complete paralysis I flicker of contraction II movement is possible where gravity excluded III movement is possible against gravity but not if any further resistance is added IV movement is possible against gravity and some resistance V normal power

38. Coordination Pastpointing, dysmetria, dysdiadochokinesia Romberg testing Gait • Tendon Reflex Hyperreflexia or Hyporeflexia • Plantar Reflex Upgoing or Downgoing

39. Line of Stroke Normal Planter reflex Barbinski reflex

41. Signs of Upper Motor Neurone Lesions • Little muscles wasting unless from disuse • Spasticity + Clonus • Hyperreflexia • Extensor Plantar response Signs of Lower Motor Neurone Lesions • Wasting is prominent • Fasciculation • Hypotonia • Hyporeflexia • Normal or equivocal plantar reflex

42. Sensation Temperature Light touch Temperature Pain Proprioception and vibration

43. Dermatone

45. Assessment of Brainstem function Brainstem reflex pupillary reactions corneal responses spontaneous eye movements oculocephalic responses (Doll’s eye reflex) oculo vesticular responses (Caloric test) respiratory patterns

46. Stroke

47. Stroke • Stroke is a syndrome of rapidly developing clinical symptoms and signs of focal or global disturbances of cerebral functions due to non-traumatic vascular causes, with symptoms lasting more than 24 hours. • Not a cerebrovascular “accident” but a consequence of cerebrovascular disease

48. Stroke is preventable • Modifiable risk factors • History of stroke or TIA • Hypertension • Cardiac diseases • Atrial fibrillation • DM • Internal carotid artery stenosis • Smoking • Alcohol abuse • Hypercholesterolemia • Obesity • Lack of exercise • Haematological diseases, coagulopathies

49. Major types of stroke • Ischaemic (70%) • Cortical • Subcortical • Posterior circulation • Lacunar infarction • Intracerebral haemorrhage (25%) • Supratentorial • Infratentorial • Both • Subarachnoid haemorrhage (5%)

50. Mortality & Morbidity