Neurological Emergencies: Assessment and Intervention Guidelines

1. Neurological Emergencies

2. CONFLICT OF INTEREST / COMMERCIAL SUPPORT DISCLOSURE This educational activity is being presented without the provision of commercial support and without bias or conflict of interest from the planners and presenters.

3. LECTURE OBJECTIVES • Describe assessment considerations for a student who exhibits an altered level of consciousness. • List assessment findings that indicate a neurologic problem requiring urgent or emergent care. • Describe appropriate interventions for a student with abnormal neurologic findings. • Discuss the unique challenges in assessment and treatment of neurologic emergencies involving students with special needs.

4. NEUROLOGICAL STATUS • Key component in the assessment process • Provides important indicator of the student’s overall condition • An accurate assessment helps • Identify neurologic deficits • Track changes in level of consciousness • Assess the student’s risk for neurologic deterioration

5. NEUROLOGICAL STATUS Evaluating neurologic status is a vital component of the assessment process

6. ALTERED MENTAL STATUS • Traumatic injury or shock • Vascular emergencies • Tumor that impinges on CNS structures • Infection • directly affecting CNS • accompanied by high fever

7. ALTERED MENTAL STATUS • Metabolic imbalance • Diabetic emergencies • Chemical toxicity • Alcohol • Drugs • Toxic exposure • Anoxia • Abnormal electrical activity in the brain resulting in seizure • Altered LOC may persist into the post-ictal state

8. SYSTEMATIC ASSESSMENT OF NEUROLOGICAL EMERGENCIES • Scene Safety Assessment • Across-the-room Assessment

9. SYSTEMATIC ASSESSMENT • Initial Assessment • Airway • Breathing • Circulation • Disability • Alert • Verbal • Pain • Unresponsive • Exposure

10. FOCUSED PHYSICAL EXAM Level of Consciousness • SAMPLE • AVPU Scale • Alert • Verbal • Pain • Unresponsive • See Table 7-2 • Pediatric Glasgow Coma Scale (PGCS) • Alertness (eye opening) • Major CNS motor pathways (best motor response) • Mentation (best verbal response) • See Table 7-3

11. AVPU SCALE (page 130)

12. PEDIATRIC GLASGOW COMA SCALE(page 132)

13. FOCUSED MENTAL EXAM • Orientation • Person, place and time • Memory • Auditory • Visual • Spatial • Short-term • Retrograde

14. FOCUSED NEUROLOGICAL ASSESSMENT • Facial symmetry • Ability to swallow • Pupil size and reactivity • Extraocular movements (including the position of the eyes at rest and the presence of abnormal spontaneous eye movement) • See Chapter 8 for detailed assessment techniques

15. FOCUSED ASSESSMENT • Motor function • Sensory function • Cerebellar function • Orthostatic vital signs • Additional assessments (See Appendix A)

16. EMERGENT CASES • Altered level of consciousness • Acute neurologic deficit • Generalized first-time seizure • Status epilepticus • Seizure with respiratory compromise • Seizure following head injury

17. URGENT CASES • Moderate headache with vomiting • History of migraines • No neurologic deficit • Early signs of VP shunt dysfunction • Syncopal episode

18. NON-URGENT • Generalized mild headache • Minor, asymptomatic head injury, without loss of consciousness • Signs and symptoms of upper respiratory infection • Signs and symptoms of sinus infection

19. TRIAGE (page 136)

20. REASSESSMENT & ONGOING MONITORING Timely reassessment is particularly important in students with neurologic abnormalities A PGCS score that decreases by 2 or more points indicates a significant change in condition, requiring reassessment of ABCDs

21. DOCUMENTATION • Chief complaint • History of initiating incident and past health history • Events that occurred at school • Neurologic findings and PGCS score • Baseline vital signs with blood glucose level, if available • Head-to-toe assessment • Identification of problem or nursing diagnosis • Interventions initiated and student’s response • Ongoing reassessments and subsequent vital signs

22. HEAD INJURY • Head injury • Blunt force impact is highly common • May have no external evidence • Cognitive impairment can be subtle • For any injury above the clavicle, suspect C-spine injury

23. SPINAL CORD INJURY • Spinal cord injury • Younger children are more often injured in the upper cervical vertebrae • Initiate full spinal stabilization if there are signs of spinal cord injury • Triage category is emergent

24. CONCUSSION Which gender do you think experience more concussions in similar sports? Boys or Girls?

25. CONCUSSION • INCIDENCE IN THE UNITED STATES • 3 million from all causes • 1.1 – 1.9 million sport- and recreation-related concussions in children < 18 years of age annually • Each day, more than 5 children, adolescents, or young adults die from concussion or mTBI • PATHOPHYSIOLOGY • Metabolic Mismatch • Cellular Damage • Release of Excitatory Amino Acid Neurotransmitters • Axonal Stretch Injury

26. CONCUSSION • SYMPTOMS • Headache or pressure (25-78%) • Nausea or vomiting • Dizziness or balance problems (50%) • Double or blurry vision • Sensitivity to light and/or noise • Feeling sluggish, hazy, foggy, or groggy • Concentration or memory problems • Not feeling like self • Insomnia or difficulty falling asleep

27. CONCUSSION • SIGNS • Appears dazed or stunned • Moves clumsily • Answers questions slowly • LOC, even briefly (incidence <10%) • Shows mood, behavior, or personality changes (50%) • Psychiatric disease criteria met (15-20%) • Retrograde or anterograde amnesia • Exhibits confusion, forgetfulness, being unsure of surroundings • Impaired visual tracking or balance

28. CONCUSSION • POSSIBLE SEQUELAE • Risk increases as number of concussion sustained increases • Post-Concussion Syndrome • Second Impact Syndrome (50% mortality) • Chronic changes in motor function, cognitive function, sensation, and emotion • Persistent decrease in attention, cognitive control, executive function and possible disruption of the developmental trajectory • Possible development of psychiatric conditions • TESTING • Neuropsych testing • ImPACT • MRI – will pick up 30% • Abbreviated trauma score • Acute Concussion Evaluation (ACE) • Many more

29. SYNCOPE • Orthostatic hypotension • Vasovagal reaction to anxiety or pain • Cardiac dysrhythmia • Cardiac outflow obstruction • Anemia • Hypoglycemia • Dehydration • Medications • Vertigo

30. SYNCOPE (page 139)

31. SEIZURE • Types of seizures • Partial seizures • Generalized seizures • Febrile seizures • Status epilepticus

32. TABLE 7-7 (page 140)

33. SEIZURE • Common causes • Fever • Infection (meningitis, encephalitis) • Trauma • Intracranial hemorrhage • Toxic exposure • Metabolic disturbances • Anoxia • Tumors • Congenital or degenerative disorder

34. SEIZURE INTERVENTIONS • Do not put anything in the student’s mouth • Do not restrict movement • Protect the student from injury • Remove eyeglasses • Move hard or sharp objects away • Get student out of chair • Assist with airway maintenance if needed • Carefully note duration of seizure • Carefully note seizure activity for later documentation and evaluation

35. DIASTAT

36. POST-SEIZURE INTERVENTIONS • Stabilize the cervical • Open and maintain the airway as necessary using the jaw-thrust maneuver • If no possibility of spinal trauma, place student in left lateral recovery position • Monitor for signs of respiratory compromise

37. ACTIVATE EMS • First time seizure or no known history of seizure • Seizure/series of seizures persisting for more than 5 minutes • Seizure with respiratory compromise • Seizure following head injury • Unexpected or atypical seizure in a student with a known seizure disorder

38. VNS • Vagal Nerve Stimulator (VNS) • Students with intractable epilepsy may have a VNS • Adverse effects are possible

39. IMPORTANT COMPONENTS • Documentation • Follow-up • Prevention

40. SHUNT DYSFUNCTION • Signs of Shunt Dysfunction • Nausea & vomiting • Decreased activity • Headache, irritability • Changes in vision • Seizures • Emergent or Urgent triage category

41. AUTONOMIC DYSREFLEXSIA • Hypertensive crisis occurring in students with • Quadriplegia • Spinal nerve damage at or above T6 • Triggered by painful or noxious stimuli • Bladder distention • Fecal impaction

42. AUTONOMIC DYSREFLEXIA • Signs • Erythema of upper body • Acute hypertension • Bradycardia • Cold lower extremities • Severe headache

43. AUTONOMIC DYSREFLEXIA • Interventions • Elevate head • Loosen tight clothing • Attempt to correct source of noxious stimuli • If above doesn’t resolve crisis • Triage as URGENT • If above does resolve crisis • Triage as NON-URGENT

44. HEADACHE Essential information • History and chronology of current complaint • Recent food and fluid intake • Duration and frequency of headaches • Physician has diagnosed a specific headache condition • Location and quality of pain • Measures that relieve pain (position, medication) • Factors that make pain worse • Associated symptoms

45. HEADACHE ASSESSMENT

46. TENSION HEADACHE Symptoms commonly reported with tension headaches include: • Difficulty falling asleep and staying asleep • Chronic fatigue, irritability, disturbed concentration • Mild sensitivity to light or noise • Generalized muscle aches

47. MIGRAINE HEADACHE Symptoms associated with migraine headaches may include: • Sensitivity to light, noise, or odors • GI problems, such as nausea or vomiting, abdominal pain, loss of appetite • Sensations of being very warm or cold • Fatigue or dizziness • Fever (rare) • Visual disturbances, such as blurred vision, bright flashing dots or lights, blind spots, wavy or jagged lines

48. HEADACHE COMPARISON

49. CONSIDERATIONS FOR STUDENTS WITH SPECIAL NEEDS

50. SUMMARY • Neurologic dysfunction may arise after • Direct insult to the central nervous system • Secondary effect of a systemic process • Establish a baseline for identifying neurologic deterioration • Any neurologic manifestation should be triaged as URGENT or EMERGENT except • Mild headaches • Minor, asymptomatic head injury