Transcript ASSESSMENT BASED MANAGEMENT

ECRN:
Assessment Based
Management; Thoracic &
Abdominal Trauma;
Neurological
Considerations
Condell Medical Center EMS System
2006
Site Code: #10-7214-E-1206
Revised by Sharon Hopkins, RN, BSN
1
Objectives
Upon successful completion of this module, the
ECRN should be able to:
1. Understand the factors that affect patient
assessment and decision making capabilities.
2. Describe the steps of patient assessment
based on ITLS guidelines.
3. Identify mechanisms of injury that can lead to
thoracic and abdominal traumatic injuries.
4. Understand EMS interventions appropriate
for thoracic and abdominal injuries.
2
Objectives cont’d
5. Describe a variety of degenerative
neurological diseases.
6. Review case scenarios.
7. Successfully complete the quiz with a score
of 80% or better.
3
ASSESSMENT BASED
MANAGEMENT
Involves the use of:
critical thinking skills
 problem solving abilities
 clinical decision making

Includes avoiding:
tunnel vision (can create distractions)
 patient labeling or jumping to conclusions
based on preconceived ideas
 “the drunk”; “the frequent flyer”; “the whiner”

4
Goals of Our Profession
Provide competent,
compassionate care
for each and every
patient interaction
You need a strong
knowledge base and
excellent
assessment skills to care for patients
5
Factors Affecting Assessment
and Decision-Making
Attitude needs to be non-judgmental




May “short circuit" information gathering
leading to insufficient information gathering
May leap to conclusions before gathering a
thorough assessment
Garbage in = garbage out
Patients depend on us for medical
assessment/ management and not
determination of social
standing or "likability"
6
Factors Affecting Assessment
and Decision-Making
Uncooperative Patients
 Perception of intoxication - drugs or
alcohol
 In all uncooperative, restless, belligerent
patients consider other possible causes
 hypoxia
 hypovolemia
 hypoglycemia
 head injury
7
Factors Affecting Assessment
and Decision-Making
Patient compliance influenced by:
 Patient confidence in the medical
team
 Prior experiences of the patient and
their family
 Cultural and ethnic barriers
8
Factors Affecting Assessment
and Decision-Making
Distracting injuries
 can divert attention from more serious
problems
Need to resist the temptation of forming an
initial diagnosis too early
Gut instincts may lead to snap judgements
Systematic approach to patient care
 helps prioritize & avoid being swayed
by the wrong impression
9
Factors Affecting Assessment
and Decision-Making
Distractors in the environment
 Scene chaos
 Violent & dangerous situations
 Crowds of bystanders
 High noise levels
 Crowds of responders
 enough
help is crucial
but they must be used
wisely
10
General Approach to
Patient Assessment in
The Field & The ED
Size-up the situation
Identify need for body substance isolation (BSI)
 gloves, gown, mask, eye protection as
needed
 Evaluate scene safety
 hazards to yourself, the team, the patient
 Identify mechanism of injury or nature of illness
 can help determine severity of situation

11
Patient Assessment
Initial assessment
To identify life-threatening conditions
 Mental status (AVPU)

A - awake, not necessarily oriented
 V - responding to verbal stimulation
 P - responding only after touch or lite pain applied
 U - unresponsive (absolutely no response)

Airway assessment
 Breathing assessment
 Circulation status
 pulses present?
 obvious bleeding to be controlled?

12
Initial assessment
cont’d

Forming a general impression
 What do you think is going on?
 These answers drive the care you want
to start providing.
 Which protocol will you follow?
13
Patient Assessment
Focused history and physical exam
performed based on chief complaint and
information gathered so far
trauma patient with significant mechanism of
injury or altered mental status
 needs rapid head-to-toe
 trauma patient with isolated injury (ie: ankle sprain)
 focus on body systems related to complaint
 medical patient (responsive) - focus exam on c/o
 medical patient (unresponsive)
 needs rapid assessment with head-to-toe
exam when patient input not available
14

Patient Assessment
Vital signs

CMC ED policy: take and record vital signs
minimally every 2 hours or more often as needed
SAMPLE history - reminds you to obtain:
symptoms
 allergies
 medications
 pertinent past medical history
 last oral intake food or liquids including water
 events leading up to the incident

Check for medic alert bracelet, necklace 15
Blood Pressure
A measurement of the force of blood against
the walls of the blood vessels
Reassessment over time gives most accurate
reflection of patient state
Changes in B/P can be very significant
Is last vital sign to change in decompensation
Cuff should cover 2/3rds of the upper arm
Cuff should not be placed over clothing
Arm should be maintained at heart level
Obese arm? Wrap cuff around forearm; place
16
stethoscope over radial pulse area
Tips, Tricks & Pearls on
Blood Pressure & Pulses
B/P by palpation can only determine a systolic
reading
As cuff is deflated, palpate over the radially area
until the pulse returns
 Record as “90/systolic”

Guidelines suggest that palpated pulses
equate with systolic blood pressures
carotid pulse felt means B/P at least 60/systolic
 radial pulse felt means B/P at least 80/systolic

No peripheral pulse? Think circulatory collapse
17
B/P should always be attempted & documented
Patient Assessment
Detailed physical exam
a more detailed & slower head-to-toe exam
than the initial one performed
 clinical experience and patient condition often
dictate how & if a detailed exam is done in the
field & if there is time before ED arrival

Ongoing Assessment - always done
used to detect trends, determine changes in
patient condition, and assess effectiveness of
interventions
 mental status, ABC’s, vital signs (pulse,
respirations, B/P, SaO2, pain level), EKG 18

Assessment Techniques
Inspection

observation; looking beyond the obvious
Palpation
use your sense of touch to gather information
 pads of fingers more sensitive than tips for touch
 back of hand is better for sense of temperature

Percussion - not often done in the field
Auscultation
listening for sounds (lungs, heart, intestines)
 for lung sounds, note abnormal sounds, location,
timing during inspiration or expiration
19

Accurate Decision
Making
Relies on:
Patient history obtained
 Physical, hands-on exam performed
 Recognizing a pattern



comparing information gathered with what you
already know (existing knowledge base)
Impression or field diagnosis made
the first diagnosis is based on the most
probable cause of the patient’s complaint
based on the information gathered during the
assessment
 used to formulate a plan of action based on the
patient’s condition and the environment

20
Use of Protocols & SOP’s
Protocol - policies and procedures of all
components of the EMS system
Standard operating procedures (SOP’s) preauthorized treatment procedures
Exercise judgement when following protocol
and SOP’s
know which protocol/SOP to choose
 know when and how to follow protocol/SOP’s
 recognize when you must deviate from the
stated protocol/SOP - allergies, abnormal vital
signs (ie: hypotension)

21
SOP’s/Protocols & The
ECRN
An ECRN, by the restriction of their
license, cannot give a medical order;
the ECRN is only authorized to give an
order if it is printed in the SOP/protocol
The ECRN must consult with the ED
MD to give an order to EMS that is not
listed in the SOP (ie: lidocaine drip after
bolus given for stable ventricular
tachycardia)
22
Difficulty Establishing
An Airway In The Field
If EMS cannot establish an airway on any
patient in the field, EMS is to transport the
patient to the closest Comprehensive
Emergency Department even if they are
on by-pass
A Comprehensive Emergency Department
is one that is open 24 hours, 7 days a
week and has a physician on duty as well
as other support services
23
Communication
Hospital reports are best when they:
Are given in less than one minute
 Are clear and concise
 Avoid use of unfamiliar or unclear medical or
technical terms including “10” codes
 Follow a basic format
 Include both pertinent findings and pertinent
negatives (findings that would be expected but
are not present)
 Conclude with specific actions, requests, or
questions related to the plan

24
Transmission of Patient
Information
Provider identified by name and vehicle number
Age, sex, and approximate weight of patient
Level of consciousness
Chief complaint and degree of distress
Vital signs, EKG, pulse oximetry, blood glucose
if obtained
If indicated, lung sounds, pupils, skin condition
and color, GCS, pain assessment
Treatment rendered and patient response
Patient history
25
ETA and destination
Calling Report on
Trauma Patients
Important for EMS to include information
the hospital can use to categorize the
trauma level for this patient as well as
determine which members of the trauma
team that need to be activated
mechanism of injury
 destruction to vehicle/surroundings
 injuries noted or suspected
 vital signs, GCS

Restlessness: first think hypoxia & shock 26
THORACIC TRAUMA
27
Anatomy & Physiology
of the Thorax
Thoracic cage responsible for moving air
in and out
Place where carbon dioxide and oxygen
exchange takes place to support
metabolism
Includes thoracic skeleton, diaphragm,
and supporting musculature
Location of major organs and vessels

heart, aorta, trachea, lungs, mediastinum
28
Thoracic Trauma
Classifying thoracic injuries
 Blunt trauma - closed
injury from kinetic
energy transmitted
through tissue
blasts
 deceleration
 compression/crush

 Penetrating
dart
trauma - open wound; direct
or indirect trauma transmitted via kinetic
energy
29
Blunt Trauma From
Blast Injuries
Blast injury - explosion caused by dust,
fumes, natural gas, explosive compounds
Confined space blast/shock wave
 pressure wave & debris cannot dissipate
as far & so maintains higher energy level
longer
 danger of structural collapse & flying
debris
 extremely deadly overpressures created
30
Thoracic Injuries
Thoracic cage - ribs &
sternal fx, flail segment
Diaphragm - tear,
laceration, rupture
Cardiovascular contusion, tamponade
Esophageal - laceration
Pleural and pulmonarycontusions, pneumo’s
Mediastinal pneumomediastinum
Penetrating cardiac
trauma - laceration
aorta, vena cava,
pulmonary arteries/veins
Spinal cord injuries
31
Flail Chest
Definition

3 or more adjacent ribs broken in 2 or more
places
Most common mechanism of injury - blunt
trauma
 falls, MVC, industrial injuries, assaults
Risks to the patient
reduces tidal volume (air moving in and out)
 increases respiratory effort
 usually accompanied by pulmonary and possibly
cardiac contusions

32
Flail Chest
Signs and symptoms

paradoxical motion of the chest wall

asymmetrical chest wall movement; flail segment
moves in opposite direction from the rest of the chest
increased respiratory effort and rate
 decreased pulse oximetry readings
 increased amount of pain to the chest wall

Treatment
support respiratory effort - supplemental O2 via
nonrebreather mask; BVM as needed
 support fractured section manually - no taping
of the chest or sandbags/IV’s placed on chest
33
 EKG monitoring

Sucking Chest Wound
Definition

open wound of the chest with air passage into the
pleural space
Risks to the patient
collapse of the lung on the affected side
 uninjured lung unable to fully expand
 change in intrathoracic pressures negatively
affect venous return to the heart
 if the chest wall opening is at least 2/3 the
diameter of the trachea (normally the size of the
patient’s little finger), air will move in & out thru
the chest wall defect & not thru the trachea 34

Sucking Chest Wound
Signs and symptoms
open wound to the thorax & frothy blood noted
around the chest wall defect
 gurgling sound heard near the chest wound
 severe dyspnea
 possible hypovolemia - associated injury &
hemorrhage
 increased pulse rate & respiratory rate;
decreased blood pressure
 evidence of air hunger if, with each breath,
more air enters thru the chest wall defect than
thru the trachea
35

Sucking Chest Wound
Treatment
Immediately seal the chest wound (gloved hand
to start with if necessary); eventually with
occlusive dressing taped on 3 sides
 Open pneumothorax now converted to closed
pneumothorax - watch for increased respiratory
distress leading to tension pneumothorax
 if needed, burp dressing by lifting one corner
during exhalation
 O2 via nonrebreather mask
 Monitor vital signs, pulse ox, EKG

36
Tension Pneumothorax
Definition

An open or simple pneumothorax that
generates and maintains a greater
pressure than atmospheric pressure within
the thorax via a created one-way valve
Risks to the patient

Air is trapped in the pleural space and puts
pressure on the affected lung, the
structures in the mediastinum, the opposite
lung
37
Tension Pneumothorax
(JVD)
Dyspnea, SOB
(rare & late sign not
often appreciated)
tachycardia
decreased
B/P
Low pulse ox,
narrowed pulse
pressure
PEA
38
Needle Decompression
Treatment
Provide supplemental oxygenation (nonrebreather
mask) or BVM
 Initially perform needle decompression

identify site: 2nd intercostal space in midclavicular line;
above the rib
 prep the site
 prepare a flutter valve on a 3 large gauged needle
 insert 3 needle largest gauge available (12-14g)
straight into the chest wall over the top of a rib
 can take the plug off the catheter end and attach a
syringe
 upon feeling a “pop” or noting air return in syringe,
advance catheter & remove needle; secure catheter 39

Needle Decompression
40
Hemothorax
Definition
 an accumulation of blood in the pleural
space due to internal hemorrhage
 more of a blood loss problem than an
airway issue
 each side of the thorax may hold up to
3000 ml of blood
Risks to the patient
hypovolemic shock
 reduction of tidal volume & efficiency of
ventilations

41
Hemothorax Signs &
Symptoms
History blunt or
penetrating trauma
decreased
blood
pressure
42
Hemothorax
Treatment
support the patient with supplemental
oxygenation (nonrebreather mask) and
potentially BVM
 IV access for fluid resuscitation

20 ml/kg normal saline (Routine Trauma Care
Protocol)
 carefully administer fluids to avoid worsening
the edema and congestion of pulmonary
contusions

Note:

Hemothorax is primarily a blood loss
problem more than a respiratory one
43
Cardiac Tamponade
Definition

A restriction to cardiac filling caused by blood
or fluid in the pericardial sac
Most common mechanism of injury

penetrating trauma (could be medical problem)
Risks to the patient
accumulating blood exerts pressure on the
heart
 pressure limits cardiac filling restricting venous
return to the heart
 cardiac output is diminished
44

Cardiac Tamponade
(JVD)
agitation
PEA
Muffled heart
tones
Diaphoretic,
ashen or
cyanotic
45
Cardiac Tamponade
Treatment
keep high index of suspicion
 field care limited to supportive oxygenation
(nonrebreather mask or BVM),IV fluids,
and rapid transport
 definitive care must be provided in-hospital
 removal of some of the accumulated
fluid from the pericardial sac in the ED
and then patient needs to go to the OR

46
ABDOMINAL TRAUMA
A high degree of suspicion
must be exercised based
on mechanism of injury
and kinematics.
47
Abdominal Anatomy and
Physiology
Boundaries
superiorly the diaphragm
 inferiorly the pelvis
 posteriorly the vertebral column, posterior
& inferior ribs, back muscles
 laterally the flank muscles
 anteriorly the abdominal muscles

48
Abdominal Anatomy and
Physiology
The 3 abdominal spaces
 peritoneal
space
 organs or portions of organs covered by
abdominal (peritoneal) lining
retroperitoneal
 organs
 pelvic
space
posterior to the peritoneal lining
space
 organs
contained within the pelvis
49
Abdominal Quadrants
RUQ
 gallbladder, right kidney, most of the liver, some
small bowel, portion of ascending & transverse
colon, small portion of pancreas
LUQ
 stomach, spleen, left kidney, most of pancreas,
portion of liver, small bowel, transverse &
descending colon
RLQ
 appendix, portions urinary bladder, small bowel,
ascending colon, rectum, female genitalia
LLQ - sigmoid colon, portion urinary bladder, small
bowel, descending colon, rectum, female genitalia
50
Blunt Abdominal Trauma
Produces least visible signs of injury
Responsible for 40% of splenic injuries
Responsible for 20% or liver injuries
Bowel and kidneys next most frequently
injured organs
Injuries must be anticipated by
evaluating mechanism of injury with
force & direction of impact
Maintain high index of suspicion based
on mechanism of injury
51
Blunt Mechanisms
Compression
forces
Shear forces
Deceleration
forces
Motor vehicle
crashes
Motorcycle
collisions
Pedestrian
injuries
Falls
Assault
Blast
injuries
52
Penetrating Abdominal
Trauma
Low velocity - injury limited to the direct area
 Knife, ice pik
Medium velocity
 Handgun & shotgun wounds
High velocity
 High power hunting rifles
 Military weapons
Ballistics - study of projectiles in motion
Trajectory - path a projectile follows
53
Distance traveled a consideration
Evisceration of the bowel caused
by a knife wound
Cover
eviscerated
area with
sterile,
moistened
dressing
Minimize
patient
movement,
coughing54
Hollow Organ Injury
Hollow organs

Stomach, small bowel, large bowel, rectum,
urinary bladder, gallbladder, pregnant uterus
Anticipated injuries
May rupture due to forces especially if the
organ is full and distended
 Can cause hemorrhage and spillage of the
contents into the peritoneal, retroperitoneal or
pelvic spaces
 Contents spilled may have high bacterial
counts, contain irritating chemicals, have high
acid counts, or contain digestive enzymes 55

Solid Organ Injury
Solid organs

spleen, liver, pancreas, kidneys
Anticipated injuries
Prone to contuse resulting in organ
damage; bleeding often minimal if organ
intact and contained within the organ but
could be severe
 If organ torn or lacerated may cause lifethreatening hemorrhage

56
Patient Assessment
Maintain high index of suspicion
Serious trauma to the abdomen is often
a surgical problem and requires prompt
and rapid transport with frequent
reassessment
Identify additional causative forces of
injury
seatbelt worn above the iliac crest
 no seatbelt restraint used, steering wheel
deformity
 type of weapon used in penetrating trauma

57
Patient Assessment For
Abdominal Trauma
Early signs of serious or continuing
internal hemorrhage
diminishing level of consciousness
 increasing anxiety or restlessness
 thirst
 increasing pulse rate
 decreasing pulse pressure - systolic and
diastolic numbers moving closer together
 increasing capillary refill time (>2 seconds)
 increasing abdominal distention, bruising 58

Abdominal Assessment
Inspection
 Redness, ecchymosis, contusions, open
wounds, distention
 May hold up to 1.5 L of blood before distended
Palpation
 Gently palpate each quadrant individually with
tips of fingers
 Quadrants with pain or injury are palpated last
 Distention, tenderness, crepitus, instability,
guarding, pulsations
Auscultation - Not often done in field in trauma too much time and need for quieter environment59
Initial Abdominal
Trauma Treatment
Timely, thorough assessment repeated
often

Critical findings: rigid or distended abdomen
or guarding; presence of shock; shock out of
proportion to findings (maybe haven’t found
all the sources of bleeding yet)
Supportive oxygenation (nonrebreather
mask)
IV access
EKG monitoring
60
Neurological
Emergencies
The human body’s ability to maintain
a state of homeostasis results
primarily from the nervous system’s
regulatory and coordinating activities
A disruption in the nervous system affects
the functioning of the body and can be
in a variety of forms from simple to
severe
61
Headache
Common ailment
Described as a symptom rather than a disorder
Can accompany many disorders
Can be brought on by emotional
events
Recurring headaches may be an
early sign of a more serious disease
Most are caused by vasodilatation
in tissues surrounding the brain
62
Headache
Immediate attention is needed if:
Severe and sudden in onset
 Other neurological impairments such as
visual disturbances, confusion, motor
dysfunction or sensory loss also occur
 Accompanied by fever
or stiff neck
 Patient states “the
worse headache in
my life”

63
Types of Headache
Migraine
 Usually one sided and accompanied by nausea
 Personal or environmental triggers
 Dietary substances or medication triggers
Cluster
 Unilateral intense pain over and behind the eye
 Lasts about an hour and occur in clusters
(bunches)
Tension
 Prolonged overwork or stress
 Usually occipital region
64
Headache
Treatment in general
 Medications based on individual history,
symptoms and needs
 Analgesics may or may not be effective
 Mild diuretics may be effective at times
 Dark environment
 Rest
 Determine trigger and
use avoidance
Accurate diagnosis
necessary in case of
more severe problem!
65
Neoplasms - Tumor
Any abnormal growth of cells
May be benign or malignant
Cell multiplication is fast and uncontrolled
Classified by origin
Treatment - depends on type, location &
age of tumor
Observation
 Chemotherapy
 Radiation therapy
 Surgical removal

66
Malignant
Neoplasms
Cancerous tumor
 Embryonic or poorly
differentiated cells
 Grow in a disorganized manner
 Necrosis and ulceration is common sign
 Invasion of surrounding tissue for
nutritional needs
 Metastatic in nature (i.e.: Initiates growth of
like tumors in other areas)

67
Benign Neoplasms
Usually not dangerous to life unless
they occur in a vital organ
Slow growth
Do not invade tissue for nutrition
Usually encapsulated
Do not form secondary tumors in other
organs
68
Assessment of
Neoplasms
Some are painful yet some have no pain at all
External presentation



Irregular borders
Rough texture
Brown/black in color
Capsule formation under the skin
Ulceration of overlying skin
Dependant on the organ or organ system
affected
69
Neoplasm
When to be concerned:
 Change in bowel or bladder habits
 A sore throat that does not heal
 Unusual bleeding or discharge
 Thickening on breast or other soft tissue
 Indigestion or difficulty swallowing
 Obvious change in a wart or mole
 Nagging cough or hoarseness
70
Neoplasm Treatment
Chemotherapy
Intravenous pharmacological therapy to
slow growth or kill tumors
 Cytotoxic to all cells of the body even
though target is cancerous cells
 Can cause lethargy, hair loss, unsteady
gait, weakness and nausea

71
Neoplasm Treatment
Radiation therapy
Ionizing radiation
 Dose of particulate or electromagnetic
radiation to a specific area of the organ or
body
 Can come from outside the body or inside
the body (implanted radiotherapy)
 More effective and less harmful than when
first introduced

72
Neoplasm
Treatment
Surgical intervention
Dependant on type and amount of tissue
involvement with the tumor
 Can be radical or precise
 Can be used in conjunction with other
therapy methods
 Can cause self esteem issues

73
Neoplasms
Prevention strategies to include in patient
teaching:
 Self breast exams
 Mammograms
 PAP smears
 Yearly physical exams
 Self testicular exams
 Prostate screening
 PSA
 Digital inspection
 Seek medical evaluation early after
abnormal finding
74
Bell’s Palsy
Seventh cranial nerve inflammation or trauma
Temporary weakness or
paralysis in facial muscles
Can reoccur
Good to complete recovery
with nerve regeneration
Conditions that compromise
the immune system increase
odds of disease

Lyme disease, herpes viruses,
mumps and HIV infections
75
Degenerative Neurological
Disorders
Muscular fatigue usually attributed to
interruption in the ability of the axon to
communicate with the muscular endplate
for various reasons
Symptoms can be mild to severe
depending on manifestation and
advancement of the disease process; can
come and go; can be localized or systemic
Chronic conditions can be debilitating and
affect quality of life
76
Degenerative Neurological
Disorders
Pathophysiology is variable and
dependant on the specific disease
Some are caused by an autoimmune type
response to a toxic invader

Example: Multiple sclerosis
Some are the muscle’s inability to use the
proteins provided by the body as fuel

Example: Muscular dystrophy
Some are actual nerve tissue breakdown

Example: Parkinson’s disease
77
Degenerative Neurological
Disorders
Partial facial paralysis

Example: Bell’s Palsy
Degeneration of the cell bodies in the gray
matter of the anterior spinal cord, brain stem
and pyramidal tract

Example: Amyotrophic Lateral Sclerosis (ALS)
Contraction of muscles or muscle groups
that can contribute to convulsive disorders

Example: Myoclonus
78
Degenerative Neurological
Disorders
An abnormal closing of the protective
bony casement for the spinal cord.
Nervous meninges may or may not be
exposed

Example: Spina bifida
Non-inflammatory lesions that affect the
peripheral nervous system

Example: Peripheral neuropathy
79
Degenerative Neurological
Disorders
General disease manifestations
Weakness
 General body aches
 Partial paralysis that comes and goes
 Parasthesia - pins & needles sensation
 Peripheral sensory impairment
 Respiratory insufficiency (chronic stages)
 Immunosuppression - more vulnerable to
contract communicable diseases
 Multiple medication interactions

80
Degenerative Neurological
Disorders
Pharmacological interventions range from
anti-inflammatory drugs to experimental
protein altering medications
Medication usage depends on the organ
system involved and the severity of symptom
Environmental changes (living in a cool area)
can help some diseases
Decreased exercise or production of
muscular heat can decrease symptoms
81
Degenerative Neurological
Disorders
Caring for the patient in crisis must
include maintaining ABC’s
Endotracheal intubation or bagging the
patient through an in-place
tracheostomy may be necessary
Supportive care for hypotension
Patients may need total lift assistance to
move
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Muscular Dystrophy
Inherited through DNA degeneration of
muscle fibers
Early recognition in children who are
slow to sit and walk
Calf muscles become bulky as
wasted muscle turns to fat
Pulmonary infections and
heart failure are frequent
causes of death
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Multiple Sclerosis
Myelin in the brain and spinal cord are
destroyed. Autoimmune system sees
myelin as foreign material.
Experience numbness to paralysis
Damage to white matter causes fatigue,
vertigo, unsteady gait,
slurred speech, pain
Some disable at onset; others
degenerative over many years
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Structure of the Neuron
and Multiple Sclerosis
The myelin sheath is a
membranous
extension of
specialized cells called
oligodendrocytes.
These form an
insulating substance.
Non-myelinated axons
(not insulated) conduct
impulses very slowly
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Parkinson’s Disease
Degeneration of nerve cell in basal
ganglia in the brain
Lack of dopamine inhibits basal ganglia
from modifying nerve pathways that
control muscle contraction
Tremors, joint rigidity
Leading cause of neuro
disability in those
over 60 years old
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Lou Gehrig’s Disease ALS
Progressive motor neuron disease
Types
Spinal muscular atrophy
 Bulbar palsy
 Primary lateral sclerosis
 Pseudobulbar palsy

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Amyotrophic
Lateral
Sclerosis
(ALS)
Upper motor
neurons affected
in the central
nervous system;
lower motor
neurons affected
in the peripheral
muscles
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Amyotrophic Lateral
Sclerosis (ALS)
More common men over 50
 Weakness, quivering
(fasciculations)
 Unable to speak, swallow, move,
breath on own
 Intellect and awareness maintained
 Become ventilator dependent
 Aspiration pneumonia constant
threat
 Starvation, failure to thrive

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Trigeminal Neuralgia
Trigeminal nerve – 5th
cranial nerve with
opthalmic, maxillary and
mandibular functions
Affects skin of upper eye,
side of nose, half of scalp
Affects mucous
membranes of nose,
forehead, upper lip
Affects lower teeth and
tongue
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Peripheral Neuropathy
Axon or myelin sheath in peripheral nervous system
damaged/irritated causing blockage of electrical
signals
Can affect:
 muscle activity
 sensation
 reflexes
 internal organ function
Can be caused locally - trauma, compression (tight
casts, tourniquet use), carpal tunnel, infections
Can be demyelination or degeneration of peripheral
nerves - diabetes, Guillain-Barre syndrome
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Myoclonus
Temporary, involuntary rapid, uncontrolled
muscular contractions (jerking) or twitching
of a group of muscles
Generally considered a symptom more
than a diagnosis
Can occur at rest or during movement
Can distort normal movement and interfere
with the ability to eat, walk, and talk
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Spina Bifida
Defect of neural tube closure
Portion of vertebra fails to develop leaving a
portion of the spinal cord unprotected
Lower back most affected
Nerve damage is permanent
Long term effects
physical & mobility limitations
 loss of bowel & bladder control
 most have some form of a
learning disability

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Spina Bifida
94
Degenerative
Neurological Diseases
Make treating the chief complaint a priority
 Do not overlook the underlying history but
do not allow it to cloud judgement for a
more serious issue
Management Plan
 History
 Acute or chronic complaint for today?
 General health?
 Previous medical conditions?
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 Medications?
Degenerative
Neurological Diseases
Management
Oxygen
 Position of comfort
 Venous access
 Pharmacological interventions
 Check for hypoglycemia in setting of
altered level of consciousness
 Antihistamine - benadryl for dystonic
reactions (impairment of muscle tone
(peculiar posturing & difficulty speaking)
after exposure usually to certain meds)
 Psychological support

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Degenerative
Neurological Diseases
Treatment concerns:
mobility often limited
 communication often difficult - hearing,
speech unclear
 respiratory compromise - especially
exacerbations of underlying problems
 anxiety - coping with debilitating disease
difficult on patient and family & stress and
anxiety levels can run high

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Case Study #1
32 year old male unrestrained in head-on
MVC at 55 mph
Awake & oriented, increased respiratory
rate, weak & rapid radial pulse
Major complaint is pain to the left side of
the chest with evident redness, crepitation
felt on palpation
Vital signs: B/P 102/50; P - 108; R - 24
pulse ox 94%; EKG - sinus tachycardia
Breath sounds - decreased left side
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Case Study #1
General impression (what are
possibilities)?
 Cardiac contusions
 Lung contusions
 Pneumothorax
The patient is becoming more restless with
increased anxiety; pulse ox dropping to
84%; respiratory rate climbing to 38 and
now shallow with increasing dyspnea
What’s going on now?
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Case Study #1
Reassess ABC’s
 Airway still open
 Breathing getting more difficult
 Breath sounds absent on the left
 Pulse more rapid and thready and
barely palpable radially
Impression:
 Tension pneumothorax
Treatment:
 Initially needle decompression
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Case Study #1
Landmarks for needle decompression?
 2nd intercostal space in the midclavicular line
 Be above the rib (avoid vessels & nerves that
run under the rib)
Equipment used in the field
 Largest gauge & longest needle available
 12-14 G and 3 inches long
 Flutter valve prepared
 Skin prepped
 Needle must be secured in place
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Case Study #2
55 year old extremely obese female
unrestrained rear seat passenger of taxi
cab involved in 60 mph MVC
Patient is agitated, complaining of pain all
over (was thrown around back of cab)
Patient is pale, slightly diaphoretic
(apologizes because she says she is
always somewhat sweaty), unable to feel
radial pulse “because of fat wrists”
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Case Study #2
If unable to take a blood pressure in the
upper arm, what are alternatives?
Place the cuff around the forearm and
place the stethoscope over the radial
pulse area.
Not acceptable to not attempt any kind of
blood pressure.
Why is this patient so restless?
Don’t be fooled by the obvious and don’t
dismiss her concerns to her “weight”
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Case Study #2
What can cause restlessness?
Hypoxia
Hypovolemia
Internal injury
Hypoglycemia
Pain
Anxiety; being scared
Being uncomfortable (pain, positioning,
full bladder)
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Acknowledgement
NIMSCA contribution for packet by:
Kathy Wexelberg RN, Advocate Christ
 Marlene Blacklaw, RN, Advocate Christ
 Lonnie Polhemus, EMT-P, Silver Cross

Additions made by:
Sharon Hopkins, RN, BSN,
Condell Medical Center
 Region X SOP’s, Effective March 2005

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