Neurological Emergencies

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.

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.

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

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

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

ALTERED MENTAL STATUS Metabolic imbalance Chemical toxicity Anoxia 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

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

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

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

AVPU SCALE (page 130)

PEDIATRIC GLASGOW COMA SCALE (page 132)

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

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

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

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

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

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

TRIAGE (page 136)

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

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

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

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

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

CONCUSSION INCIDENCE IN THE UNITED STATES PATHOPHYSIOLOGY 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

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

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

CONCUSSION POSSIBLE SEQUELAE TESTING 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

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

SYNCOPE (page 139)

SEIZURE Types of seizures Partial seizures Generalized seizures Febrile seizures Status epilepticus

TABLE 7-7 (page 140)

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

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

DIASTAT

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

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

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

IMPORTANT COMPONENTS Documentation Follow-up Prevention

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

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

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

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

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

HEADACHE ASSESSMENT Assessment Points P Q R S T Problem: How does the student describe the chief complaint? Provoke: What makes the headache worse? Palliate: What makes the headache better? Q Quality: What is the quality or character of the headache? R Radiate: Does pain or discomfort seem to travel or move? S Severity: Using a developmentally appropriate assessment tool, how does the student rate the severity of pain or discomfort? Signs: What clinical signs accompany the problem? Symptoms: What subjective problems does the student report? T Timing: When did the problem start? Was the onset sudden or gradual?

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

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

HEADACHE COMPARISON

CONSIDERATIONS FOR STUDENTS WITH SPECIAL NEEDS Condition Associated Complications Hydrocephalus with CSF shunt Increased intracranial pressure secondary to loss of shunt integrity, disconnection, infection, or obstruction Congenital heart disease Aortic stenosis, arterial occlusion, venous occlusion Diabetes Syncope, seizures; altered mental status due to hypoglycemia or DKA Hemophilia Intracranial hemorrhage from relatively minor trauma Myasthenia gravis Muscle weakness, ptosis, diplopia; ventilatory compromise due to myasthenic crisis Seizure disorder Seizures, status epilepticus; changes in consciousness associated with postictal state Sickle cell disease Cerebral infarction; hemorrhage

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

RESOURCES International Headache Society: www.ichd-3.org CDC HEADS UP to Brain Injury Awareness: www.cdc./gov/headsup CT State Department of Education’s Concussion Education Plan: www.sde.ct.gov Brain Injury Alliance of CT: www.biact.org CT Concussion Task Force: www.connecticutconcussiontaskforce.org Brain Injury Association of America: www.biausa.org CT Athletic Trainers Association: www.cata45.wildapricot.org CT Interscholastic Athletic Conference (CIAC) Officials Concussion Protocol: www.casciac.org American Academy of Pediatrics: www.AAP.org SNEMS-C Manual Chapter 7, pp 125-150 Key points, p 587 Appendices A and B

QUESTIONS?