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 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

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 Memory Person, place and time 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 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

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 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

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 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?

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
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

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

51. RESOURCES International Headache Society: www.ichd-3.org
CDC HEADS UP to Brain Injury Awareness:
CT State Department of Education’s Concussion Education Plan:
Brain Injury Alliance of CT:
CT Concussion Task Force:
Brain Injury Association of America:
CT Athletic Trainers Association:
CT Interscholastic Athletic Conference (CIAC) Officials Concussion Protocol:
American Academy of Pediatrics:
SNEMS-C Manual
Chapter 7, pp
Key points, p 587
Appendices A and B

52. QUESTIONS?