1. Management of clients with nervous diseases

2. Stroke
is acute disorders of cerebral blood circulation, rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other then that of vascular origin

3. Stroke morbidity in different countries
per 100 OOO of population
Stroke morbidity in different countries
Ischemic stroke
1:3,6
Hemorrhagic stroke
1:7

4. Stroke morbidity
per of population

5. Stroke mortality in different countries
per of population

6. Mortality from different types of stroke in Ukraine
per of population

7. Nowadays

8. ... Every fifth Ukrainian resident will die of stroke ...

9. Every fifth one will finish his life as depending from others disabled person

10. Classification Strokes: Haemorrhage subdural, epidural
intracerebral haemorrhage
ventricular hemorrage
mixed
Ischemic
Atherothrombotic
Cardioembolic
Hemodynamic
Rheologic
Lacuna

12. Combined hemorrhages (they take the whole region of basal nuclei: subcortical nuclei, thalamus, internal capsule)

13. Peculiarities of hemorrhage
Sudden onset (during day – time, after physical or emotional stress, while activity)
In young people (age 40 – 45)
Precursors are very rare (headache, dizziness)
It is associated with severe headache
Vomiting with blood portion can be observed
Consciousness disorders, psychomotor agitation
Facial hyperemia, tachycardia, tachypnoe, increased BP – autonomic changes

14. Peculiarities of hemorrhage
There are two groups of symptoms – general cerebral and focal
General cerebral are well expressed at hemorrhage and dominate over focal ones
While hemorrhage in right hemisphere involuntary movements of non – paralyzed extremities (parakinesis) or syndrome of automatic gesticulation can be observed
State of patients with hemorrhage is very severe

15. Coma
is characterized by deep consciousness disorder, disturbance of breathing and heart activity. The patient doesn’t respond to stimuli.

16. C o m a response to stimuli is absent eyes are closed, mouth is opened
face is red, lips are cyanotic, skin is cold,
neck vessels are pulsing
there is breathing disturbance
pulse is strained and slow
blood pressure is increased
temperature increases in 24 hours
patient is lying on his back
all muscles are relaxed
pupils are changed (there can be anizokoria, cross – eyes, sometimes gaze paresis can be observed)
mouth angle is a little bit lower

18. Brain infarction

19. Clinical features
Precursors - transient ischemic attacks in the same region where brain infarction is developed. Gradually during several hours focal neurologic symptoms are developed.
The prevalence of focal symptoms over the general cerebral ones.
General cerebral symptoms manifest as:
Headache
Vomiting
Consciousness disorders
Focal symptoms depend on localization of the infarction, damaged vessel and state of collateral blood circulation.

20. Clinical features Atherothrombotic stroke
Occur at older age
Developed during some ours and days
TIA present in anamnesis
Developed at night or in the morning time
Stenosis and occlusion of MAH at ultrasound examination
Decreased of Internal Carotid artery pulsation on the neck

21. Ischemic stroke
Extensive
Lacunar 21

23. Smoking
Risk of recurring stroke in smokers increases in 1.5 times

24. Weight
For all over weighted people is recommended to keep weight index between 18,5 and 24,9 kg/m2 and size of waist not more than 88 sm in women and not more than 102 sm in men (Northern Manhattan Study)

25. Physical activity
For patients are recommended physical exercises not less than 30min per day

26. Definition
Spinal osteochondrosis – is a degenerative lesion of cartilage - between vertebral disc associated with reactive changes in neighboring vertebras, between vertebral joints and connecting apparatus

27. Vertebrogenous syndrome
Limitation of movements in lumbar – sacral part of spinal cord (bending forward, backward)
Increasing of pain while movements, coughing and laughing
Protective straining of long back muscles
Extension of lumbar lordosis, cyphosis in lumbar – sacral division
Scoliosis, sometimes with rotation
Painful paravertebral points and vertebral processes

28. Vertebrogenous syndrome
Discharge – postures and symptoms
Knee – elbow position
While standing the patient keeps his leg aside in order to make the load less on his leg
While lying in the bed he bends his leg in all joints.
The symptoms of spinal cord instability (it is difficult for the patient to stand, to wash himself, but it is much more easier to walk)

30. The points of pain: Pain along the crista iliaca
The point of iliosacral joint
The point of m. gluteus minimus (just under the crista iliaca)
The point of m. gluteus medius (1 sm lower)
The point under the backside fold
Trochanter os iliaca
Along the ischiadic nerve (the posterior surface of hip and fossa subpoplitea)

31. The symptoms of strain
Lasegue’s symptom – in case of straining and lifting the leg the low back pain appears
Neri symptom – there is pain in leg at bending head forward
Matskevych symptom – there is pain in the anterior surface of the leg at knee bending while lying on abdomen
Wasserman symptom – the same clinical picture at lifting the leg

32. The symptoms of strain
Sequar symptom – there is pain on posterior surface of leg at foot flexing
Turin symptom – the same clinical picture at toe’s flexing
Bechterev’s symptom – there is pain at knee – flexed leg extension
Dejerine’s symptom - there is pain in posterior surface of the leg at coughing, sneezing

34. Prevention Hypokinesia prevention Moderate physical activity
Treatment of chronic diseases

35. Epilepsy and convulsion syndromes

36. Epilepsy
is a chronic disorder, which is characterized by the presence of:
Epileptic focus
Recurrent attacks with various clinical signs
Personality disorders between attacks
Some specific paraclinical signs

39. Clinical features A. General seizures.
Epileptic general tonic – clonic attack (grandmal) usually begins with short initial stage that lasts several seconds. The last can manifest as:
Bilateral general muscle jerks
Loss of consciousness
Autonomic changes
Enlargement of pupils

40. Clonic epileptic attacks
general typical clonic attacks are often observed in newborn babies.
loss of consciousness
autonomic disorders
rhythmic clonic seizures
between the attacks of clonic muscles jerks there is muscle hypotonia
If the attacks last 1–2 min the consciousness recovers quickly. But these attacks can last 4–5 min and even more. Then after the attack coma can be developed.

41. Treatment of patients with epileptic status

42. Measures Time, min Treatment 0-5
Definition of state of living functions. Oxigenotherapy.
6-10
Intravenous infusion of physiological solution. Checking of tempeature, BP, biochemical blood analysis.
Intravenous injection of Tiaminum 100 mg, then 50 ml 40 % glucose.

43. Time, min
Treatment
11-15
Intravenous injection of Diazepam 0,2 mg per kg (speed 5 mg per min). Injection is repeated every 5 min. General dose is not more then 20 mg
16-45
Intravenous injection by drops of Fenitoin in dose 20 mg per kg (speed 50 mg per min).
While injection ECG is made, BP is checked. At changes on ECG or BP injection is stopped. If attacks continue we can add 5 – 10 mg per kg of Fenitoin.

44. Time, min
Treatment
46-59
If attacks continue we make endotracheal intubation, then use Fenobarbitalum in dose 20 mg per kg (speed 100 mg per min)
60-90
If attacks continue we introduce patient in barbiturate coma. It is recommended to start usage of Fenobarbital in dose 5 mg per kg up to stopping of epileptic activity on EEG.Then continue usage of 0,5-3,0 mg per kg per hour to stop recurring attacks. From time to time we decrease speed to prove ourselves that the attacks are absent. While infusion we check EEG, ECG, BP and breathing functions.