Title: ECRN: Assessment Based Management Thoracic
1ECRNAssessment 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
2Objectives
- 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.
3Objectives contd
- 5. Describe a variety of degenerative
neurological diseases. - 6. Review case scenarios.
- 7. Successfully complete the quiz with a score of
80 or better.
4ASSESSMENT 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
5Goals 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
6Factors 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"
7Factors 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
8Factors 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
9Factors 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
10Factors 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
11General 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
12Patient 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?
13Initial assessment contd
- 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?
14Patient 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
15Patient 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
16Blood 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
stethoscope over radial pulse area
17Tips, 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
- B/P should always be attempted documented
18Patient 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, ABCs, vital signs (pulse,
respirations, B/P, SaO2, pain level), EKG
19Assessment 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
20Accurate 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 patients complaint based on the
information gathered during the assessment - used to formulate a plan of action based on the
patients condition and the environment
21Use of Protocols SOPs
- Protocol - policies and procedures of all
components of the EMS system - Standard operating procedures (SOPs) -
preauthorized treatment procedures - Exercise judgement when following protocol and
SOPs - know which protocol/SOP to choose
- know when and how to follow protocol/SOPs
- recognize when you must deviate from the stated
protocol/SOP - allergies, abnormal vital signs
(ie hypotension)
22SOPs/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)
23Difficulty 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
24Communication
- 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
25Transmission 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
- ETA and destination
26Calling 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
27THORACIC TRAUMA
28Anatomy 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
29Thoracic Trauma
- Classifying thoracic injuries
- Blunt trauma - closed
injury from kinetic
energy transmitted through
tissue - blasts
- deceleration
- compression/crush
- Penetrating trauma - open wound direct or
indirect trauma transmitted via kinetic energy
dart
30Blunt 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
31Thoracic Injuries
- Thoracic cage - ribs sternal fx, flail segment
- Cardiovascular - contusion, tamponade
- Pleural and pulmonary- contusions, pneumos
- Mediastinal - pneumomediastinum
- Diaphragm - tear, laceration, rupture
- Esophageal - laceration
- Penetrating cardiac trauma - laceration aorta,
vena cava, pulmonary arteries/veins - Spinal cord injuries
32Flail 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
33Flail 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/IVs placed on chest - EKG monitoring
34Sucking 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
patients little finger), air will move in out
thru the chest wall defect not thru the trachea
35Sucking 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
36Sucking 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
37Tension 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
38Tension Pneumothorax
(JVD)
Dyspnea, SOB
(rare late sign not often appreciated)
tachycardia
Low pulse ox, narrowed pulse pressure
decreased B/P
PEA
39Needle 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
40Needle Decompression
41Hemothorax
- 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
42Hemothorax Signs Symptoms
History blunt or penetrating trauma
decreased blood pressure
43Hemothorax
- 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
44Cardiac 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
45Cardiac Tamponade
agitation
(JVD)
PEA
Muffled heart tones
Diaphoretic, ashen or cyanotic
46Cardiac 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
47ABDOMINAL TRAUMA
A high degree of suspicion must be exercised
based on mechanism of injury and kinematics.
48Abdominal 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
49Abdominal Anatomy and Physiology
- The 3 abdominal spaces
- peritoneal space
- organs or portions of organs covered by abdominal
(peritoneal) lining - retroperitoneal space
- organs posterior to the peritoneal lining
- pelvic space
- organs contained within the pelvis
50Abdominal 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
51Blunt 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
52Blunt Mechanisms
- Compression forces
- Shear forces
- Deceleration forces
- Motor vehicle crashes
- Motorcycle collisions
- Pedestrian injuries
- Falls
- Assault
- Blast injuries
53Penetrating 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
- Distance traveled a consideration
54Evisceration of the bowel caused by a knife wound
Cover eviscerated area with sterile, moistened
dressing Minimize patient movement, coughing
55Hollow 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
56Solid 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
life-threatening hemorrhage -
57Patient 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
58Patient 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 (gt2 seconds)
- increasing abdominal distention, bruising
59Abdominal 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 environment
60Initial 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 havent found all
the sources of bleeding yet) - Supportive oxygenation (nonrebreather mask)
- IV access
- EKG monitoring
61Neurological Emergencies
- The human bodys ability to maintain a state of
homeostasis results primarily from the nervous
systems 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 -
62Headache
- 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 -
63Headache
- 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
64Types 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
65Headache
- 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!
66Neoplasms - 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
-
67Malignant 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) -
68Benign 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
69Assessment 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
-
70Neoplasm
- 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
71Neoplasm 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
72Neoplasm 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
73Neoplasm 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
74Neoplasms
- 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 -
75Bells 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 -
76Degenerative 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 -
77Degenerative 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 muscles inability to use the
proteins provided by the body as fuel - Example Muscular dystrophy
- Some are actual nerve tissue breakdown
- Example Parkinsons disease
-
78Degenerative Neurological Disorders
- Partial facial paralysis
- Example Bells 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
79Degenerative 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
80Degenerative 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
-
81Degenerative 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
82Degenerative Neurological Disorders
- Caring for the patient in crisis must include
maintaining ABCs - 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
-
83Muscular 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 -
84Multiple 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 -
85Structure 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
86Parkinsons 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 -
87Lou Gehrigs Disease - ALS
- Progressive motor neuron disease
- Types
- Spinal muscular atrophy
- Bulbar palsy
- Primary lateral sclerosis
- Pseudobulbar palsy
88Amyotrophic Lateral Sclerosis
(ALS)Upper motor neurons affected in the central
nervous system lower motor neurons affected in
the peripheral muscles
89Amyotrophic 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
-
90Trigeminal 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
91Peripheral 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 -
92Myoclonus
- 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
93Spina 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 -
94 Spina Bifida
95Degenerative 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?
- Medications?
-
96Degenerative 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
-
97Degenerative 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
98Case 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
99Case 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 - Whats going on now?
100Case Study 1
- Reassess ABCs
- 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
101Case 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
102Case 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
103Case 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?
- Dont be fooled by the obvious and dont dismiss
her concerns to her weight
104Case Study 2
- What can cause restlessness?
- Hypoxia
- Hypovolemia
- Internal injury
- Hypoglycemia
- Pain
- Anxiety being scared
- Being uncomfortable (pain, positioning, full
bladder)
105Acknowledgement
- 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 SOPs, Effective March 2005