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ECRN: Assessment Based Management; Thoracic

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Title: ECRN: Assessment Based Management; Thoracic


1
ECRNAssessment 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

2
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.

3
Objectives 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.

4
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

5
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

6
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"

7
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

8
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

9
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

10
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

11
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

12
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?

13
Initial 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?

14
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

15
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

16
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
    stethoscope over radial pulse area

17
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
  • B/P should always be attempted documented

18
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, ABCs, vital signs (pulse,
    respirations, B/P, SaO2, pain level), EKG

19
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

20
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 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

21
Use 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)

22
SOPs/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)

23
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

24
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

25
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
  • ETA and destination

26
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

27
THORACIC TRAUMA
28
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

29
Thoracic 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
30
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

31
Thoracic 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

32
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

33
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/IVs placed on chest
  • EKG monitoring

34
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
    patients little finger), air will move in out
    thru the chest wall defect not thru the trachea

35
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

36
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

37
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

38
Tension Pneumothorax
(JVD)
Dyspnea, SOB
(rare late sign not often appreciated)
tachycardia
Low pulse ox, narrowed pulse pressure
decreased B/P
PEA
39
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

40
Needle Decompression
41
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

42
Hemothorax Signs Symptoms
History blunt or penetrating trauma
decreased blood pressure
43
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

44
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

45
Cardiac Tamponade
agitation
(JVD)
PEA
Muffled heart tones
Diaphoretic, ashen or cyanotic
46
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

47
ABDOMINAL TRAUMA
A high degree of suspicion must be exercised
based on mechanism of injury and kinematics.
48
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

49
Abdominal 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

50
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

51
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

52
Blunt Mechanisms
  • Compression forces
  • Shear forces
  • Deceleration forces
  • Motor vehicle crashes
  • Motorcycle collisions
  • Pedestrian injuries
  • Falls
  • Assault
  • Blast injuries

53
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
  • Distance traveled a consideration

54
Evisceration of the bowel caused by a knife wound
Cover eviscerated area with sterile, moistened
dressing Minimize patient movement, coughing
55
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

56
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
    life-threatening hemorrhage

57
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

58
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 (gt2 seconds)
  • increasing abdominal distention, bruising

59
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 environment

60
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 havent found all
    the sources of bleeding yet)
  • Supportive oxygenation (nonrebreather mask)
  • IV access
  • EKG monitoring

61
Neurological 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

62
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


63
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

64
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

65
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!

66
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


67
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)


68
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

69
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


70
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

71
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

72
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

73
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

74
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


75
Bells 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

76
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


77
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 muscles inability to use the
    proteins provided by the body as fuel
  • Example Muscular dystrophy
  • Some are actual nerve tissue breakdown
  • Example Parkinsons disease


78
Degenerative 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

79
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

80
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


81
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

82
Degenerative 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


83
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

84
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

85
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

86
Parkinsons 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

87
Lou Gehrigs Disease - ALS
  • Progressive motor neuron disease
  • Types
  • Spinal muscular atrophy
  • Bulbar palsy
  • Primary lateral sclerosis
  • Pseudobulbar palsy

88
Amyotrophic Lateral Sclerosis
(ALS)Upper motor neurons affected in the central
nervous system lower motor neurons affected in
the peripheral muscles
89
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

90
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

91
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

92
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

93
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

94
Spina Bifida
95
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?
  • Medications?

96
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

97
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

98
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

99
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
  • Whats going on now?

100
Case 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

101
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

102
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

103
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?
  • Dont be fooled by the obvious and dont dismiss
    her concerns to her weight

104
Case Study 2
  • What can cause restlessness?
  • Hypoxia
  • Hypovolemia
  • Internal injury
  • Hypoglycemia
  • Pain
  • Anxiety being scared
  • Being uncomfortable (pain, positioning, full
    bladder)

105
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 SOPs, Effective March 2005
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