MOD E Tech 28 Nervous Disorders

Question 1

Stroke

Answer 1

• Also known as Cerebrovascular Accident (CVA)
• 3rd biggest killer in the UK
• In the UK someone has a stroke every 5 minutes – approx. 150,000 / year
• Age group most affected >65 years
• 1,000 adults <30 years have a stroke each year

Question 2

Blood Supply to Brain

how much blood supply goes to your brain

Answer 2

Question 3

Blood Supply to the Brain

circle of willis plays what role

% of cardiac output

mls

Answer 3

• Two internal carotid and two vertebral arteries
• Internal carotid branches to form anterior and middle cerebral
• Vertebral join together to form the basilar artery
• Basilar splits again to form posterior cerebral arteries
• Major branches are joined together to form circle of willis

•Circle of willis plays major role in ensuring constant supply of oxygen and glucose when head is moved and when contributing artery is narrowed

• Brain receives approx 15% of cardiac output
• •Approx 750ml/min
• Autoregulation keeps blood flow constant by adjusting diameter of vessels across range of blood pressure (About 65-140 mmHg)

Question 4

Stroke Definition

Answer 4

•Stroke – “A stroke is a clinical syndrome characterised by rapidly developing clinical symptoms and/or signs of focal, and at times global, loss of cerebral function, with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.” (Hatano 1976 )

Question 5

•Transient Ischaemic Attack (TIA) –Definition

Answer 5

•Transient Ischaemic Attack (TIA) – “…a clinical syndrome characterised by an acute loss of focal cerebral or monocular function with symptoms lasting less than 24 hours and which is thought to be due to inadequate cerebral or ocular blood supply as a result of arterial thrombosis or embolism associated with arterial, cardiac or haematological disease.” (Hankey and Warlow 1994)

Question 6

Causes/Types of Stroke

Name two different types

% which cause each one

Answer 6

1.Ischaemic (80%) – caused by”a blockage of a blood vessel (embolus or thrombus) causing hypoxic damage to a critical area of brain tissue”

1.Haemorrhagic (20%) – caused by a “ruptured blood vessel in the brain which applies pressure to, or bleeds into, the surrounding brain tissue”

Question 7

Ischaemic Stroke

Ischaemic Stroke - Causes

Name them?

Answer 7

–Atherosclerotic (thickened, hardened arteries narrowed by fatty deposits).

–Thrombotic (blood clot)

–Embolic (any foreign substance e.g. air)

Question 8

Haemorrhagic Stroke

Name types?

Answer 8

•Haemorrhagic strokes account for approx. 20% of all stroke deaths. This group includes:

1. Intra-cerebral haemorrhage (bleeding within the brain)
2. Sub-arachnoid haemorrhage (bleeding outside the brain)

Question 9

Clinical Signs of Stroke

Answer 9

• Slow, full pulse
• Flushed and warm skin
• Possibly unequal pupils
• Blurred vision
• Noisy breathing

Paralysis of muscles on one side of the body (hemiplegia

• Weakness
• Patients may not understand simple instructions
• Slurred speech with dribbling of saliva
• Incontinence
• Agitation/Confusion
• Hypoxia induced fits
• Hypertension
• Possible altered consciousness
• Vomiting
• Headache

Loss of balance

Question 10

Management of Stroke

Answer 10

• Correct any ABCD problems
• Administration of O2 therapy if patient is hypoxic (<94%) – maintain SpO2 94% - 98%
• Assess for FAST positive features
• Note time of onset
• Consider appropriate patient positioning
• Obtain Blood Glucose level
• Apply 12 lead ECG and Pulse Oximetry monitoring
• Assist in obtaining IV access if required
• Utilise direct admission pathway if in place

Question 11

FAST” Test for Stroke

list and why?

Answer 11

•Facial droop – assess the smile or ability to expose the teeth using facial muscles.

•

•Arm drift – ask the patient to close their eyes and hold their arms straight-out in-front-of them.

Weakness will result in the affected arm drifting down

•Speech – ask the patient to repeat a simple sentence.

Slurred words (dysarthia) or inability to speak (aphasia) are important indicators.

Question 12

Epilepsy

Causes of Fitting/Convulsions/Seizures

List possible causes?

Answer 12

Causes of Fitting/Convulsions/Seizures

• Epilepsy
• Febrile Convulsions
• Cardiac Arrest
• Hypoglycaemia
• Hypoxia
• Stroke
• Cerebral tumour
• Electrolyte imbalance
• Drug overdose
• Hypotension

Question 13

Epileptiform Seizure

Main Types

Answer 13

2 main types:

1. Generalised - Both sides of the Brain
2. Partial - Discharge is in a localised area of the brain

Question 14

Classifications

Epileptiform Seizure

Answer 14

GENERALISED

•

•Tonic Clonic

•Tonic

•Atonic

Absences

PARTIAL

•

•Simple

•Complex

•Secondarily

Generalised

Question 15

Tonic Clonic Seizure (Generalised Seizure)

Answer 15

Question 16

Stages of Tonic Clonic Seizures

Answer 16

• Aura - Visual disturbance, strange taste, smell or feeling.
• Tonic phase - Stiffening of the body
• Clonic phase - Jerking of muscles
• Post-ictal phase - gradual return to consciousness in which confusion, stupor, weakness & combativeness may occur.

Question 17

Absence Seizure (Generalised Seizure)

Answer 17

Question 18

Status Epilepticus

Answer 18

•Potentially life threatening

•Seizures continue for more than 30 minutes with no recovery (lucid interval) in between

Question 19

Non-epileptiform Seizures

Causes of Non-epileptiform Seizures

Answer 19

• Hypoxia
• Trauma
• Stroke
• Intracranial tumour
• Drug intoxication
• Septicaemia
• Hyper
• Hypoglycaemia
• Metabolic disturbances
• Eclampsia
• Fever (Febrile)
• Meningitis
• Uraemia

tension

Question 20

Assessment - History

Seizures

list

Answer 20

• Is the patient known to be epileptic?
• If so, are they on medication, and are they taking it?
• Have they had convulsions recently?
• Has the adult patient been unwell at present? Have they had a pyrexia?
• Is the patient diabetic?
• Is the patient pregnant?
• Is there any history of head injury?
• Is there any evidence of alcoholism or drug usage?

Question 21

Assessment - General

Answer 21

• Assess ABCD’s
• Are there any time critical features? :

–Any major ABCD problems

–Serious head injury

–Status epilepticus

–Underlying infection (e.g. meningococcal infection)

Eclampsia?

• Assess ECG - Is there any sign of arrhythmia?
• Check blood glucose level - alcohol use?
• Assess the type of convulsion – is it generalised or focal?
• Assess for raised temperature and any sign of rash
• Assess for arrhythmia
• Blood pressure – hypotension?
• Assess for mouth/tongue injury, incontinence

Question 22

Management of Seizures

Answer 22

• Ensure high flow O2 if active convulsion
• Post-Ictal - Administer O2 if hypoxaemic
• Establish if any treatment has already been administered (e.g. rectal diazepam)
• Administer patient’s own prescribed midazolam
• Position for airway security, comfort and protection from dangers
• Consider a nasopharyngeal airway if patient still convulsing (Don’t force the mouth open!)
• Assist in obtaining IV access if convulsion persists or recurs
• Apply ECG and pulse oximetry
• Check blood glucose level
• Assist with the administration of Diazemuls/Diazepam
• If patient can be moved, remove to hospital a.s.a.p

Question 23

Febrile Convulsion

Answer 23

• Most commonly occurs between the ages of 6 months and 5 years
• Usually had an infection accompanied by a rapid rise in temperature
• May have experienced a febrile convulsion before
• Present as a tonic clonic seizure

Question 24

Clinical Performance Indicator

Answer 24