BACHELOR OF SCIENCE IN NURSING:

NCMB 418 - CARE OF THE CLIENT WITH LIFE-

THREATENING CONDITIONS, ACUTELY ILL / MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND
EMERGENCY SITUATION (ACUTE AND CHRONIC)
COURSE MODULE COURSE UNIT WEEK
3 12 14

Neurologic Emergencies

✓ Comprehend the course unit objectives.

✓ Peruse through the study guide prior to class attendance.
✓ Analyze the required learning resources; refer to course unit
terminologies for jargons.
✓ Proactively participate in classroom discussions.
✓ Participate in weekly discussion board (Canvas).
✓ Answer and submit course unit tasks on time.

At the end of this unit, the students are expected to:

1. Discuss the pathophysiologic responses of critically ill clients with cerebrovascular accident
and spinal cord injuries.
2. Analyze the health status/competence of critically ill clients with cerebrovascular accident and
spinal cord injuries.
3. Formulate a plan of care based on critically ill clients’ priorities to address the cerebrovascular
accident and spinal cord injuries.
4. Institute appropriate corrective actions to prevent or minimize harm arising from adverse
effects.
5. Apply safe and quality interventions to address the needs of critically ill clients with
cerebrovascular accident and spinal cord injuries.
 6. Offer client health education using selected planning models as appropriate for critically ill
clients with cerebrovascular accident and spinal cord injuries.
7. Document nursing care and services rendered and processes outcomes of the findings/ result
of the client data.
8. Ensure completeness, integrity, safety, accessibility, and security of information.
9. Adhere to protocols of confidentiality in safekeeping and releasing of records and other
information.
10. Evaluate the health status / competence and/or expected outcomes of nurse-client working
relationship of critically ill clients with cerebrovascular accident and spinal cord injuries.

Burns, S. and Delgado, S. (2019). Essentials of Critical Care Nursing, 4th ed. USA: McGraw-Hill.

Neurologic emergencies arise frequently and, if not diagnosed and treated quickly, can have
devastating results, with high rates of long-term disability and death (Kottapally and Josephson,
2016).

SPINAL CORD INJURY (SCI)

Damage to any part of the spinal cord or nerves at the end of the spinal canal
often causes permanent changes in strength, sensation and other body functions
below the site of the injury (Mayo Clinic, 2019); occurs when a force is exerted
on the vertebral column, resulting in damage to the spinal cord.

Pathophysiology: Damage to the spinal cord ranges from transient concussion

(from which the patient fully recovers) to contusion, laceration, and compression
of the cord substance (either alone or in combination), to complete transection
of the cord (which renders the patient paralyzed below the level of the injury).

Categories:
1. Primary injuries – the result of the initial insult or trauma and are usually permanent
2. Secondary injuries – usually the result of a contusion or tear injury; produces ischemia, hypoxia,
edema, and hemorrhagic lesions, which in turn result in destruction of myelin and axons (these
are believed to be the principal causes of spinal cord degeneration at the level of injury; now are
thought to be reversible 4-6 hours after injury
Causes:
• traumatic blow to the spine causing fractures, dislocation, crushing or compression of one or
more of the vertebrae
• Penetrating gunshot or knife wound
• Diseases/Conditions: Arthritis, cancer, inflammation, infections or disk degeneration of the spine
Severity Classification:
1. Complete – if all sensory and all motor functions are lost below the spinal cord injury
2. Incomplete – if some motor or sensory functions below the affected area are still present;
there are varying degrees of incomplete injury.
Emergency signs and symptoms
1. Impaired breathing after injury
 2. An oddly positioned or twisted neck or back
3. Extreme back pain or pressure in your neck, head or back
4. Weakness, incoordination or paralysis in any part of your body
5. Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
6. Loss of bladder or bowel control
7. Difficulty with balance and walking

IMPORTANT! For suspected back or neck injury, DO NOT move the injured person
(permanent paralysis and other serious complications may result).

Management:
Goal – prevent secondary injury (immobilization of spine)
- Assess ABCs and neurologic status (i.e. observe for progressive neurologic deficits,
adequate oxygenation and airway)
- Steroid therapy
- Halo vest - a lightweight vest with an attached halo that stabilizes the cervical spine
- Surgery:
o Indications: cord compression, unstable vertebral body, wound penetrates the cord, bony
fragments in canal, deterioration of neurologic status; tumor
o Skeletal fracture reduction and traction

ACUTE ISCHEMIC STROKE

The brain cannot store oxygen or glucose and therefore requires a constant flow of blood to supply
these nutrients. The blood supply to the brain can be altered through several different processes.
The pathophysiology of stroke varies based on the precipitating event.
- Etiology: embolism, thrombosis, hemorrhage, and compression or spasm of the vessels
- Stroke is a medical emergency and is treated with the same urgency as acute MI

Risk factors:
1. Hypertension
2. Diseases:
✓ Cardiac disease (CAD, heart failure, atrial fibrillation, endocarditis, patent foramen ovale,
MI, carotid artery disease),
✓ Diabetes
✓ Hypercoagulability (cancer, pregnancy, high RBCs, sickle cell)
3. Dyslipidemia
4. Hormone therapy
5. Increased age, race (African American), male
6. Prior stroke and/or family history
7. Smoking, alcohol or illicit drugs
8. Obesity / Physical inactivity

Transient ischemic attack (TIA)

- An important warning sign for stroke
- Development of stroke symptoms that resolve without tissue infarction
- Most resolve within minutes (but still needs extensive workup to identify treatable causes)
Ischemic stroke
- Accounts for approximately 85% of all strokes
- Edema occurs in the area of ischemic or infarcted tissue (contributes to
further neuronal cell death)
- If ischemia is not reversed, neuronal cell death and infarction of brain
tissue occurs
- Causes:
1. Embolism – refers to the occlusion of a cerebral vessel, most often
by a blood clot (i.e. infectious particles, fat, air, or tumor fragments)
- often associated with heart disease (bacterial vegetations or blood clots)
- Common causes: chronic atrial fibrillation, valvular disease, prosthetic valves,
cardiomyopathy, atherosclerotic lesions of the proximal aorta
- Onset = rapid, with symptoms that develop without warning
2. Thrombus formation – most common cause of ischemic stroke (atherosclerosis)
✓ Thrombosis due to atherosclerosis of large cerebral vessels results in large areas of
infarct (significant functional deficits are common)
✓ If thrombus forms in a smaller branching artery, a lacunar infarct develops (lacunar infarcts
result in smaller areas of neuronal cell death)
✓ Thrombotic strokes tend to develop during periods of sleep or inactivity, when blood flow
is less brisk

Penumbra – an area of tissue surrounding the core ischemic area.

The penumbra receives some blood flow from adjacent vessels but perfusion is marginal
If CBF is improved, the penumbra may recover.

Signs and Symptoms

- range from very mild to significant loss of functional abilities; based on the area of ischemia or
infarction
1. weakness in an extremity or on one side of the body
2. sensory changes
3. difficulty speaking or understanding speech
4. facial droop
5. headache
6. visual changes

Diagnostic Tests
Goal of initial diagnostic testing in acute stroke = to rule out intracranial
hemorrhage (treatments for hemorrhagic and ischemic stroke differ
significantly)
1. Noncontrast head CT scan – available at most hospitals,
o can be performed quickly
o an excellent tool for detecting intracranial bleeding
o evidence of ischemia may not appear or may be very subtle on
standard CT scanning until 12 to 24 hours after symptom onset
2. Specialized MRI scans (diffusion-weighted imaging, perfusion-weighted imaging) – can detect
areas of ischemia before they are apparent on CT
3. MRA – detects areas of vascular abnormality
4. Cerebral angiography and carotid ultrasound
5. Transthoracic or transesophageal echocardiography – to assess cardiac causes of stroke
6. ECG – for cardiac monitoring for at least 24 hours
7. Cardiac biomarkers – there is a correlation between cerebrovascular and cardiovascular disease

Principles of Management of Acute Ischemic Stroke - “time is brain” when cerebral ischemia
occurs
- Goals of treatment:
✓ restore circulation to the brain when possible
✓ stop the ongoing ischemic process, and
✓ prevent secondary complications

1. Evaluation of Conditions That Mimic Acute Ischemic Stroke

- hypoglycemia – may cause stroke-like symptoms (easily detected by checking blood glucose)
- toxic or metabolic disorders
- migraines, seizures
- mass lesions such as brain tumors or abscesses
- psychological disorders

2. Fibrinolytic Therapy
- Administered in an attempt to restore perfusion to the affected area
- IV rtPA = within 3 hours of the onset of symptoms (recommended dose = 0.9 mg/kg, with
10% of the total dose given as a bolus over 1-2mins followed by the remainder of the dose
as an infusion over 1 hour
- Vital signs and neurologic checks = every 15 minutes for the first 2 hours, then every 30
minutes for 6 hours, and then hourly until 24 hours following initial treatment
3. Endovascular Treatment
4. Blood pressure management
5. Management of increase intracranial pressure
6. Glucose management
7. Preventing and treating secondary complications
8. Preventing recurrent stroke

Seizure – a sudden, abnormal, excessive discharge of electrical activity within the brain that disrupts
the brain’s usual system for nerve conduction
Classification:
1. Absence (petit mal)
2. Atonic
3. Myoclonic
4. Clonic
5. Idiopathic (unclassified seizures)
Diagnostics:
1. Electroencephalography (EEG) – definitive test to diagnose seizure activity
2. SPECT scan – scan of choice for a diagnostic evaluation of certain types of CNS disorders
Treatment:
1. Medication therapy – hallmark of seizure management
2. Surgery – respective procedures or palliative corpus callosotomy
3. Seizure precautions
4. Oxygen and suction equipment at bedside
5. Re-orient client upon waking
Status Epilepticus – potential complication of all types of seizures. This is a seizure that lasts
longer than 5 minutes, or more than 1 seizure within a 5-minute period, without returning to normal
level of consciousness between episodes. Hence, this is a medical emergency that may lead to
permanent brain damage or death.
• Causes: Stroke, low blood glucose levels, excessive alcohol, withdrawal symptoms
• Diagnostics: EEG, CT scan, MRI, LP
Principle of Management:
• Goal: control seizure as quickly as possible, preventing recurrence, maintaining patient safety
and identifying the underlying cause.
Medications:
1. Lorazepam (Ativan) – induces respiratory depression
2. Flumazenil (Romazicon) – decrease respiratory depression
3. Phenytoin via central venous line
4. Phenobarbital (Luminal)

Patient education on DOs and DON’Ts

✓ Do not hold the person down or try to stop his or her movements.
✓ Do not put anything in the person’s mouth. This can injure teeth or the jaw. A person
having a seizure cannot swallow his or her tongue.
✓ Do not try to give mouth-to-mouth breaths (like CPR). People usually start breathing
again on their own after a seizure.
✓ Do not offer the person water or food until he or she is fully alert
✓ Ease the person to the floor.
✓ Turn the person gently onto one side. This will help the person breathe.
✓ Clear the area around the person of anything hard or sharp. This can prevent injury.
✓ Put something soft and flat, like a folded jacket, under his or her head.
✓ Remove eyeglasses.
✓ Loosen ties or anything around the neck that may make it hard to breathe.
✓ Note the duration of the seizure.

Meningitis – an inflammation of the membranes covering the brain and spinal cord
Causative agents:
• Bacterial - Haemophilus influenza or Neisseria meningitides
• Fungal – Cryptococcus neoformans (most common)
• Neonatal – group B streptococcus or Escherichia coli
• Syphyllitic – Treponema pallidum

Diagnostic: Lumbar puncture (LP) – use to diagnose most cases

Treatment:
1. Rifampin (Rifadin) is the first line and initial treatment for bacterial meningitis
2. Vaccines:
• Haemophilus influenza type b (Hib) for meningococcal meningitis
• Meningococcal conjugate vaccine [MCV4 (Menactra)] and meningococcal polysaccharide
vaccine [MPSV4 (Menomune)] against Neisseria meningitides
Complete spinal cord lesion - a condition that involves total loss of sensation and voluntary muscle
control below the lesion

Incomplete Spinal cord lesion - a condition where there is preservation of the sensory or motor
fibers, or both, below the lesion

Spinal cord injury (SCI) – an insult to the spinal cord resulting to temporary or permanent changes
in the cord’s normal motor, sensory, or autonomic functions; an injury to the spinal cord, vertebral
column, supporting soft tissue, or intervertebral disks caused by trauma

Neurogenic bladder - bladder dysfunction that results from a disorder or dysfunction of the nervous
system; may result in either urinary retention or bladder overactivity

Paraplegia - paralysis of the lower extremities with dysfunction of the bowel and bladder from a
lesion in the thoracic, lumbar, or sacral regions of the spinal cord

Quadriplegia (tetraplegia) - paralysis of both arms and legs, with dysfunction of bowel and bladder
from a lesion of the cervical segments of the spinal cord

Transection - severing of the spinal cord itself; transection can be complete (all the way through the
cord) or incomplete (partially through)

Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis:
Elsevier Mosby. pp 504-593

Torregrossa, F. Salli, M., and Grasso, G. (2020 August). Emerging Therapeutic Strategies for
Traumatic Spinal Cord Injury, World Neurosurgery, vol. 140. Retrieved from
https://www.sciencedirect.com/science/article/pii/S1878875020306707

Although stroke is easily preventable, it remains the second leading cause of death and a first leading
cause of acquired disability in adults worldwide currently.

From the stroke algorithm shown below (https://resources.acls.com/free-resources/acls-

algorithms/suspected-stroke) give and explain the rationale for each of the action(s) stated inside
the Gray Boxes. Make sure to indicate and cite your source(s) accordingly.
ACLS Certification Institute. (2020, March 3). Suspected stroke
algorithm [article]. https://resources.acls.com/free-
resources/acls-algorithms/suspected-stroke

Burns, S. and Delgado, S. (2019). Essentials of Critical Care

Nursing, 4th ed. USA: McGraw-Hill.

Centers for Disease Control and Prevention (CDC) (n.d.).

https://www.cdc.gov/

Department of Health (Kagawaran ng Kalusugan). (n.d). https://www.doh.gov.ph

Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis:
Elsevier Mosby.

Hinkle, J. and Cheever, K. (2017). Brunner & Suddharth’s Textbook of Medical-Surgical Nursing,
14th ed. USA: Wolters Kluwer
Kottapally, M. and Josephson, S.A. (2016 February). Common neurologic emergencies for
nonneurologists: When minutes count, Cleveland Clinical Journal of Medicine, 83(2): 116-126.
Retrieved from doi: 10.3949/ccjm.83a.14121.

Mayo Clinic (2019). Spinal cord injury. Retrieved from https://www.mayoclinic.org/diseases-

conditions/spinal-cord-injury/symptoms-causes/syc-20377890

Norris, T. (2019). Porth's Pathophysiology: Concepts of Altered Health States, 9th ed. USA: Wolters-
Kluwer

Torregrossa, F. Salli, M., and Grasso, G. (2020 August). Emerging Therapeutic Strategies for
Traumatic Spinal Cord Injury, World Neurosurgery, vol. 140. Retrieved from
https://www.sciencedirect.com/science/article/pii/S1878875020306707
SPINAL CORD
INJURY
NEUROLOGIC DISEASES
Spinal cord injury
REVIEW: Spinal Cord Anatomy
REVIEW: Spinal Vertebrae Anatomy
REVIEW:
Spinal
Vertebrae
Innervations
Modes of Injury: Fracture
Modes of Injury: Disc Herniation
Modes of Injury: Tumor Formation
SCI Manifestations
 Neurologic ER

Colleen C. Flores, MAN Spinal cord injury

Body parts affected depend on the level of injury
Spinal cord injury
 D AD - a syndrome of massive
imbalanced reflex sympathetic
A Y discharge occurring in patients
U S with spinal cord injury (SCI)
above the splanchnic
T R sympathetic outflow (T5-T6);
O E this causes a spike in BP
N F Causes: B.O.B.S
O L 1. Bladder & bowel distention
M E 2. Obstructions (kidney stone)
and constrictions (clothing,
I X shoes, apparatus)
C I 3. Bowel impaction
4. Strong odors, pain, pressure
A
 • Damage to one lateral half of the
spinal cord (extramedullary lesions &
penetrating trauma/tumor)
S
S • loss of sensation and motor function
Y (paralysis and ataxia) that is caused by
B E
N the lateral hemisection (cutting) of
R Q the spinal cord.
D
O U
R Brown-Séquard Syndrome symptoms:
W A
O * = Side of the lesion
N R 1 = hypotonic paralysis (ipsilateral)
M 2 = spastic paralysis and loss of vibration
D and proprioception (position sense) and
E
fine touch (ipsilateral)
3 = loss of pain and temperature
sensation (contralateral)
Spinal cord injury: Management
Spinal cord injury: Management
■ Promote adequate breathing and airway clearance
■ Improve mobility and proper body alignment
■ Promote adaptation to sensory and perceptual alterations
■ Maintain skin integrity
■ Maintain urinary elimination
■ Improve bowel function
■ Provide Comfort measures
■ Monitor and manage complications
– Thrombophlebitis
– Orthostatic hypotension
– Spinal shock
– Autonomic dysreflexia
SEIZURES
SEIZURES: ETIOLOGY

1. Fever
2. Head injury
3. CNS infection
4. Metabolic and
toxic conditions
5. Idiopathic
SEIZURES: Management
SEIZURES

■Levetiracetam (Keppra)
■Clonazepam (Klonopin)
SEIZURES
■Valproic acid (Depakene)
■Phenytoin(Dilantin)
■Ethosuxamide (Zarontin)
■Carbamazepine (Tegretol)
REFERENCES

Hinkle, J (2018) Brunner and

Burns, S. (2018) AACN
Suddarth’s Textbook of
Essentials of Critical Care
Medical and Surgical
Nursing. Mc Graw Hill
Nursing, Lippincott, Williams
Education.
and Wilkins

A picture depicting a synapse

showing neurotransmitters from
Schumacher L. (2012) the presynaptic neurons and
receptors at the post synaptic
Saunder’s Nursing survival
neuron) Retrieved from
guide: Critical Care and https://www.ck12.org/biology/n
Emergency Nursing. Elsevier erve-impulse/lesson/Nerve-
Cells-and-Nerve-Impulses-MS-
LS/
BACHELOR OF SCIENCE IN NURSING:
NCMB 418 - CARE OF THE CLIENT WITH LIFE-
THREATENING CONDITIONS, ACUTELY ILL / MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND
EMERGENCY SITUATION
COURSE MODULE COURSE UNIT WEEK
3 11 13

Neurologic Emergencies - 1

✓ Comprehend the course unit objectives.

✓ Peruse through the study guide prior to class attendance.
✓ Analyze the required learning resources; refer to course unit
terminologies for jargons.
✓ Proactively participate in classroom discussions.
✓ Participate in weekly discussion board (Canvas).
✓ Answer and submit course unit tasks on time.

At the end of this unit, the students are expected to:

1. Trace the pathophysiologic responses of critically ill clients with brain injuries.
2. Analyze the health status/competence of critically ill clients with brain injuries.
3. Formulate a plan of care based on critically ill clients’ priorities to brain injuries.
4. Institute appropriate corrective actions to prevent or minimize harm arising from adverse
effects.
5. Apply safe and quality interventions to address the needs of critically ill clients with brain
injuries.
6. Provide client health education using selected planning models as appropriate for critically ill
clients with brain injuries.
 7. Document nursing care and services rendered and processes outcomes of the findings/ result
of the client data.
8. Ensure completeness, integrity, safety, accessibility, and security of information.
9. Adhere to protocols of confidentiality in safekeeping and releasing of records and other
information.
10. Evaluate the health status / competence and/or expected outcomes of nurse-client working
relationship of critically ill clients with brain injuries.

Burns, S. and Delgado, S. (2019). Essentials of Critical Care Nursing, 4th ed. USA: McGraw-Hill.

Neurologic emergencies arise frequently and, if not diagnosed and treated quickly, can have
devastating results, with high rates of long-term disability and death (Kottapally and Josephson,
2016).

Increased Intracranial pressure

• A dynamic scare that reflects the pressure of cerebrospinal (CSF) within the skull
• Increased ICP is described as pressure ≥20 mmHg

Intracranial compliance
• The ability of the brain to tolerate increases in intracranial volume without adversely increasing
ICP
• Monro-Kellie Hypothesis

Intracranial elastance
• The ability of the brain to tolerate and compensate for an increase in intracranial volume through
distention or displacement.
• CPP – a pressure gradient across the brain and is the difference between the arterial blood
entering and the return of venous blood exiting the neurovascular system.

CPP = MAP – ICP

MAP = systolic BP + 2x diastolic BP
3
Purposes of ICP and CPP Monitoring:
o To diagnose increased ICP
o Enable interventions
o Provide a tool for predicting the level of injury and patient outcome.
TRAUMATIC BRAIN INJURY
- Head injury is injury to the scalp, skull, or brain
1. Primary injury
- the initial damage to the brain that results from the traumatic event.
- may include contusions, lacerations, torn blood vessels from impact, acceleration/
deceleration, or foreign object penetration
2. Secondary injury
- evolves over the ensuing hours and days after the initial injury and is due primarily to brain
swelling or ongoing bleeding

Figure 1.

Brain Injury
- most important consideration in any head injury
- even seemingly minor injury can cause significant brain damage secondary
to obstructed blood flow and decreased tissue perfusion (brain cannot store
oxygen and glucose to any significant degree)
- irreversible brain damage and cell death may occur when the blood supply
is interrupted for even a few minutes.

Concussion
- Temporary loss of neurologic function with no apparent structural damage
- Generally involves a period of unconsciousness lasting from a few seconds to a few minutes.
- Jarring of the brain may be so slight as to cause only dizziness and spots before the eyes (“seeing
stars”), or it may be severe enough to cause complete loss of consciousness for a time.
- If the frontal lobe is affected = may exhibit bizarre irrational behavior
- If temporal lobe is affected = may produce temporary amnesia or disorientation

Contusion
- A more severe injury; brain is bruised with possible surface hemorrhage
- May be unconscious for more than a few seconds or minutes
- Clinical signs and symptoms depend on the size of the contusion and the amount of associated
cerebral edema
- Client may lie motionless, with a faint pulse, shallow respirations, and cool, pale skin; involuntary
evacuation of the bowels and the bladder is often experienced
- Client may be aroused with effort but soon slips back into unconsciousness
- Vital signs: BP & temperature – subnormal (somewhat similar to that of shock)

Intracranial Hemorrhage Figure 2. Epidural and Subdural Hematoma

- Hematomas (collections of blood) that develop within the
cranial vault
- Most serious brain injuries (Norris, 2019)
- A hematoma may be:
a. epidural (above the dura)
b. subdural (below the dura)
c. intracerebral (within the brain)
- Major symptoms are frequently delayed until the hematoma is
large enough to cause distortion of the brain and increased
ICP; cerebral ischemia results from the compression by a hematoma
A. Epidural Hematoma (Extradural Hematoma or Hemorrhage) – blood collecting in the epidural
(extradural) space between the skull and the dura
- Cause: a skull fracture resulting to a rupture or laceration of the middle meningeal artery
(the artery that runs between the dura and the skull inferior to a thin portion of temporal
bone); hemorrhage from this artery causes rapid pressure on the brain
B. Subdural Hematoma – collection of blood between the dura and the brain (space is normally
occupied by a thin cushion of fluid)
- May be acute, subacute, or chronic, depending on the size of the involved vessel and the
amount of bleeding present
- Most common cause: trauma
- Other causes: coagulopathies or rupture of an aneurysm

Management of Brain Injuries

- Assessment and diagnosis of the extent of injury are accomplished by the initial physical and
neurologic examinations, i.e. CT Scan, MRI, PET scan
- Any individual with a head injury is presumed to have a cervical spine injury until proven otherwise
- Move and transport client on a board with the head and neck aligned with the body
- Apply cervical collar and maintained until cervical spine x-rays have been obtained and the
absence of cervical SCI documented

Treatment of Increased Intracranial Pressure

As the damaged brain swells with edema or as blood collects within the
brain, a rise in ICP occurs requiring aggressive treatment.
- If ICP remains elevated = CPP can decrease (ICP is monitored closely)
- Initial management – based on the principle of preventing secondary
injury and maintaining adequate cerebral oxygenation.
- Surgery = for evacuation of blood clots, debridement and elevation of
depressed fractures of the skull, and suture of severe scalp lacerations.
- Increased ICP:
✓ Maintain adequate oxygenation, elevate the head of the bed, maintain normal blood volume
 ✓ Devices to monitor ICP or drain CSF (could be inserted during surgery or at the bedside using
aseptic technique

Seizure – a sudden, abnormal, excessive discharge of electrical activity within the brain that disrupts
the brain’s usual system for nerve conduction
Classification:
1. Absence (petit mal)
2. Atonic
3. Myoclonic
4. Clonic
5. Idiopathic (unclassified seizures)
Diagnostics:
1. Electroencephalography (EEG) – definitive test to diagnose seizure activity
2. SPECT scan – scan of choice for a diagnostic evaluation of certain types of CNS disorders
Treatment:
1. Medication therapy – hallmark of seizure management
2. Surgery – respective procedures or palliative corpus callosotomy
3. Seizure precautions
4. Oxygen and suction equipment at bedside
5. Re-orient client upon waking

Status Epilepticus – potential complication of all types of seizures. This is a seizure that lasts
longer than 5 minutes, or more than 1 seizure within a 5-minute period, without returning to normal
level of consciousness between episodes. Hence, this is a medical emergency that may lead to
permanent brain damage or death.
• Causes: Stroke, low blood glucose levels, excessive alcohol, withdrawal symptoms
• Diagnostics: EEG, CT scan, MRI, LP
Principle of Management:
• Goal: control seizure as quickly as possible, preventing recurrence, maintaining patient safety
and identifying the underlying cause.
Medications:
1. Lorazepam (Ativan) – induces respiratory depression
2. Flumazenil (Romazicon) – decrease respiratory depression
3. Phenytoin via central venous line
4. Phenobarbital (Luminal)

Patient education on DOs and DON’Ts

✓ Do not hold the person down or try to stop his or her movements.
✓ Do not put anything in the person’s mouth. This can injure teeth or the jaw.
✓ Do not try to give mouth-to-mouth breaths (like CPR). People usually start breathing
again on their own after a seizure.
✓ Do not offer the person water or food until he or she is fully alert
✓ Ease the person to the floor.
✓ Turn the person gently onto one side. This will help the person breathe.
✓ Clear the area around the person of anything hard or sharp. This can prevent injury.
✓ Put something soft and flat, like a folded jacket, under his or her head.
✓ Remove eyeglasses.
✓ Loosen ties or anything around the neck that may make it hard to breathe.
 ✓ Note the duration of the seizure.
Meningitis – an inflammation of the membranes covering the brain and spinal cord
Causative agents:
• Bacterial - Haemophilus influenza or Neisseria meningitides
• Fungal – Cryptococcus neoformans (most common)
• Neonatal – group B streptococcus or Escherichia coli
• Syphyllitic – Treponema pallidum
Diagnostic: Lumbar puncture (LP) – use to diagnose most cases
Treatment:
1. Rifampin (Rifadin) is the first line and initial treatment for bacterial meningitis
2. Vaccines:
• Haemophilus influenza type b (Hib) for meningococcal meningitis
• Meningococcal conjugate vaccine [MCV4 (Menactra)] and meningococcal polysaccharide
vaccine [MPSV4 (Menomune)] against Neisseria meningitides

Brain injury - an injury to the skull or brain that is severe enough to interfere with normal functioning

Brain injury, closed (blunt) - occurs when the head accelerates and then rapidly decelerates or
collides with another object and brain tissue is damaged, but there is no opening through the skull
and dura

Brain injury, open - occurs when an object penetrates the skull, enters the brain, and damages the
soft brain tissue in its path (penetrating injury), or when blunt trauma to the head is so severe that it
opens the scalp, skull, and dura to expose the brain

Concussion - a temporary loss of neurologic function with no apparent structural damage to the
brain

Contusion - bruising of the brain surface

Increased ICP – increased pressure inside the skull; a medical emergency

Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis:
Elsevier Mosby. pp 504-593

Torregrossa, F. Salli, M., and Grasso, G. (2020 August). Emerging Therapeutic Strategies for
Traumatic Spinal Cord Injury, World Neurosurgery, vol. 140. Retrieved from
https://www.sciencedirect.com/science/article/pii/S1878875020306707
Short Case Analysis: Read the scenario below and answer the questions that follow in 5-10
sentences only. Do not forget to cite your references to support/justify your answers.

You are caring for Tim, a 78-y/o man admitted with a neurologic problem. As you enter his room, he
says, “Hi, you must be my son’s friend. Come in. I’m Tim & this is my wife, Martha. I’m sorry our
house is a mess. This year, 1968, isn’t a good year for us.”
1. How would you describe and document his mental status?
2. What may have contributed to this? Give at least three.
3. From your answer in #2, what will be your 3 topmost priority plans of care?

Burns, S. and Delgado, S. (2019). Essentials of Critical Care Nursing, 4th ed. USA: McGraw-Hill.

Centers for Disease Control and Prevention (CDC) (n.d.).

https://www.cdc.gov/

Department of Health (Kagawaran ng Kalusugan). (n.d).

https://www.doh.gov.ph

Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis:
Elsevier Mosby.

Hinkle, J. and Cheever, K. (2017). Brunner & Suddharth’s Textbook of Medical-Surgical Nursing,
14th ed. USA: Wolters Kluwer

Kottapally, M. and Josephson, S.A. (2016 February). Common neurologic emergencies for
nonneurologists: When minutes count, Cleveland Clinical Journal of Medicine, 83(2): 116-126.
Retrieved from doi: 10.3949/ccjm.83a.14121.

Norris, T. (2019). Porth's Pathophysiology: Concepts of Altered Health States, 9th ed. USA: Wolters-
Kluwer
 NEUROLOGIC
EMERGENCIES

NEUROLOGIC
EMERGENCIES
 Nervous System
Brain

The Brain The Spinal Cord

Review: Anatomy and Physiology of the
Nervous System
Diagrammatic representation of the cerebrum showing locations for
control of motor movement of various parts of the body.
Anatomy
of the
Autonomic
Nervous
System
The CSF
CVA
Blood Supply of the Brain
Neurologic Assessment
Assessment:
L.O.C.
FOUR Score
Assessment: MENTAL
STATUS
 MENTAL STATUS
Type of Aphasia Brain Area Involved
Auditory-receptive Temporal
Visual-receptive Parietal-occipital
Expressive-speaking Inferior posterior frontal

Expressive-writing Posterior frontal

Smeltzer, S.C., et al., 2010
Confusion Assessment Method for
the Intensive Care Unit
Assessment:
• Motor – 5-point scale
(grades 0-5)
• Sensation
• Cranial nerves
• Reflexes
DIAGNOSTICS: M.R.I.
DIAGNOSTICS: C.T Scan
DIAGNOSTICS:
Cerebral Angiography
DIAGNOSTICS:
Transcranial Doppler Sonography
DIAGNOSTICS
DIAGNOSTICS: EEG
DIAGNOSTICS: EMG
Lumbar Puncture
REFERENCES
• Burns, S. (2018) AACN Essentials of Critical Care Nursing. Mc
Graw Hill Education.

• Hinckle, J (2018) Brunner and Suddarth’s Textbook of Medical

and Surgical Nursing, Lippincott, Williams and Wilkins

• Retrieved from https://emottawablog.com/2018/07/gcs-

remastered-recent-updates-to-the-glasgow-coma-scale-gcs-
p/

• Schumacher L. (2012) Saunder’s Nursing survival guide:

Critical Care and Emergency Nursing. Elsevier