Transcript Focused History & Physical Exam - Neurological Patient

Principles of Patient Assessment
in EMS
Focused History & Physical Exam
of the Patient with a Neurological
Problem
Introduction
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The nervous system is the most complex
of all body systems.
The components of the nervous system
can be easily assessed and tested to form
a reasonable field impression.
The most common neurological
emergencies include: stroke, AMS, seizure,
headache, and traumatic brain injury.
The Neurological Patient
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Duration of onset is a helpful feature in
making a field impression
Vascular pathologies tend to be acute in
onset (i.e. seconds to minutes)
 Some vascular causes may provide a
warning sign, such as a TIA, prior to a
CVA
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The Neurological Patient
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Changes occurring over 2 to 3 days may
be caused by dehydration, CNS infection,
subdural hematoma, medications, or other
toxic metabolic conditions.
Degenerative or chronic neurologic
diseases progressively worsen over weeks
to years.
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The Focused History
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Obtaining the FH of a patient experiencing
a neurological emergency can be
challenging.
The patient may have difficulty
communicating.
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Unable to form words, speak clearly or say
what he or she is thinking
Whenever possible verify information with
family, caretakers, coworkers or MDs.
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OPQRST History
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O – What were the circumstances when this
event began?
P – Is there anything making the condition
worse or better?
Q – What is the quality of neurologic symptoms
(i.e. severe headache, or acute parathesia)?
R – Is there any progression of symptoms. Have
you attempted anything to improve the
condition?
S – Is this similar to prior episodes? Rate on the
scale of 1-10.
T – How long has this event been going on?
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SAMPLE History
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S – Consider the associated symptoms with a
neurologic complaint:
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Headache
Memory loss
Confusion
Motor disturbance
Neck or back pain
Paralysis
Parathesia
Paresis
Speech disturbances
Weakness
Loss of bladder or bowel control
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SAMPLE History (continued)
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A – Any allergies to medications?
M – What changes have there been to the
patient’s medication schedule recently?
P – Any history of a condition that could
cause a neurologic condition (i.e.
hypertension)?
L – What was the last oral intake?
E – What may have precipitated the
incident (i.e. medication non-compliance)?
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Causes of AMS (AEIOU-TIPS)
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Alcohol
Epilepsy
Infection
Overdose
Uremia
Trauma
Insulin
Psychosis
Stroke
Physical Exam
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The neurological exam evaluates 6
components:
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Mental status (MS)
Cranial nerves
Motor response
Sensory response
Coordination
Reflexes
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Physical Exam
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Assessing for symmetry is a key objective:
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Asymmetry is abnormal till proven otherwise
In some people asymmetry is normal. Always
ask “Is this normal for you?”
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Mental Status
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A reliable indicator of nervous system
dysfunction is the finding of subtle
changes.
In the IA use AVPU for the minineurological exam followed by the GCS.
AVPU is quick and easy to perform and
provides a gross estimation of the
neurological status.
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Mental Status (continued)
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GCS is easy to perform and provides a
more quantitative measure of dysfunction.
There is a pediatric version of the GCS
(the modified coma score for infants).
Evaluation of MS includes the patient’s
affect, behavior, cognition and memory.
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Mental Status (continued)
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Recall, short, and long term memory are
tested by asking questions such as:
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Recall – instruct the patient to remember the
name of an object and then ask the name of
the object at 5 minute intervals.
Short – What day of the week is it? When did
you eat last?
Long – What is your date of birth? Social
security number? Address?
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Cranial Nerves: Pupils
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Normally equally round and 3-5 mm in
size. A difference of > 1 mm is abnormal.
Aniscoria means unequal pupils and may
indicate a CNS disease or traumatic injury.
Pupils should constrict to light sources.
Light in one pupil should constrict both
(consensual light reflex CN-3).
Assess visual acuity by asking the patient
to read your name tag.
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Cranial Nerves: Pupils (continued)
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Accomodation is the ability of the eyes to
focus on various distances.
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Normally the eyes move apart (diverge) to a
parallel position (conjugate gaze) as they
focus on a distant object. As an object comes
closer to the face the eyes should converge
and pupils constrict.
Ask the patient to focus on a distant object
and then on your finger in front of their face
(CNS 2 & 3).
Assess the field of vision by checking the
patient’s peripheral vision (CN 2).
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Cranial Nerves: Pupils (continued)
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Assess EOMs to measure brainstem
integrity (pons and midbrain).
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Assess the 6 cardinal positions of gaze.
The inability to move one or both eyes
indicates a neurological deficit (CN 3, 4, 6).
Paralysis of a lateral gaze is an early sign of
rising ICP
Paralysis of the upward gaze may indicate an
orbit fracture.
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Cranial Nerves: Pupils
(continued)
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Nystagmus is a fine motor twitching of
eyeball during extreme lateral gaze. It is
normal but in other positions it may be
due to ETOH, MS, inner ear problem or
brain lesion.
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Cranial Nerves: Pupils/Face
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(continued)
PERRLA – pupils equally round, reactive to
light and accomodating.
Assess facial movement/sensation by
asking the patient to smile, show their
teeth, frown and raise the brows. Touch
the forehead, cheeks and chin.
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Unilateral drooping is abnormal and
associated with paralysis as in a CVA (CN 7).
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Cranial Nerves: Face
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Assess the palate by asking the patient to
say “aah,” the soft palate should rise in
the middle and the uvula midline (CN 10).
Ask the patient to stick out the tongue.
Midline position is normal (CN 12).
Assess for an intact gag reflex (CN 9 and
10).
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Cranial Nerves: Face (continued)
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Note any abnormal speech (i.e. aphasia,
dsyphasia, dysarthria) or difficulty
swallowing (dysphagia), chewing or
drooling.
Assess CN 5 by asking the patient to move
the jaw from side-to-side while you place
resistance with your hands.
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Cranial Nerves: Face (continued)
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A sudden hearing loss is a significant
finding involving CN 8.
Assess CN 6 by testing strength any
symmetry of shoulder shrug.
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Motor Response
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Assess equality of muscle strength, tone,
and symmetry in both upper and lower
extremities.
When pain or injury are present do not
test the affected extremity.
Test upper extremities for grip strength
and pronator drift.
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Motor Response
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Test lower extremities by asking patient to
push and pull their feet against resistance.
Note any unilateral weakness.
When appropriate have the patient take a
few steps to assess balance and gait.
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Sensory Response
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This component of the neurological exam
is useful in a patient who is conscious or
has a suspected spinal cord injury (SCI).
Dermatomes are the areas on the surface
of the body that are innervated by
affected nerve fibers from one spinal
route.
Assessing dermatomes is helpful to
estimate a rough correlation to the level of
spine injury.
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Sensory Response (continued)
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For a patient with suspected SCI, with loss
of sensation or paralysis, begin at the
head and work down to find the line of
demarcation for loss of sensation.
For a non-SCI patient assess for
destination between sharp and dull touch
on the skin of the face and extremities.
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Sensory Response (continued)
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Ask the patient to close the eyes while you
alternate between sharp and dull touch.
In the unconscious patient assess for deep
pain response.
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Coordination and Reflexes
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Cerebellar function is concerned with the
control of muscular contractions of the
extremities.
Assess function by testing a patient’s
balance, fine motor movements, and
coordination.
When appropriate observe a patient’s gait.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Coordination and Reflexes
(continued)
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Examples of abnormal gait:
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Ataxia – wobbly and unsteady
Festination – uneven & hurried (Parkinsons)
Spastic hemiparesis – unilateral weakness and
foot dragging
Steppage – steps appear to be walking up
stairs while on even surface
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Coordination and Reflexes
(continued)
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Assess fine movements by asking the
patient to touch the nose with a finger
while the eyes are closed.
Assess reflexes on patients who are
unconscious, unresponsive, or with a
possible SCI.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Coordination and Reflexes
(continued)
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The level of reflex response from good to
bad:
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Purposeful withdrawal from pain
Absent gag reflex
Flexion (decorticate posturing)
Extension (decerebrate posturing)
No response
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Coordination and Reflexes
(continued)
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Assess motor response in the lower
extremities by testing the plantar
(Babinski) reflex:
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Using a capped pen draw a light stroke up the
lateral side of the sole of the foot and across
the ball.
The normal response is plantar flexion of the
toes and foot.
The abnormal response is dorsi-flexion of the
big toe and fanning of all the toes.
In children (<18 months) a positive Babinski
is normal.
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Diagnostic Tools
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The use of diagnostic tools in the
neurological exam includes:
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Glucometer or dexistrips
Thermometer
ECG monitor
SpO-2
EtCO-2
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Neurologic Emergencies
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Cerebrovascular Accident (CVA)
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CVA is an acute loss of blood flow to the
brain.
Transient ischemic attack (TIA) is an acute
temporary loss of blood flow to the brain.
AHA recognizes 2 prehospital mini stroke tests
to help in the assessment of a suspected
stroke patient:
The Cincinnati Prehospital Stroke Scale
 The Los Angles Prehospital Stroke Screen (LAPSS)
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Altered Mental Status: AEIOU-TIPS
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Can range from a subtle confusion or
agitation to unconsciousness and coma.
Try to exclude hypoxia, hypoglycemia and
trauma first.
Obtain VS as well as temperature and
blood glucose (especially in the young and
elderly).
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Seizure
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Is this the first or is there a history?
Is there a history of recent head trauma,
illness or infection?
Is the patient compliant with meds?
Is this seizure different from previous
seizures?
Consider variable causes for each age
group?
Be prepared for another seizure.
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Seizure (continued)
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Three phases: preictal, ictal, and postictal.
After the seizure most patients will feel
exhausted and initially confused with
progressive improvement over several
minutes.
Types of seizure include:
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Partial
Generalized
Absence
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Seizure (continued)
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Partial seizures:
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Occur in a specific area of the brain
Affect only specific area of the body
Often present with an aura
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Seizure (continued)
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Generalized seizures:
Involve the entire brain and may include
an aura
 Classified as: complete motor seizure,
absence seizure, and atonic seizure
 Postictal confusion, fatigue, or headache
 Loss of consciousness. Convulsive
activity – tongue biting, incontinence
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Seizure (continued)
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Absence seizures:
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Formerly called petit mal
Common in children
Daydreaming with convulsive activity
Usually no aura or postictal activity period
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Headache
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Common neurological complaint.
Associated symptom of other medical
conditions.
Most caused by: tension, musclecontraction, and sinusitis.
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Headache
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Other causes include:
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Vascular (including migraine)
Cluster
Meningitis
Temporal arteritis
Subarachnoid bleed or increased ICP
Glaucoma or eyestrain
Systemic problems (i.e. anemia, uremia, brain
tumor, infection)
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Headache (continued)
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Is it acute, recurrent, or chronic.
Types and Severity:
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Tension – due to stress and anxiety
Sinus – begin in am and worsen throughout
the day. Pressure increases with coughing
and sneezing
Migraine – severe and throbbing followed by
dull pain. Light sensitive, nausea, vomiting
and sometimes an aura. May last hours to
days
Cluster – severe, stabbing and burning pain
recurring in patterns
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Headache (continued)
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Location of pain – does not always
indicate the cause.
There are conditions that present with
associated findings:
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Headache and hypertension – subarachnoid
hemorrhage
Headache and fever – meningitis,
encephalitis, brain abcsess.
Obtain as much info on associated findings to
report to the ED.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Traumatic Brain Injury (TBI)
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Open or closed?
Consider the MOI.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Traumatic Brain Injury (TBI)
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Categories include:
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Focal head injury – brain lesions such as:
cerebral contusion, intracranial hemorrhage or
epidural hematoma
Diffuse axonal injuries – resulting from rapid
acceleration/deceleration
Coup – develop directly beneath the point of
impact
Contra-coup – develop on the opposite side of
the point of impact
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Traumatic Brain Injury (continued)
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Deterioration of a mild injury to a severe
injury and death has a predictable pattern
of signs and symptoms.
Mild to severe TBIs cause:
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AMS
Amnesia of the event
Confusion and disorientation
Combativeness
Focal neurological deficits
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TBI: Effects of Rising Pressure
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On the hypothalamus - causes a vomiting
reflex.
Mild injuries: on the brainstem - causes BP
to rise.
Severe injuries: on the brainstem - causes
vagal stimulation (bradycardia) and
posturing (flexion or extension).
On the 3rd cranial nerve - causes unequal
and unreactive pupils.
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TBI: Effects of Rising Pressure
(continued)
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On the respiratory center – causes
irregular respirations, C0-2 retention, brain
swelling, and hypoxemia in the brain
tissue.
The earliest indication of a TBI is the MOI
and presence of subtle changes in the
mental status.
When bleeding is present neurological
deficits may indicate the area of the brain
that was involved.
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Traumatic Brain Injury (continued)
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Epidural hematoma – usually involves a
middle meningeal artery tear from a blow
to the temporal skull. Usually involves a
period of AMS followed by a lucid interval
then rapidly deteriorating mental status.
Subdural hematoma – ruptured bridging
veins between the cortex and dura. Can
be acute, chronic or delayed.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Traumatic Brain Injury (continued)
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Intracerebral hematoma – bleeding within
the brain tissue. Deficits reflect the area
involved.
The skull is hard and non-expandable.
When bleeding and swelling progress the
ICP goes up and the brain shift downward
towards the foramen magnum.
Three phases to brain herniation:
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Early
Late
Terminal
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Neurogenic Shock
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Fainting resulting from nervous system
disorders.
Absence of sympathetic response results
in:
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Decreasing BP
Normal or slightly slow pulse rate
Decreasing respiratory rate
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Neurogenic Shock
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Causes of neurogenic shock:
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Injury or transection of the spine “spinal
shock”
CNS injury
Anaphylactic reaction
Insulin OD
Septicemia
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Conclusion
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Key aspect is to determine if baseline
assessment findings are changing and in
which direction.
You need to know what is “baseline” for
this patient to know what is “normal” or a
change.
Many of the signs of nervous system
disorders are subtle changes in mental
status.
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