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Emergency Nursing Course. Neurological Emergencies Dr. Fu Tat Lee ( 李富達醫生 ) Princess Margaret Hospital ( 瑪嘉烈醫院 ). Outline. Neurological assessment Stroke Seizure Acute generalized weakness Headache. Neurological assessment. What is it? Where is it?. The Neurological Assessment.

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Emergency nursing course

Emergency Nursing Course

Neurological Emergencies

Dr. Fu Tat Lee


Princess Margaret Hospital



  • Neurological assessment

  • Stroke

  • Seizure

  • Acute generalized weakness

  • Headache

Neurological assessment
Neurological assessment

  • What is it?

  • Where is it?

The neurological assessment
The Neurological Assessment

  • History should direct the neurological examination to the most relevant areas.

  • Symptoms may occur before signs can be detected.

  • In the absence of symptoms, any signs are less likely to be important.

The neurological assessment1
The Neurological Assessment

  • Look for asymmetrical abnormalities

  • Tendon reflexes can be absent in health but may

    indicate an abnormality in the sensory or motor system

  • An EXTENSOR PLANTAR REFLEX which is reproducible is never normal (except in infants)

The neurological assessment2
The Neurological Assessment

A. Mental Status

Glasgow Coma Scale eye opening

motor response

verbal response

B. Cranial nerves (1st - 12th)

C. Upper & lower limbs

- motor

- sensory

- coordination

- reflexes

Decorticate posture

Decerebrate posture

Neurological examination
Neurological Examination

Cranial nerves

(1) 1st (olfactory) nerve

- anosmia (loss of smell)

2nd (optic) nerve

- visual acuity

- visual field

3rd (Oculomotor), 4th (Trochlear) and

6th (Abducent) nerves

- eye movements, upper eyelid & pupil size

5th trigeminal nerve
5th (Trigeminal) nerve

Motor: Masseter

Sensory: ophthalmic, maxillary & mandibular divisions

Bell s palsy
Bell’s palsy

  • 1st described by Dr Charles Bell in 1882

  • Lower Motor neuron lesion of 7th nerve

  • idiopathic etiology

    - Dx on i) no identifiable cause (viral/post viral Sx)

    ii) peripheral


  • Pain

  • Tearing

  • Drooling

  • Hypersensitivity to sound

  • Impairment of taste

Other causes of LMN lesion of VII nerve: frontalis muscle

Acoustic neuroma

Parotid gland tumour

Ramsey Hunt Syndrome:

facial nerve palsy due to Herpes Zoster

vesicles at the external auditory canal and ear.

Bell s palsy1
Bell frontalis muscle ’s palsy

Treatment : - Prednisolone 60 mg daily for 5 days

- ? Acyclovir

- physiotherapy

- eyedrops and cover

- refer medical or ENT if fail to recover

Prognosis : 80% recover completely within 3 months

8th (Acoustic) nerve frontalis muscle

- balance

- deafness

Weber & Rinnie Test to distinguish conductive deafness

from sensory deafness

Rinnie test frontalis muscle

Weber test

9 frontalis muscle th Glossopharyngeal nerve

Muscles for swallowing

10th vagus nerve
10th Vagus nerve frontalis muscle

  • Smooth muscles of GI & respiratory tract

  • Pacemaker

  • Muscles of heart, pharynx & Larynx

gag reflex

(sensory 9th)

(motor 10th)

11th (accessory) nerve frontalis muscle

- sternomastoid & trapezius muscle

12th (hypoglossal) nerve frontalis muscle

- tongue

Neurological examination1
Neurological Examination frontalis muscle

Upper & Lower limbs assessment


  • Posture, Muscle wasting, Fasciculation

  • Muscle Tone: Hypertonic or Hypotonic

  • Muscle power :

  • Grading : 0 complete paralysis

    I flicker of contraction

    II movement is possible where gravity


    III movement is possible against gravity

    but not if any further resistance is


    IV movement is possible against gravity

    and some resistance

    V normal power

  • Coordination frontalis muscle

    Pastpointing, dysmetria, dysdiadochokinesia

    Romberg testing


  • Tendon Reflex

    Hyperreflexia or Hyporeflexia

  • Plantar Reflex

    Upgoing or Downgoing

Line of Stroke frontalis muscle

Normal Planter reflex

Barbinski reflex

Signs of Upper Motor Neurone Lesions frontalis muscle

  • Little muscles wasting unless from disuse

  • Spasticity + Clonus

  • Hyperreflexia

  • Extensor Plantar response

    Signs of Lower Motor Neurone Lesions

  • Wasting is prominent

  • Fasciculation

  • Hypotonia

  • Hyporeflexia

  • Normal or equivocal plantar reflex

Sensation frontalis muscle


Light touch



Proprioception and vibration

Dermatone frontalis muscle

Assessment of brainstem function
Assessment of Brainstem function frontalis muscle

Brainstem reflex

pupillary reactions

corneal responses

spontaneous eye movements

oculocephalic responses (Doll’s eye reflex)

oculo vesticular responses (Caloric test)

respiratory patterns

Stroke frontalis muscle

Stroke frontalis muscle

  • Stroke is a syndrome of rapidly developing clinical symptoms and signs of focal or global disturbances of cerebral functions due to non-traumatic vascular causes, with symptoms lasting more than 24 hours.

  • Not a cerebrovascular “accident” but a consequence of cerebrovascular disease

Stroke is preventable
Stroke is frontalis muscle preventable

  • Modifiable risk factors

    • History of stroke or TIA

    • Hypertension

    • Cardiac diseases

    • Atrial fibrillation

    • DM

    • Internal carotid artery stenosis

    • Smoking

    • Alcohol abuse

    • Hypercholesterolemia

    • Obesity

    • Lack of exercise

    • Haematological diseases, coagulopathies

  • Major types of stroke frontalis muscle

    • Ischaemic (70%)

      • Cortical

      • Subcortical

      • Posterior circulation

      • Lacunar infarction

    • Intracerebral haemorrhage (25%)

      • Supratentorial

      • Infratentorial

      • Both

    • Subarachnoid haemorrhage (5%)

Mortality morbidity
Mortality & Morbidity frontalis muscle

Circle of Willis frontalis muscle

Principles of management
Principles of management frontalis muscle

  • Assess vital signs

  • Confirm the diagnosis

  • Differentiate ischaemic from haemorrhagic stroke

  • Look out for clues for aetiology

  • Screen for early complications

Specific management of ischaemic stroke
Specific management of Ischaemic Stroke frontalis muscle

Stroke is an emergency

Acute therapy is available for ischaemic stroke within 3 hours of onset.

Tissue Plasminogen activator (TPA) 0.9mg/kg

10% as bolus and 90% infusion over 1 hour

within 3 hours increases the proportion of patients with minimal or no disability by 13-16%

6% risk of transforming infarction into symptomatic haemorrhagic

Antiplatelet therapy frontalis muscle

Low dose Aspirin (160 to 300mg daily) within 48 hours

of onset prevents 11 recurrent ischaemic strokes or

deaths at the expense of 2 extra cases of haemorrhagic

transformation per thousand patients treated.

?? Glycoprotein IIb/IIIa inhibitor

Anticoagulation frontalis muscle

Spontaneous haemorrhagic transformation of infarction

commonly occurs within 2-4 days

Clinical trials not support indiscriminate use of


  • Neurosurgery frontalis muscle

    • Not needed in most cases

    • Obstructive hydrocephalus

    • Cerebellar haematoma or infarct

    • Large superficial or lobar haematoma

    • Markedly raised ICP

Seizure frontalis muscle

Seizure frontalis muscle

- Primary epilepsy, idiopathic, onset before 20

- Secondary epilepsy, symptomatic, by parenchymal abnormality e.g. tumor, AVM, aneurysm, contusion/hematoma

Different types of seizure
Different types of seizure frontalis muscle

- generalized/grand mal : witnessed LOC with generalized activities

- minor/petit mal (absence) : prolonged unresponsive staring without LOC, + focal muscular activity

- focal : repetitive motor activity without LOC

- temporal lobe : hallucinations (visual, auditory, and olfactory), memory loss, and/or bizarre behavior which may progress to focal-generalized motor activity

- Todd frontalis muscle ’s paralysis - focal weakness/paralysis after seizure lasting up to several days

  • febrile convulsion :

    3 months to 5 years, rapidly rising fever

Clinical evaluation
Clinical evaluation frontalis muscle


examine for trauma including head/facial

abrasions, contusions, lacerations, tongue,

buccal lacerations

Is patient seizing? Is patient awake?

Look for eye deviation and

focal/generalized tonic/clonic


Treat reversible causes
Treat reversible causes frontalis muscle


H ypotension due to hypovolemia, arrhythmia

H ypoxia

H ypoglycemia

O verdose & others

(Electrolyte disturbance,Intracranial SOL,

CVA, Infection)

mnemonics of frontalis muscle “ A E I O U”“T I PS”

Status epileticus
Status epileticus frontalis muscle

  • Traditional definition:

    • 30 minutes of continuous seizure activity or a series of seizures without return to full consciousness between the seizures.

(D) Treatment frontalis muscle

- support airway, IV, O2 and monitor

- treat reversible causes

1st line - Diazepam 0.25mg/kg IV or

0.5mg/kg PR

- Lorazepam 0.1mg/kg iv

- Midazolam 0.1 mg - 0.3 mg/Kg IVI

or 0.2mg/kg IMI

2nd line - Phenytoin 18 mg/Kg IV load at 50mg/min with cardiac monitoring

3rd line - Consider phenobarbitone (200mg=1ml=1 Ampule) imi, generalized anaesthesia

Discharge? frontalis muscle

  • Breakthrough seizure

  • No underlying cause

  • No head or other serious injury

  • Good drug compliance

  • No recent change on medication

  • Escort by an responsible adult

Acute generalized weakness
Acute generalized weakness frontalis muscle

  • Spinal cord compression

  • Neuropathies

    • Guillain-Barre syndrome

    • Metallic poisons (lead & arsenic)

    • Vitamin deficiencies (B12)

    • Systemic diseases (DM, Renal failure)

    • Drugs

Acute generalized weakness1
Acute generalized weakness frontalis muscle

  • Motor end plate

    • Myasthenia gravis

    • Botulism

    • Eatom-Lambert syndrome

  • Myopathies

    • Acute periodic paralysis (Hyper, hypo or normokalemia)

    • Alcoholic myopathy

    • Polymyositis

    • Drug (steroid)

Guillain Barre Syndrome(GBS) frontalis muscle

George Charles Guillain

Jean Alexandre Barre

Guillain barre syndrome
Guillain Barre Syndrome frontalis muscle

Pathology : An autoimmune disease causing

acute demyelinating inflammatory


GBS frontalis muscle

usually follow acute febrile illness, URTI, (days/weeks)

typical pattern : symmetrical ascending flaccid

motor paralysis, commonly with some sensory

Symptoms (tingling sensation)

Impaired breathing, BP and Heart rate


A&E patient with lower extremity weakness and loss of lower extremity reflexes

Investigations treatment
Investigations & treatment frontalis muscle

  • Investigation

    • Nerve conduction test

    • CSF: high protein

  • Management (mainly supportive)

    • ICU care

    • Ventilatory & circulatory support

    • Plasmaparesis

    • High dose Ig

    • Psychological support

GBS frontalis muscle

  • 90% weakest at the 3rd week

  • Most patients recover

Myasthenia gravis
Myasthenia Gravis frontalis muscle

- autoimmune disease

- antibodies against acetylcholine receptors at the neuromuscular junction of striated muscle


Myasthenia gravis1
Myasthenia Gravis frontalis muscle

bimodal distribution in age and gender, 2nd/3rd decade female; 6th/7th decade male

- associated with thymic hyperplasia/thymoma

  • complaints of muscle weakness, frontalis muscle worsened byprolonged activity and improved with rest

  • most common begin with ocular ptosis, diplopia and blurred vision

  • Respiratory failure

  • Confirm by bedside Tensilon test (Endrophonium)

Headache frontalis muscle

Headache frontalis muscle

  • Tension headache

  • Migraine

  • Cluster headache

  • Subarachnoid hemorrhage

  • Hypertension (DBP >130mmHg)

  • Meningitis

  • Space occupying lesion

  • Sinusitis

  • Acute Glaucoma

  • Postconcussion

  • Temporal arteritis

  • Trigeminal neuralgia

Possible causes
Possible causes frontalis muscle

  • Intracranial

    • Hemorrhage

      • SAH, Subdural, Intracerebral

    • Tumour

    • Meningitis

    • Vessel

      • Migraine, Hypertension

  • Extracranial

    • Vessel

      • Temporal arteritis

    • Nerve

      • Trigeminal neuralgia

    • Muscle

      • Tension

    • Referred pain

      • Acute glaucoma, Sinusitis

Meningitis frontalis muscle

Meningitis frontalis muscle

  • Viral

  • Bacterial

    • Pneumococcus

    • Meningococcus

    • Haemophilus Influenzae Type B

Kernig frontalis muscle ’s sign

Brudzinski’s sign

Temporal arteritis frontalis muscle

Trigeminal Neuralgia frontalis muscle

Watch out
Watch out !!!! frontalis muscle

  • The first or the worst headache of patient’s life, especially the onset is acute and associated with neurology

  • Progressively gets worse over days or weeks and subacute in onset

  • Associated with fever, nausea and vomit

  • Associated with neck stiffness, focal neurology, papilloedema, and changes in conscious level and cognition

  • No obvious identifiable cause