Neurological Emergencies Study Guide for the CEN

General Information

One of the most-questioned areas of emergency nursing on the CEN is that of neurological emergencies, with about 12% of the questions pertaining to this area. You’ll need to know all about the brain and nervous system, as well as how to assess and treat emergencies pertaining to them.

Neurological Disorders

Neurological disorders are conditions that affect the central nervous system (the brain and spine) and peripheral nerves throughout the body. Both sensory and motor neurons can be affected, resulting in altered mental status, speech, and voluntary and involuntary muscle control. Common neurological disorders include multiple sclerosis, transverse myelitis, myasthenia gravis, Guillain-Barre syndrome, and amyotrophic lateralizing sclerosis (ALS).

Assessment

Symptoms most commonly present as weakness or loss of sensation. The patient may notice that they are tripping more frequently, falling, can’t walk as far, or having difficulty with fine motor skills such as opening jars or fastening shirt buttons. The symptoms can be localized to one or two limbs or generalized throughout the patient’s entire body. Even the ability to speak, swallow, and breathe can be affected in extremely severe cases. Symptoms can appear slowly over months or years, as in ALS, or in a matter of hours/days, as in Guillain-Barre syndrome. The primary method of diagnosis is CT scans or MRIs, usually of the spine and head. Peripheral nerve dysfunction can be diagnosed using electromyography (EMG), which measures muscle response to electrical stimulation to determine the health of motor neurons.

Treatment

The treatment for the neurological disorder depends on the cause of the disorder. In disorders that are immune-mediated such as multiple sclerosis, myasthenia gravis, and Guillain-Barre syndrome, the first line of treatment will be corticosteroids to suppress the immune system and then the next line of treatment will be immunosuppressants to keep the immune system in check long term. Chemotherapy may also be necessary, as will antiinflammatory drugs to reduce inflammation around the nerves. The downside is that the patient’s risk of serious infections will increase due to the immunosuppression. Rehabilitation (physical, occupational, and speech therapy) will help the patient to regain their strength after the phase of acute inflammation has passed. Some neurological disorders unfortunately don’t have a treatment yet, such as ALS, and experimental treatments have not yet proven to be effective.

Headache

A headache can be dull, sharp, mild, or completely incapacitating. While most resolve spontaneously, some require hospital admission for further treatment and/or workup. Causes of headache include temporal arteritis (inflammation of the temporal artery), migraine, head trauma, muscle tension, and sinus headache, as well as other underlying neurological disorders. The three most common causes are migraines, muscle tension, and sinus issues.

Assessment

Symptoms vary depending on the cause of the headache. Diagnosing a headache is usually a diagnosis of exclusion. For instance, migraines won’t show up on an X-ray, CT scan, or MRI of the head, but imaging can be used to rule out a brain tumor or cerebral hemorrhage that is causing the headache. Here’s a quick rundown of the most common symptoms of migraines, muscle tension, and sinus headaches.

Migraines occur when blood vessels at the base of the brain change size. The pain is usually severe and described as pounding, pulsating, stabbing, or throbbing. Some migraines cause nausea/vomiting, dizziness, or light intolerance. Visual migraines cause visual changes such as flashing lights or partial vision loss. Hemiplegic migraines are rare and can cause severe unilateral weakness or other stroke-like symptoms.
Tension headaches are caused by muscle tension in the shoulders and neck and usually cause a dull or aching pain at the base of the skull that may worsen with positional changes.
Sinus headaches are caused by fluid accumulation in the sinuses that results in painful pressure around the eyes, upper cheeks, and forehead. Respiratory symptoms such as nasal congestion, a cough, low-grade fever, and post-nasal drip may also be present.

Treatment

As with symptoms, the treatment varies depending on the cause of the headache. Here’s a quick rundown of treatment options for migraines, tension headaches, and sinus headaches.

Migraines can be controlled with prescription medications taken daily to prevent migraines such as Nurtec ODT (rimegepant), tricyclic antidepressants like amitriptyline, or beta blockers like propranolol. Acute migraine attacks can be treated with PRN medication like Imitrex (sumatriptan). If the attack doesn’t respond to at-home medications, the ER will provide a “migraine cocktail” usually consisting of NSAIDs, magnesium, antiemetics, triptans, and IV fluids. Botox injections can be used to treat chronic migraines. Dietary changes such as avoiding alcohol, caffeine, aged cheeses, and chocolate can also be helpful.
Tension headaches can usually be controlled with over-the-counter NSAIDs or acetaminophen and application of heat/cold. Massage, neck/shoulder stretches, and stress reduction techniques like meditation and good sleep hygiene practices are also beneficial.
Sinus headaches are treated by addressing the accumulation of fluid and reducing nasal pressure through the use of nasal decongestants (both PO and via nasal spray), using over-the-counter pain medication to manage symptoms, and treating any bacterial infections with antibiotics.

Increased Intracranial Pressure (ICP)

Increased intracranial pressure within the brain occurs frequently as a complication of head trauma/intracranial hemorrhage, brain tumor, or other disorders affecting the brain. According to the Monroe-Kellie hypothesis, the three compartments in the brain—cerebrospinal fluid, blood, and tissue—must have reciprocal changes to maintain a normal pressure in the brain. If one compartment increases without a decrease in another compartment, then intracranial pressure will increase and adversely affect brain function.

Assessment

Increased intracranial pressure can result in a number of symptoms that include severe headache, altered mental status, restlessness, sluggishly reacting or nonreactive dilated or pinpoint pupils, seizures, and generalized weakness. Watch for the Cushing’s triad, in which hypertension with widened pulse pressure, bradycardia, and irregular respirations indicate impending brain herniation and compression of the brainstem. Normal ICP is between 1-15 mmHg on the transducer or between 13.6-203.9 mmH20 on the manometer. Increased fluid on the brain can be observed via CT scan or MRI, but the definitive diagnosis of ICP is through an intracranial pressure monitoring device inserted into the patient’s brain. Monitoring devices include:

intraventricular catheters to monitor pressure in the patient’s lateral ventricle
intracranial pressure monitor bolts inserted through a burr hole measuring pressure in the subarachnoid space
epidural monitors in the epidural space
fiber optic monitors to monitor pressure within the brain itself

Treatment

The best method of treatment for increased intracranial pressure is to reduce the amount of fluid or blood in the brain or tissue. If an intracranial hemorrhage occurs, blood can be drained using a burr hole surgical procedure. A brain tumor or a small piece of the skull can be removed to reduce pressure in a procedure called a craniotomy. Cerebrospinal fluid can be drained using an intraventricular catheter in the short term or using an ventriculoperitoneal shunt to drain fluid into the abdomen in the long term. Steroids can reduce inflammation in the brain, and medication such as mannitol, furosemide, hypertonic saline, and acetazolamide can help to diurese excess fluid. The head of the patient’s bed should be elevated at 30 to 45 degrees, and the transducer of the intraventricular drain should be leveled at the patient’s tragus or corner of their eye for accurate measurement.

Meningitis

Meningitis is an acute inflammation of the protective covering of the brain and spinal cord called the meninges. It occurs after a bacterial or fungal infection invades the central nervous system as a result of invasive devices, nasal colonization, surgical wounds or procedures, trauma, or distant infection. The infective process and inflammation obstruct the drainage of cerebrospinal fluid and cause increased cranial pressure.

Assessment

Symptoms include sudden onset, severe headache, fever, chills, altered mental status, nausea and vomiting, severe neck pain, neural rigidity, and symptoms specific to a particular bacteria such as rash, sore joints, or ear drainage. In the later stages, symptoms of increased intracranial pressure will be present as well. Diagnosis is made through an examination and culture of a cerebrospinal fluid obtained via lumbar puncture. A head CT and blood cultures are also commonly obtained.

Treatment

Treatment for meningitis includes the administration of intravenous antibiotics for bacterial meningitis and antifungal medications for fungal meningitis, the administration of anticonvulsant medication to prevent seizures, maintaining a calm and dark environment, intravenous fluid administration, and taking the measures listed above to reduce intracranial pressure. Meningitis will resolve when the underlying infection has been successfully treated and inflammation has decreased.

Seizure Disorders

Seizures occur as a result of electrical signals that misfire in the brain. These misfirings can occur due to head trauma, stroke, brain tumor, infection, genetic causes, metabolic issues, brain malformation, alcohol or drug withdrawal, or an unknown etiology. Recurring seizures are known as epilepsy and can occur in patients of all ages. There are two main types of seizures: generalized seizures, which begin in both hemispheres of the brain simultaneously, and partial seizures, which affect only one side of the brain.

Assessment

A general seizure is characterized by a total collapse, loss of consciousness, and generalized muscle twitching. The patient may also lose control of their bladder and bowel. Absence seizures are a subset of general seizures in which the patient appears to stare or not respond but does not lose motor function; they are also known as staring spells. Partial or focal aware seizures are characterized by weakness, numbness, dizziness, unusual smells, muscle twitching, vision changes, or brief paralysis. However, the patient usually retains consciousness.

In focal onset impaired awareness seizures, the patient demonstrates abnormal behavior or inappropriate interactions with their environment; other symptoms include lip smacking, jerking, frequent eye blinking, unpleasant smells, or visual hallucinations. Some patients experience an aura prior to the actual seizure when they have visual changes or hallucinations. A period of confusion and lethargy after the seizure, known as the postictal state, is very common.

The primary test used to diagnose seizures is an EEG, which measures the electrical waves of the brain. Each area of abnormal waveform correlates with seizures in a specific portion of the brain. It is important to note that patients can have an abnormal EEG and never experience a seizure; patients can also have a normal EEG and demonstrate seizure activity. Brain imaging such as a CT scan or MRI can be used to rule out underlying causes such as a tumor, head trauma, stroke, infection, or brain malformation.

Treatment

The primary treatment for seizures is antiepileptic medications, examples of which include Keppra, Dilantin, phenobarbital, Tegretol, Depakote, Topamax, and Klonopin. The medications need to be taken regularly at the same time each day. Sometimes seizures aren’t controlled with antiepileptic medications. In such instances, the patient can experience status epilepticus, seizure activity lasting 5 or more minutes or recurrent seizure activity without a recovery period in between, which can be life threatening. Benzodiazepines used as rescue medications to interrupt the seizure include diazepam, midazolam, and lorazepam.

If a patient experiences an aura or expects that they are going to have a seizure, they should lay down in a safe place away from any hard objects. The person with them should ensure that their airway remains patent, but should not insert anything into their mouth. After the seizure, patients frequently experience fear and confusion as part of their postictal state; providing calm reassurance is necessary. In the case of persistent, severe seizures, the patient may require a surgical resection of the part of the brain triggering the seizures or placement of a vagus nerve stimulator to regulate the electrical signals within the brain.

Stroke

A cerebral vascular accident (CVA) is also known as a stroke. It is an interruption in blood flow to the brain that results in brain damage. This brain damage can lead to a variety of mental and physical disabilities depending on the specific part of the brain that is affected. Strokes are the fifth leading cause of death in the United States.

There are two types of strokes: ischemic and hemorrhagic. Ischemic strokes are caused by an embolus or thrombus, often from atherosclerosis, that blocks flow within a vessel. Hemorrhagic strokes are caused by a rupture in a vessel that causes bleeding within the brain and deprives part of the brain of blood flow. Only 13 percent of strokes can be considered hemorrhagic.

Assessment

Symptoms include balance loss, loss of coordination (ataxia), unilateral weakness or numbness in an upper or lower extremity, unilateral facial drooping, sudden vision changes, sudden mental status changes including confusion, sudden severe headache, or sudden difficulties with speech. Strokes in the left hemisphere of the brain can cause receptive and expressive aphasia and right-sided paralysis. Strokes in the right hemisphere cause left-sided paralysis and lack of awareness of any problems happening. The acronym to remember to describe stroke symptoms is BE FAST, which stands for:

B: balance loss
E: eyesight changes
F: facial drooping
A: arm weakness
S: speech difficulties
T: time to call 911

Strokes are diagnosed using a CT scan or MRI, which helps the healthcare provider determine which type of stroke has occurred: hemorrhagic or ischemic. Knowing the type of stroke will guide the patient’s course of treatment. The cause of the stroke—for instance, a thrombus caused by atrial fibrillation or an embolus from atherosclerosis in the carotid artery—will be determined by testing such as an EKG or ultrasound of the carotid arteries. The nurse should perform frequent head-to-toe neurological checks to determine the patient’s baseline neurological status and watch for any changes.

Treatment

Prompt treatment is key to preventing permanent brain damage. Initial treatment methods differ significantly in treating hemorrhagic and ischemic strokes. The primary treatment method for treating ischemic strokes is tissue plasminogen activator (tPA), which is administered intravenously and helps to dissolve the thrombus causing the stroke. It must be initiated within three hours of symptom onset to be effective.

Depending on the location of the thrombus, it may also be removed via a surgical procedure called a thrombectomy. Hemorrhagic strokes are treated by locating the source of the bleeding and applying a surgical clip to stop the bleeding, performing a burr hole surgery to drain the blood, or inserting a drain to drain fluid from the skull and reduce pressure.

All patients who have experienced a stroke will need to have a swallow study to determine whether their swallowing muscles have been affected, and all will need speech, occupational, and physical therapy to address any physical or mental impairments that have been caused by their stroke. Many people will need to use mobility aids, if only temporarily.

The underlying cause of the stroke will also need to be treated, such as initiating oral anticoagulants in the case of a thrombus caused by atrial fibrillation and treating blockages in the carotid artery with a carotid endarterectomy. All patients who have experienced an ischemic stroke will have aspirin and clopidogrel initiated for at least 30 days post-stroke. Blood pressure control, statin use, and smoking cessation are also important.

Transient Ischemic Attack (TIA)

A transient ischemic attack (TIA) is a temporary interruption in blood flow to the brain that causes stroke-like symptoms that resolve within 24 hours without treatment. It can be considered a warning sign of stroke, and approximately one-third of individuals who experience a TIA will go on to experience a stroke. Anyone who experiences a TIA needs to follow up promptly with their physician, especially if they do not immediately present to the emergency room.

Assessment

The symptoms of a TIA are the same as of those of a stroke, but will resolve spontaneously within 24 hours. If a head CT or MRI are performed promptly, a TIA may be seen on imaging, but in most cases, imaging is negative. The negative imaging and prompt resolution of symptoms helps to distinguish a TIA from a stroke. Most imaging and diagnostic tests will be performed to help determine the cause of the TIA, such as an EKG to check for atrial fibrillation and an ultrasound of the carotid arteries to check for atherosclerosis. In some instances, a cause for the TIA may not be found.

Treatment

The TIA resolves independently, so treatment for the symptoms is not needed. Instead, treatment focuses on addressing the underlying cause of the thrombus or embolus that led to the TIA. A patient with atrial fibrillation will receive oral anticoagulants and antiarrhythmic medication and may undergo a cardioversion to return them to normal sinus rhythm. The patient will likely be prescribed aspirin and clopidogrel for at least 30 days post TIA to reduce the risk of a stroke.

Lifestyle changes such as a low-fat diet, incorporating regular exercise, and smoking cessation are key. Blood pressure control and taking a statin are also important. Sometimes a cause cannot be found. In that case, lifestyle changes and blood pressure control are crucial.

Head and Spinal Cord Trauma

Head and spinal cord trauma occurs as the result of a sudden injury due to an accident such as a motor vehicle crash, falling, or diving into a shallow pool. The specific mechanism of injury varies with age; younger patients are more likely to dive into a shallow pool, and older patients are more likely to fall and have a serious injury, especially if they are on blood thinners.

Assessment

The nurse should consistently assess the patient’s neurological status, including cranial nerves and pupil checks, and strength/sensation in the extremities, after injury as ordered by the healthcare provider or if they notice a change in a patient’s condition. The checks will frequently be every 15 minutes for the first hour post-injury, then transition to every hour if the patient’s neurological condition remains stable, and then to every 2 or 4 hours after the first day if the patient’s condition still remains stable.

The nurse should also monitor closely for altered mental status, decreased level of consciousness, or increased confusion. The patient’s level of responsiveness and orientation can be assessed using the Glasgow Coma Scale, which runs from 0 (completely obtunded) to 15 (alert and oriented x3). Head and spinal cord trauma is diagnosed through X-ray, CT scan, and MRI of the affected body part.

Spinal cord injuries can be complete, meaning no sensation/motion remains below the level of injury, or incomplete, meaning that the patient retains some sensation/motion. Injuries that initially appear complete can improve over time as the spinal cord heals. In high-level injuries, the patient can develop hypoxia due to respiratory dysfunction and require assistance with breathing, such as temporary intubation and placement of a tracheostomy for long-term support. Spinal cord injuries are assessed using the ASIA Impairment Scale, which is as follows:

Grade A: The injury is complete.
Grade B: The impairment is incomplete; some sensation, but no motion, remains below the level of injury.
Grade C: Some sensation and motion are preserved, but the patient cannot move more than half of their joints below the level of injury against gravity.
Grade D: More sensation and motion are preserved, and the patient can move more than half of their joints below the level of injury against gravity.
Grade E: The patient’s sensation and motion are unimpaired.

Treatment

The specific intervention depends on the severity of the injury. In some instances, serial imaging (such as daily CT scans) for several days post-injury is sufficient to make sure a head bleed resolves. The patient’s head of bed should be elevated at 30 to 45 degrees. If a vertebral fracture or ligamentous injury has occurred, but is stable and does not need surgery, bracing such as a TLSO brace, halo brace, or cervical collar may need to be worn for several months to support the injured area.

Surgical intervention is necessary if the fracture is more severe to both relieve pressure on the brain or spinal cord and stabilize the injured area to prevent further damage from occurring. The patient’s blood pressure should be tightly controlled to reduce any further pressure on the brain or spinal cord. A common goal is to keep the systolic blood pressure below 140, but it varies by healthcare facility. Corticosteroids help to reduce inflammation during the acute phase of injury.

After the acute phase has passed, the patient will need extensive rehabilitation consisting of physical, occupational, and speech therapy to optimize the function that the patient has remaining and educate the patient about assistive devices and mobility aids.

Neurogenic Shock

Neurogenic shock occurs in the event of a high-level spinal cord injury, specifically above T6. The patient is unable to maintain their blood pressure due to the spinal cord injury, and major vasodilation occurs because the body cannot effectively regulate vasoconstriction below the level of injury. The patient also experiences bradycardia and generalized instability of the autonomic nervous system.

Assessment

The nurse should monitor the patient’s vital signs closely, especially blood pressure, heart rate, oxygen saturation, and temperature, and immediately intervene if a patient with a high-level spinal cord injury changes from their baseline. Neurogenic shock can cause severe organ damage or even be fatal if prompt intervention does not occur. There is no specific lab work or diagnostic imaging that can diagnose neurogenic shock. Rather, it is diagnosed dependent on the patient’s other health conditions (in this case a high-level spinal cord injury).

Treatment

Treatment of neurogenic shock consists of medical management to raise the heart rate and blood pressure until the patient’s body has adapted to the injury. Fluid resuscitation helps to raise the patient’s blood pressure, while medications such as atropine raise the heart rate, vasopressors cause vasoconstriction to address the vasodilation, and inotropes increase the contractility of the patient’s heart.