NEUROLOGICAL DISTRESS
DEFINITION :
Neurological distress is defined as an impairment of nervous function, i.e. impairment of the central or peripheral nervous system, the development of which may affect, in the short term, the other vital functions of the body (circulatory function, respiratory function) and lead to the death of the victim. Loss of consciousness is a major neurological distress that requires immediate first aid, but the victim may present visible signs of neurological distress without having lost consciousness (impairment of respiratory mechanics due to neurological impairment of the nerves innervating the respiratory muscles).
Cause :
Traumatic: brain or spinal cord injury.
Non-traumatic: metabolic: hypoglycemia, hyponatremia, hyperglycemia toxic: ingestion of toxic, drugs infectious: cerebral abscess, encephalitis vascular: stroke, cerebral thrombophlebitis tumor: cerebral Tm, metastasis.
Consequences
-Convulsion
-Disturbance of consciousness
-Impact on respiratory function
- Impact on hemodynamic status
Signs
Neurological distress is manifested by common signs, which may be isolated or associated:
- Neurological signs:
– impaired consciousness, even coma
– convulsions.
-sign of HIC: headache, projectile vomiting.
– facial asymmetry (facial paralysis)
– decreased or loss of sensitivity, decreased or loss of motor skills.
– abnormality of pupillary reactions or asymmetry of pupil diameter
– speech impairment.
– behavioral disorder.
– balance disorders.
- signs due to the interaction of major vital functions: Any neurological damage can lead to an alteration of other vital functions (respiratory and circulatory distress).
NEUROLOGICAL DISORDER
Principle of relief action
The relief action must allow:
1- Assess the level of consciousness: neurological scores, the most used is the Glasgow score
2- Assess other vital functions, rule out hypoglycemia.
3- place the victim in a suitable waiting position in order to preserve cerebral circulation:
– Conscious victim: Lay the conscious victim flat on his back.
- Unconscious victim: – if trauma is suspected, immobilize the head and spine in the event of a sudden fall at the slightest doubt – Place in PLS until full consciousness is regained if no evidence of trauma.
4- Administer O2 by inhalation if necessary.
5- Protect the victim against the cold or bad weather.
6- Calm and reassure the victim.
7-to carefully monitor the victim and adapt the first aid measures to the development of the situation.
NEUROLOGICAL DISORDER
CONVULSION
A convulsion is the involuntary and sudden onset of muscle spasms of cerebral origin, in specific locations or throughout the body. (Muscle rigidity followed by muscle jerks) accompanied by loss of consciousness and often loss of urine (generalized tonic-clonic seizures).
Almost all seizures are relatively short in duration, lasting from a few seconds to a few minutes. Most seizures last 1 to 2 minutes.
Seizures can be described as follows:
Epileptic: These seizures have no apparent trigger (i.e., they are not provoked). Epileptic seizures are called a seizure disorder or epilepsy. The cause of epileptic seizures is often unknown (idiopathic epilepsy).
Non-epileptic: These seizures are triggered by a reversible disorder or transient condition that irritates the brain, such as an infection, head trauma, or a reaction to a medication. In children, fever can trigger non-epileptic seizures (hyperpyretic seizures).
Symptoms of seizure disorders
An aura (unusual sensations) describes how a person feels before the seizures begin. An aura can include any of the following:
- Abnormal odors or tastes
-Knots in the stomach
- Sensation of déjà vu or the opposite feeling, that is to say something seems unknown while it is familiar (what we call jamais vu)
-An intense feeling that the convulsion is about to begin
Tonic-clonic seizure
It is part of generalized epilepsy of the brain. The discharge of neurons is immediately propagated to both cerebral hemispheres. The patient presents a loss of consciousness followed by bilateral and symmetrical motor manifestations. There is a tonic phase (intense muscle contraction), then clonic (symmetrical rhythmic jerks), at the end of the seizure the patient presents a stertor noisy breathing. During the seizure, the patient can bite his tongue on the side or lose his urine. The patient regains consciousness several minutes later, he is often confused (lost) at the beginning and little by little consciousness returns. He will have no memory of the episode.
Focal crisis
Initial treatment
The patient convulses
Protect from trauma, ensure airway is clear, loosen clothing.
Most seizures resolve spontaneously and rapidly. Administration of an anticonvulsant is not systematic. If a generalized seizure lasts more than 5 minutes, stop the seizure with:
Diazepam
Child: 0.5 mg/kg intrarectally preferably without exceeding 10 mg.
Slow IV administration is possible (0.3 mg/kg over 2 to 3 minutes) provided that ventilatory assistance equipment is available (Ambu and mask).
Adult: 10 mg slow IV
The patient no longer convulses
Keep diazepam and glucose on hand in case the patient re-vulses.
The patient can be placed in the lateral safety position (PLS) only when the tonic-clonic phase is over, i.e. when the jerks have stopped.
NEUROLOGICAL DISORDER
DISORDER OF CONSCIENCE
This is an alteration of consciousness that lasts for more than 5 minutes and can be mild or profound.
Obnubilation : Corresponds to a slowing down of all functions of consciousness with deterioration of attention.
Mental confusion : represents a moderate form of alteration of the strategic functions of consciousness marked by a combined alteration of the major cognitive functions (memory, language, calculation, temporo-spatial orientation, task planning, etc.), an alteration of vigilance and attention most often fluctuating with the nycthemeron.
NEUROLOGICAL DISORDER
Coma: is defined by a profound and lasting alteration of consciousness and vigilance, not reversible by external stimulation. A state of behavioral unresponsiveness in a patient who has his eyes closed (therefore in a state of apparent sleep), but who cannot be awakened, including by intense painful stimulation. This is the most severe form of disturbance of consciousness.
Clinical examination of a coma
The clinical examination of a coma must include at least three stages:
1-immediately, look for vital distress
For any patient in a coma, it is imperative to look for an immediate vital threat and to look for major vegetative or metabolic disorders, and this by means of a careful clinical examination.
– Circulatory status: presence of pulse, blood pressure, heart rate, search for peripheral signs of shock.
– Respiratory status: respiratory rate, rhythm, range of motion; signs of pulmonary congestion or edema, cyanosis, tachypnea, desaturation, bradypnea or respiratory pauses.
– Perform a capillary blood sugar test: Hypoglycemia should be ruled out as a matter of principle because it can cause brain damage if it is prolonged.
The observation of a vital failure requires immediate therapeutic actions: oxygenation, intubation, vasoactive drugs, etc.
2-Interrogation of the entourage
A real “police investigation” is sometimes necessary to gather information on the possible cause(s) of this coma. This investigation can be difficult if the patient wanted to hide a suicidal gesture, if he was alone at the time of the coma;
- history, treatment followed, lifestyle, possible professional or domestic exposure to a toxin, chronic or acute alcoholism, possible drug addiction;
- the history of the onset of the coma, which must be carefully reconstructed: brutality, warning signs, clinical state preceding the coma, circumstances of occurrence;
- respiratory or motor activity since the onset of the coma: the possible existence of abnormal or repetitive movements;
- any substances possibly ingested
3-General physical examination
Inspection of the whole body is necessary.
We look for signs of trauma
We also look for significant skin lesions such as purpura, even a few spots, rashes, traces of bites.
The presence of loss of urine, visible on clothing, or a bitten tongue should suggest an epileptic seizure.
Meningeal stiffness
Body temperature measurement should be taken with a thermometer.
4-Neurological examination
→Brain activity is assessed by observing spontaneous movements and then by observing the response to stimuli.
Spontaneous eye movements, eyelid opening, eyeball movements, should be observed by raising the eyelids. Pendulum movements or nystagmus are significant.
Spontaneous movements such as swallowing and breathing do not provide information about its depth.
Depending on the severity of brain damage, the following responses have been described:
- decortication, adduction of the arm, slow flexion of the forearm on the arm;
- decerebration adduction and extension in internal rotation of the arms, associated with a projection of the shoulder forward, achieving the classic rolling movement.
These phenomena are not specific to brain damage but only suggest increasingly deeper levels of neuronal damage.
→Eye examination
In a coma, the tone of the orbicularis oculi predominates over that of the levator of the upper eyelid and the eyes are closed.
When the coma is deep, the tone of these muscles disappears and the eyelids tend to be half-open.
A simulated coma is suggested when a high tone of the orbicularis muscles is observed, which prevents the eyelids from opening.
→Pupil analysis
Any finding or appearance of uneven pupillary diameter (anisocoria) should be noted.
–Bilateral mydriasis, unilateral mydriasis, bilateral myosis, unilateral myosis.
–the search for photomotor and consensual reflexes: carried out using a bright light flooding each eye separately and hiding the other from the light, we observe a pupillary contraction of the illuminated eye, this is the protomotor reflex, and, to a lesser degree, of the pupil of the unilluminated eye, this is the consensual reflex. In the event of no response, we speak of an areactive reflex.
The blink reflex to threat reflects a near-normal state of wakefulness
5-Measuring the depth of a coma
During the neurological examination, in order to be able to quantify the clinical severity, monitor the patient and give a prognosis, the use of scores makes it possible to classify the patient’s clinical state.
—The Glasgow score allows, at a given moment, to quantify the depth of a coma and to follow its evolution in patients undergoing spontaneous ventilation.
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•Additional explorations ???????
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•differential diagnosis
- Hypersomnia: this is a sleep attack that is quickly reversible by stimulation. Hypersomnia can be due to narcolepsy or sleep apnea syndrome.
-Locked-in syndrome: trauma to the lower part of the brain stem, generally due to occlusion of the basilar artery.
-Akinetic mutism: this is an alteration of the frontal lobes, and therefore of self-awareness, with major attention disorders , motor and sensory neglect.
-Hysterical conversion: it is a psychiatric illness.
-Chronic vegetative state : it follows the coma but is not a coma, the eyes open but with an absence of awareness of their being and environment, the respiratory and circulatory functions are stabilized.
ACTION TO BE TAKEN
Initial medical care
Therapeutic management in the acute phase of consciousness disorders must ensure the maintenance of the patient’s hematosis and hemodynamics.
If there is no cardiac activity, cardiac resuscitation maneuvers are undertaken.
If there is no effective ventilation, the patient is intubated.
Place the victim in a suitable waiting position
A venous access is placed and crystalloids are infused. A complete biological assessment is taken.
If there are clinical signs of involvement, osmotherapy is indicated.
Blood pressure management depends on the etiology causing the neurological deterioration.
Immobilization of the head-trunk-neck axis is the rule, until the traumatic origin is eliminated.
The 15° inclined head position, avoiding jugular compression, allows the best venous drainage/cerebral perfusion ratio.
Antiepileptic treatment should be considered in cases of clinical seizures.
Treatment of the cause: Specific etiological management is obviously the most important element (medical or surgical) →specialized service.
NEUROLOGICAL DISORDER
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NEUROLOGICAL DISTRESS