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Neurologic Emergencies
Chapter 13
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Brain Structure
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The Spinal Cord
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Common Causes of Brain Disorder
• Many different disorders can cause brain dysfunction and can affect LOC, speech, and muscle control.
• If problem is caused by heart and lungs, entire brain will be affected.
• If problem is in the brain, only that portion of brain will be affected.
• Stroke is a common cause of brain disorder and is treatable.
• Seizures and altered mental status are other causes of brain disorder.
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Cerebrovascular Accident and Stroke
• Cerebrovascular accident
– Interruption of blood flow to the brain that results in the loss of brain function
• Stroke
– The loss of brain function that results from a CVA
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Potential Results of a CVA
• Thrombosis—Clotting of cerebral arteries
• Arterial rupture— Rupture of a cerebral artery
• Cerebral embolism —Obstruction of a cerebral artery caused by a clot that was formed elsewhere and traveled to the brain
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Hemorrhagic Stroke
• Results from bleeding in the brain
• High blood pressure is a risk factor.
• Some people are born with aneurysms
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Ischemic Stroke
• Results when blood flow to a particular part of the brain is cut off by a blockage inside a blood vessel
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Atherosclerosis
• Atherosclerosis is a condition in which fatty material collects along the walls of arteries. This fatty material thickens, hardens (forms calcium deposits), and may eventually block the arteries
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Transient Ischemic Attack (TIA)
• A TIA is a “mini-stroke.”
• Stroke symptoms go away within 24 hours.
• Every TIA is an emergency.
• TIA may be a warning sign of a larger stroke.
• Patients with possible TIA should be evaluated by a physician.
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Signs and Symptoms of Stroke
• Left hemisphere – Aphasia: Inability to speak or understand speech
– Receptive aphasia: Ability to speak, but unable to understand speech
– Expressive aphasia: Inability to speak correctly, but able to understand speech
• Right hemisphere – Dysarthria: Able to understand, but hard to be
understood
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Stroke Mimics
• Hypoglycemia
• Postictal state
• Subdural or epidural bleeding
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You Are The Provider
• You and your paramedic partner arrive to a 70-year-old man with a severe headache and decreased level of consciousness.
• He is seated in the kitchen with his wife standing next to him.
• When you speak to him, he stares at you blankly.
• You notice that he is drooling from the right side of his mouth.
• His wife says, “A few minutes ago, he told me that he had a very bad headache.”
• “When I came back from the bathroom with some ibuprofen, I tried to hand him a glass of water and he dropped the glass on the floor. I don’t know what’s wrong with him.”
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Continued…
• What do you suspect is wrong with this patient?
• What other signs and symptoms would you suspect in this scenario?
• What tests could you use to verify your suspicions?
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Scene Size up:
• Scene safety remains a priority.
• Ensure that needed resources are requested.
• Consider spinal immobilization.
• Be aware that many serious medical conditions can mimic stroke; consider all possibilities.
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Initial Assessment
• Chief complaint may include confusion, slurred speech, or unresponsiveness.
• Patient may have difficulty swallowing or choke on own saliva.
• Ensure adequate airway.
• If unresponsive, place in recovery position.
• Administer oxygen.
• Raising patient’s arms and legs may aggravate hemorrhage.
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You are the Provider
• You utilize a portion of the Cincinnati Stroke Scale by asking the patient to smile.
• He attempts, but the right side of his face remains flaccid.
• You assist the patient to the cot and place him upright, slightly on his affected side.
• As you obtain a quick set of baseline vital signs, your partner applies high-flow oxygen.
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Transport Decision
• Thrombolytics may reverse stroke symptoms or stop a stroke if given within 2 to 3 hours of onset.
• Spend as little time on scene as possible.
• Place paralyzed side down and well protected with padding.
• Elevate head approximately 6".
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Focused History and Physical Exam
• Quickly determine when patient last appeared normal.
• Medications may give you a clue to the patient’s past medical history.
• Patient may still be able to hear and understand; be careful what you say.
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Cincinnati Stroke Scale
• Speech – Abnormal if words are slurred or confused
• Facial droop – Abnormal if asymmetrical
• Arm drift – Abnormal if arms do not move equally
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Baseline Vital Signs
• Excessive bleeding in the brain may slow pulse and cause erratic respirations.
• Blood pressure is usually high.
• Excessive bleeding in the brain may cause changes in pupil size and reactivity.
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Interventions
• Based on assessment findings
• If the patient is unresponsive, you may consider the recovery position to protect the airway.
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Detailed Physical Exam
• Perform when time and conditions permit.
• Generally performed en route to the hospital.
• Do not delay transport, especially due to the time sensitivity of stroke treatment.
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Ongoing Assessment
• Reassess ABCs, interventions, vital signs.
• Stroke patients can lose airway without warning.
• Watch for changes in GCS scores.
• Relay information to the hospital as soon as possible.
• Report any pertinent physical findings, Cincinnati Stroke Scale, GCS score, any other changes.
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Emergency Care for Stroke
• Patient needs to be evaluated by computed tomography (CT).
• Recognizing the signs and symptoms of stroke can shorten the delay to CT.
• Treatment needs to start as soon as possible, within 3 to 6 hours of onset.
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Seizures
• Generalized (grand mal) seizure
– Unconsciousness and generalized severe twitching of the body’s muscles that lasts several minutes
• Absence (petit mal) seizure
– Seizure characterized by a brief lapse of attention
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Signs and Symptoms of Seizures
• Seizures may occur on one side or gradually progress to a generalized seizure.
• Usually last 3 to 5 minutes and are followed by postictal state
• Patient may experience an aura.
• Seizures recurring every few minutes are known as status epilepticus.
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Causes of Seizures
• Congenital (epilepsy)
• High fevers
• Structural problems in the brain
• Metabolic disorders
• Chemical disorders (poison, drugs)
• Sudden high fever
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Recognizing Seizures
• Cyanosis
• Abnormal breathing
• Possible head injury
• Loss of bowel and bladder control
• Severe muscle twitching
• Postseizure state of unresponsiveness with deep and labored respirations
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Postictal State
• Patient may have labored breathing.
• May have hemiparesis: weakness on one side of the body.
• Patient may be lethargic, confused, or combative.
• Consider underlying conditions:
– Hypoglycemia
– Infection
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Scene Size Up
• Spinal immobilization may be needed with a seizure.
• Ensure that scene is safe and wear BSI.
• Request ALS assistance earlier rather than later
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Initial Assessment
• Most seizures last only a few minutes at most.
• Assess level of consciousness.
• Use AVPU scale to determine how well patient is progressing through postictal stage.
• Focus on ABCs upon arrival.
• Expect pulse to be rapid and deep.
• Pulse should slow to normal rates after several minutes.
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Transport Decision
• It is difficult to package a seizing patient for transport.
• Treat ABCs while waiting for seizure to finish. • Protect the seizing patient from his or her
surroundings. • Never restrain an actively seizing patient. • Not every patient who has a seizure wishes to
be transported. • Encourage every patient to be seen and
evaluated in the emergency department.
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Focused History and Physical Exam
• Obtain some information from family or bystanders.
• Observe patient for recurrent seizures.
• If the patient displays an altered mental status, perform a rapid physical exam.
• If patient is responsive, begin with SAMPLE history.
• If the patient has an altered mental status, utilize the Glasgow Coma Scale.
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Interventions
• Most seizures will be over by the time you arrive.
• Treat trauma as you would for any other patient.
• For patients who continue to seize, suction the airway according to local protocol, provide positive pressure ventilation, transport quickly to hospital.
• Consider rendezvous with ALS, who have medications to stop prolonged seizures.
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Detailed Physical Exam
• If life threats are treated, consider performing detailed physical exam.
• Check patient for injuries, including tongue.
• Assess for weakness or loss of sensation on one side of body.
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Ongoing Assessment
• Note additional seizure activity.
• Reassess ABCs, interventions, vital signs.
• Provide complete history to receiving facility.
• Include descriptions of seizure from witnesses if available.
• Document whether this is first seizure or whether patient has history of seizures.
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Emergency Medical Care for Seizure
• Most patients should be evaluated by a physician after a seizure.
• With severe injury, suspect spinal injury.
• Attempt to lower body temperature if febrile seizure.
• Patient and family may be frightened.
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Altered Mental Status
• Hypoglycemia
• Hypoxemia
• Intoxication
• Drug overdose
• Unrecognized head injury
• Brain infection
• Body temperature abnormalities
• Brain tumors
• Glandular abnormalities
• Poisoning
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Assessing a Patient With AMS
• Same assessment process
• Patient cannot tell you reliably what is wrong.
• Be vigilant in ongoing assessment.
• Monitor for changes or deterioration.
• Provide prompt transport to hospital while monitoring the patient.