Neurologic Emergencies

Chapter 13

Brain Structure

The Spinal Cord

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.

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

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

Hemorrhagic Stroke

• Results from bleeding in the brain

• High blood pressure is a risk factor.

• Some people are born with aneurysms

Ischemic Stroke

• Results when blood flow to a particular part of the brain is cut off by a blockage inside a blood vessel

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

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.

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

Stroke Mimics

• Hypoglycemia

• Postictal state

• Subdural or epidural bleeding

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.”

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?

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.

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.

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.

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".

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.

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

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.

Interventions

• Based on assessment findings

• If the patient is unresponsive, you may consider the recovery position to protect the airway.

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.

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.

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.

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

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.

Causes of Seizures

• Congenital (epilepsy)

• High fevers

• Structural problems in the brain

• Metabolic disorders

• Chemical disorders (poison, drugs)

• Sudden high fever

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

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

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

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.

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.

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.

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.

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.

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.

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.

Altered Mental Status

• Hypoglycemia

• Hypoxemia

• Intoxication

• Drug overdose

• Unrecognized head injury

• Brain infection

• Body temperature abnormalities

• Brain tumors

• Glandular abnormalities

• Poisoning

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.