EMT Chapter 17 - Neurologic Emergencies
When you should suspect stroke
severe headache, vomiting, seizures, AMS
Cincinnati Prehospital Stroke Scale
*Facial Droop*: Ask patient to smile Normal: Both sides of face move equally Stroke: Unequal Movement *Arm Drift*: Ask patient to close eyes and hold both arms out with palms up Normal: Both arms move same, or neither move Stroke: One arm drifts downward or one arm does not move *Speech*: Ask patient to repeat a simple phrase Normal: Patient restates without slurring Stroke: Patient slurs, uses inappropriate words, or cannot speak at all
How many cranial nerves run from the brain to parts of the head?
12
Your patient opens his eyes, moans, and pulls away from you when you pinch his trapezius muscle. You should assign a Glasgow Coma Scale (GCS) score of:
8.
You are performing a Glasgow Coma Scale on a patient who opens her eyes in response to pain, is confused in her responses to questions, and has abnormal flexion. What is this patient's GCS score and corresponding state of dysfunction?
9 - moderate dysfunction
what most accurately describes a simple partial seizure?
: A seizure that begins in one extremity
A 30-year-old male experienced a generalized (tonic-clonic) seizure, which stopped before you arrived at the scene. The patient is conscious, is answering your questions appropriately, and refuses EMS transport. Which of the following would be the MOST compelling reason to disagree with his refusal of transport? Select one: A. He is currently not prescribed any medications B. His wife states that this was his "usual" seizure C. His Glasgow Coma Scale (GCS) score is 15 D. He has experienced seizures since he was 20
A
A patient who is possibly experiencing a stroke is NOT eligible for thrombolytic (fibrinolytic) therapy if he or she: Select one: A. has bleeding within the brain. B. has a GCS score that is less than 8. C. has had a prior heart attack. D. is older than 60 years of age.
A
A patient with an altered mental status is: Choose one answer. A. not thinking clearly or is incapable of being aroused. B. typically alert but is confused as to preceding events. C. usually able to be aroused with a painful stimulus. D. completely unresponsive to all forms of stimuli.
A
A transient ischemic attack (TIA) occurs when: Choose one answer. A. the normal body processes destroy a clot in a cerebral artery. B. medications are given to dissolve a cerebral blood clot. C. a small cerebral artery ruptures and causes minimal damage.
A
An absence seizure is also referred to as a: Choose one answer. A. petit mal seizure. B. grand mal seizure. C. generalized motor seizure. D. total body seizure.
A
Law enforcement has summoned you to a nightclub, where a 22-year-old female was found unconscious in an adjacent alley. Your primary assessment reveals that her respirations are rapid and shallow and her pulse is rapid and weak. She is wearing a medical alert bracelet that identifies her as an epileptic. There is an empty bottle of vodka next to the patient. You should: Choose one answer. A. assist ventilations, perform a rapid exam, and prepare for immediate transport. B. apply oxygen via a non-rebreathing mask, place her on her left side, and transport. C. apply oxygen via non-rebreathing mask and transport her for a blood-alcohol test. D. place a bite block in her mouth in case she has a seizure and transport at once.
A
Status epilepticus is characterized by: Choose one answer. A. prolonged seizures without a return of consciousness. B. an absence seizure that is not preceded by an aura. C. profound tachycardia and total muscle flaccidity. D. generalized seizures that last less than 5 minutes.
A
What Glasgow Coma Scale (GCS) score would you assign to a patient who responds to painful stimuli, uses inappropriate words, and maintains his or her arms in a flexed position? Choose one answer. A. 8 B. 6 C. 9 D. 10
A
When obtaining medical history information from the family of a suspected stroke patient, it is MOST important to determine: Choose one answer. A. when the patient last appeared normal. B. if there is a family history of a stroke. C. the patient's overall medication compliance. D. if the patient has been hospitalized before.
A
When you are obtaining medical history from the family of a suspected stroke patient, it is MOST important to determine: Select one: A. when the patient last appeared normal. B. if the patient has been hospitalized before. C. the patient's overall medication compliance. D. if there is a family history of a stroke.
A
Which of the following MOST accurately describes a simple partial seizure? Choose one answer. A. a seizure that begins in one extremity B. a generalized seizure without incontinence C. a seizure that is not preceded by an aura D. a seizure that causes the patient to stare blankly
A
You are caring for a 68-year-old man with sudden onset of left-sided paralysis and slurred speech. His airway is patent, his respirations are 14 breaths/min with adequate depth, and his oxygen saturation is 98%. Treatment for this patient should include: Select one: A. recovery position and transport. B. high-flow oxygen and transport. C. oral glucose gel and transport. D. ventilatory assistance and transport.
A
You are caring for a semiconscious man with left-sided paralysis. His airway is patent and his respirations are 14 breaths/min with adequate tidal volume. Treatment for this patient should include: Choose one answer. A. oxygen via a nonrebreathing mask, left lateral recumbent position, and transport. B. an oral airway, assisted ventilation with a bag-mask device, Fowler's position, and transport. C. assisted ventilation with a bag-mask device, right lateral recumbent position, and transport. D. oxygen via a nonrebreathing mask, supine position with legs elevated 6″ to 12″, and transport.
A
You respond to a residence for a child who is having a seizure. Upon arrival at the scene, you enter the residence and find the mother holding her child, a 2-year-old male. The child is conscious and crying. According to the mother, the child had been running a high fever and then experienced a seizure that lasted approximately 3 minutes. You should: Select one: A. transport the child to the hospital and reassure the mother en route. B. cover the child with wet towels and give oxygen via nasal cannula. C. advise the mother to take her child to the doctor the following day. D. call medical control and request permission to give the child aspirin.
A
What is the difference between a stroke and a transient ischemic attack?
A TIA resolves completely within 24 hours of onset.
embolus
A blood clot or other substance in the circulatory system that travels to a blood vessel where it causes a blockage.
thrombosis
A blood clot, either in the arterial or venous system.
hypoglycemia
A condition characterized by a low blood glucose level.
status epilepticus
A condition in which seizures recur every few minutes or last more than 30 minutes.
transient ischemic attack (TIA)
A disorder of the brain in which brain cells temporarily stop working because of insufficient oxygen, causing strokelike symptoms that resolve completely within 24 hours of onset.
ischemia
A lack of oxygen that deprives tissues of necessary nutrients, resulting from partial or complete blockage of blood flow; potentially reversible because permanent injury has not yet occurred.
postictal state
A period following a seizure that lasts between 5 and 30 minutes; characterized by labored respirations and some degree of altered mental status.
partial seizure
A seizure affecting a limited portion of the brain.
aura
A sensation experienced prior to a seizure; serves as a warning sign that a seizure is about to occur.
coma
A state of profound unconsciousness from which one cannot be roused.
tonic-clonic seizure
A type of seizure that features rhythmic back-and-forth motion of an extremity and body stiffness.
Subarachnoid Hemorrhage
A type of stroke that occurs when in is overstretched or ruptured, blood spurts into an area between 2 of the coverings of the brain called subarachnoid space
Postictal state
After seizure ends patient in unresponsive at first and then gradually regains consciousness.
cerebrovascular accident (CVA)
An interruption of blood flow to the brain that results in the loss of brain function. Also called a stroke.
stroke
An interruption of blood flow to the brain that results in the loss of brain function; also called a cerebrovascular accident (CVA).
Interruption of cerebral blood flow may result from all of the following, EXCEPT: Choose one answer. A. a thrombus. B. cerebral vasodilation. C. an acute arterial rupture. D. an embolism.
B
Hemiparesis
weakness on one side of body, resembling a stroke. Can happen in postictal state. Unlike a stroke, hypoxic hemiparesis soon resolves.
Interruption of cerebral blood flow may result from all of the following, EXCEPT: Select one: A. a thrombus. B. cerebral vasodilation. C. an acute arterial rupture. D. an embolism.
B
Successful treatment of a stroke depends on whether: Choose one answer. A. medications are given to restore the function of infarcted cells. B. thrombolytic therapy is given within 3 hours after symptoms began. C. surgical intervention is performed to remove obstructive clots. D. the stroke occurs within the left or right hemisphere of the brain.
B
Glasgow Coma Scale
Assesses eye opening, verbal response, and motor response
A patient whose speech is slurred and difficult to understand is experiencing: Select one: A. paraplegia. B. dysarthria. C. dysphagia. D. aphasia.
B
The left cerebral hemisphere controls: Choose one answer. A. the right side of the face. B. the right side of the body. C. heart rate and pupil reaction. D. breathing and blood pressure.
B
The most basic functions of the body, such as breathing, blood pressure, and swallowing, are controlled by the: Choose one answer. A. cerebellum. B. brain stem. C. cerebral cortex. D. cerebrum.
B
You arrive at the residence of a 33-year-old woman who is experiencing a generalized seizure. She has a small amount of vomitus draining from the side of her mouth. After protecting her from further injury, you should: Choose one answer. A. place a bite block in between her teeth, apply high-flow oxygen via a non-rebreathing mask, and consider inserting a nasopharyngeal airway. B. maintain her airway with manual head positioning, suction her airway to remove the vomitus, insert a nasopharyngeal airway, and administer high-flow oxygen. C. wait for the seizure to stop, manually open her airway, insert an oropharyngeal airway, and assess her oxygen saturation with the pulse oximeter. D. restrain her extremities to prevent her from injuring herself, suction her airway to remove the vomitus, and assist her ventilations with a bag-mask device.
B
Cerebral hemorrhage
Bleeding in the brain. May have very high bp. High bp can cause the bleeding, but often high bp is the body trying to compensate for bleeding as well
Hemorrhagic stroke
Blood vessel ruptures, causing increased pressure in the brain and subsequent brain damage. The free blood clots, which squeezes the tissue next to it. When the tissue is compressed, oxygenated blood cannot get into the area and brain cells begin to die. Occurs in people experiencing stress or exertion. People at high risk have high bp or long term elevated bp that is not treated.Less common (10-20%)
BP during cerebral hemorrhage
Bp will increase to compensate for bleeding, then it will be tapered off, then it will drop as the patient's condition worsens
A generalized seizure is characterized by: Choose one answer. A. a core body temperature of greater than 103°F (40°C). B. unconsciousness for greater than 30 minutes. C. severe twitching of all the body's muscles. D. a blank stare and brief lapse of consciousness.
C
A patient who is possibly experiencing a stroke is NOT eligible for thrombolytic (fibrinolytic) therapy if he or she: Choose one answer. A. has a GCS score that is less than 8. B. is older than 60 years of age. C. has bleeding within the brain. D. has had a prior heart attack.
C
The MOST significant risk factor for a hemorrhagic stroke is: Select one: A. severe stress. B. heavy exertion. C. hypertension. D. diabetes mellitus.
C
The three major parts of the brain are the: Choose one answer. A. brain stem, midbrain, and spinal cord. B. cerebellum, medulla, and occiput. C. cerebrum, cerebellum, and brain stem. D. midbrain, cerebellum, and spinal cord.
C
When caring for a patient with documented hypoglycemia, you should be MOST alert for: Choose one answer. A. an acute stroke. B. respiratory distress. C. a seizure. D. a febrile convulsion.
C
Which of the following MOST accurately describes what the patient will experience during the postictal state that follows a seizure? Select one: A. Hyperventilation and hypersalivation B. A gradually decreasing level of consciousness C. Confusion and fatigue D. A rapidly improving level of consciousness
C
Which of the following conditions would MOST likely affect the entire brain? Select one: A. Reduced blood supply to the left hemisphere B. Blocked cerebral artery in the frontal lobe C. Respiratory failure or cardiopulmonary arrest D. Ruptured cerebral artery in the occipital lobe
C
Which of the following conditions would be the LEAST likely to mimic the signs and symptoms of a stroke? Choose one answer. A. hypoglycemia B. intracranial bleeding C. hypovolemia D. a postictal state
C
Your patient opens his eyes, moans, and pulls away from you when you pinch his trapezius muscle. You should assign a Glasgow Coma Scale (GCS) score of: Select one: A. 9. B. 6. C. 8. D. 7.
C
Neglect
when patients forget certain parts of their body even exist. Causes many patients who have had large strokes delay seeking help
Febrile seizures
Caused by high fever, usually in children
Sinus headaches
Caused by pressure as the result of fluid accumulation in the sinus cavities
You are treating a patient who is exhibiting slurred speech, facial droop, and an inability to move his left arm. Which neurologic examination emphasizes these possible stroke signs?
Cincinnati Prehospital Stroke Scale
Stroke assessment tools
Cincinnati Prehospital Stroke Scale, Los Angeles Prehospital Stroke Screen. Evaluates face, arms and speech. Speech: Ask patient to repeat simple phrase. Facial Movement: Ask patient to show their teeth. Arm movement: ask patient to hold arms in front of his/her body with palms facing up and tell them to close their eyes for 10 sec (If both arms fall, move the patient's arms into place yourself)
You are examining a patient whose signs include lip smacking, jerking of the left arm, and agitation. Based on these signs, what type of seizure is this patient experiencing?
Complex partial
Cerebellum
Controls muscle and body coordination
A patient who is experiencing aphasia is: Choose one answer. A. not able to swallow without choking. B. usually conscious but has slurred speech. C. experiencing a right hemispheric stroke. D. unable to produce or understand speech.
D
A patient who may experience a speech disorder; the inability to produce or understand speech is experiencing: Select one: A. paraplegia. B. dysarthria. C. dysphagia. D. aphasia.
D
During the primary assessment of a semiconscious 70-year-old female, you should: Select one: A. immediately determine the patient's blood glucose level. B. ask family members if the patient has a history of stroke. C. insert a nasopharyngeal airway and assist ventilations. D. ensure a patent airway and support ventilation as needed.
D
Febrile seizures: Choose one answer. A. are also referred to as petit mal seizures. B. often result in permanent brain damage. C. occur when a child's fever progressively rises. D. are usually benign but should be evaluated.
D
What is the name of the condition when the patient forgets about the injured side after a stroke?
Neglect
When assessing arm movement of a patient with a suspected stroke, you should: Choose one answer. A. observe for approximately 5 minutes. B. ask the patient to hold his or her arms up with the palms down. C. expect to see one arm slowly drift down to the patient's side. D. ask the patient to close his or her eyes during the assessment.
D
When transporting a stable stroke patient with unilateral paralysis, it is best to place the patient in a: Choose one answer. A. recumbent position with the paralyzed side up. B. sitting position with the head at a 45° to 90° angle. C. supine position with the legs elevated 6″ to 12″. D. recumbent position with the paralyzed side down.
D
Which of the following conditions is NOT a common cause of seizures? Choose one answer. A. poisoning or overdose B. acute alcohol withdrawal C. acute hypoglycemia D. severe hypovolemia
D
Which of the following is NOT an assessment parameter included in the Cincinnati Prehospital Stroke Scale? Choose one answer. A. arm drift B. speech C. facial droop D. memory
D
Which of the following symptoms would lead the EMT to believe that a patient's headache is caused by sinus congestion? Select one: A. There is numbness in the extremities B. The headache began suddenly C. There is associated neck stiffness D. The pain is worse when bending over
D
Ischemic Stroke
Due to direct blockage of bloodflow through the cerebral arteries. Blockage is due to thrombosis (clot forms at site of blockage), or due to embolus (where clot forms in a remote area). Most common type (80%). Atherosclerosis is often the cause. In some cases, atherosclerotic plaque in the carotid artery will rupture and blood clot will form over the crack and can sometimes grow large enough to block the artery completely.
Causes for seizures
Epilepsy, high fever, structural problems in brain, metabolic or chemical problems in body, benign or cancerous tumor, infection (brain abcess), scar tissue from some type of injury
What are the three components of the Cincinnati Prehospital Stroke Scale?
Evaluates face, arms and speech.
Signs and symptoms of stroke
Facial drooping, sudden weakness or numbness in face, arm, leg or one side of body, loss of movement and sensation on one side of body, lack of muscle coordination (ataxia), sudden vision loss in one eye, blurred and double vision, difficulty swallowing, decreased or increased level of responsiveness, speech disorder (dysphasia), difficulty expressing thought or inability to speak (expressive aphasia), slurred speech (dysarthria), difficulty understanding others (receptive aphasia), decreased or absent movement in one or more extremities, sudden and severe headache, sudden loss of balance or trouble walking, confusion, dizziness, weakness, combativeness, restlessness, tongue deviation, coma
Epidural bleeding
Fracture near the temples may cause artery to bleed on top of the dura, resulting in pressure on the brain. Usually very rapid after injury
seizure
Generalized, uncoordinated muscular activity associated with loss of consciousness; a convulsion.
A 30-year-old male experienced a generalized (tonic-clonic) seizure, which stopped before you arrived at the scene. The patient is conscious, is answering your questions appropriately, and refuses EMS transport. What would be the most compelling reason to disagree with his refusal of transport?
He is currently not prescribed any medications
what mimics a stroke and also causes a seizure?
Hypoglycemia
Conditions that may mimic stroke
Hypoglycemia, Postictal state (labored respirations, AMS), subdural and epidural bleeding (collection of blood near skull that presses on brain)
SAMPLE history
In patients with stroke make an extreme effort to determine when the last time they appeared healthy was, because this will help physicians determine what meds to give. Most meds don't do any good if given later than 3 hours after stroke begins.
What happens when blood flow to a particular part of the brain is cut off by a blockage, resulting in tissue damage?
Ischemic stroke
Where is speech controlled?
Left cerebral hemisphere the middle
You are dispatched to a home where you find a 70-year-old man. He is exhibiting facial drooping and, when you ask him to tell you what day it is, he says "January." Which part of the brain is most likely to have been affected?
Left hemisphere
incontinence
Loss of bowel and/or bladder control; may be the result of a generalized seizure.
________ affect(s) the entire brain, often causing anxiety, restlessness, and confusion.
Low oxygen levels in the bloodstream
If back part of cerebrum is affected by stroke
May neglect certain parts of their vision
Hypoglycemia v. Seizure
Mental status of a patient who has had typical seizure is likely to improve. Patient with hypoglycemia will have mental status that is not likely to improve, even after several minutes
Men, women and ethnicity with strokes
More men than women have strokes but it is more fatal in women. African Americans, Hispanics and Asians are more at risk.
Tension Headache
Most common, caused by muscle contractions in the head or neck and are attributed to stress.
If left hemisphere is effected by stroke
Patient may have a speech disorder called aphasia (inability to produce or understand speech). May also experience difficulty moving the right side of the body.
Stroke v. Hypoglycemia
Patient who has had a stroke may be alert and attempting to communicate normally, whereas patient with hypoglycemia almost always has an altered or decreased LOC
Tonic phase
Phase of seizure , usually only lasting seconds, when patient experiences constant muscle contraction and trembling, tongue biting, bladder and bowel incontinence.
Signs of patients with Hemorrhagic Stroke
Pressure on the brain slows pulse and causes respirations to be erratic. BP is usually high to compensate for poor perfusion. Changes in pupil sizes and reactivity indicate significant bleeding and pressure on brain
Status epilepticus
Seizures lasting more than 5 minutes are likely to progress into this. Seizures occur every few minutes without the person regaining consciousness or last longer than 30 min.
Most common types of headaches
Tension, migraine, sinus. They are not life threatening
aphasia
The inability to understand and/or produce speech.
Migraine Headaches
Thought to be caused by changes in the blood vessel size in the base of the brain
Therapy for Strokes
Thrombolytic therapy may reverse stroke symptoms and even stop the stroke if given within 2 to 3 hours of onset of symptoms. Cannot bee given to patients with hemorrhagic strokes
Generalized seizure
Unconscious and generalized severe twitching of all the body's muscles that lasts for several minutes or longer. Or may be characterized by brief lapse of consciousness in which patient seems to stare and not respond to anyone (petit mal or absence seizure). Results from abnormal discharges from large areas of the brain, usually involving both hemispheres,formerly known as a grand mal seizure.
Subdural bleeding
Veins just below the dura may be torn and bleed. Occurs more slowly, sometimes over period of days.
hemiparesis
Weakness on one side of the body.
Transient Ischemic Attack (TIA)
When stroke symptoms go away on their own within 24 hours. Aprroximatly 1/3 of patients who experience a TIA will experience another stroke soon after
You are assessing a 49-year-old man who, according to his wife, experienced a sudden, severe headache and then passed out. He is unresponsive and has slow, irregular breathing. His blood pressure is 190/94 mm Hg and his pulse rate is 50 beats/min. His wife tells you that he has hypertension and diabetes. He has MOST likely experienced:
a ruptured cerebral artery.
Receptive aphasia
able to speak clearly but has difficulty understanding
When assessing for arm drift of a patient with a suspected stroke, you should:
ask the patient to close his or her eyes during the assessment.
Partial seizure
begins in one side of brain. Classified as simple or complex, Simple partial seizure: no change in patient's LOC. May complain of numbness, weakness or dizziness. May report visual changes and unusual spells. May have brief paralysis. Complex partial seizure: patient has AMS and does not interact normally with his/her environment. Results from abnormal discharges from temporal lobe . Lip smacking, eye blinking, isolated convulsions or jerking of body or one part of the body. May experience unusual smells and visual hallucinations, exhibit uncontrollable fear, and perform receptive physical behavior such as constant sitting and standing.
The most basic functions of the body, such as breathing, blood pressure, and swallowing, are controlled by the:
brain stem.
Idiopathic
cause of seizure cannot be determined
Interruption of cerebral blood flow may result from all of the following, EXCEPT:
cerebral vasodilation.
Stroke
cerebrovascular accident (CVA), interruption of bloodflow to the brainthat results in loss of brain function. Can be ischemic and hemorrhagic
Petit Mal/ Absence seizure
characterized by brief lapse of consciousness in which patient seems to stare and not respond to anyone . Sometimes only lasts seconds and patient fully recovers with brief lapse of memory of event.
Epilepsy
congenital
Expressive aphasia
difficulty expressing thoughts or inability to speak
Phenytoin
drug used to control seizures, can cause seizures itself if person takes too much
A patient whose speech is slurred and difficult to understand is experiencing:
dysarthria.
3 types of seizures
generalized, partial, status epilepticus
Serious conditions that include headache as a symptom
hemorrhagic stroke, brain tumors, meningitis. You should be concerned if patient complains of sudden ionset, severe headache, or sudden headache that has associated symptoms
The most significant risk factor for a hemorrhagic stroke is:
hypertension.
what is a metabolic cause for a seizure?
hypoglycemia
You are dispatched to a residence for a 66-year-old male who, according to family members, has suffered a massive stroke. Your primary assessment reveals that the patient is unresponsive, apneic, and pulseless. You should:
initiate cardiopulmonary resuscitation (CPR) and attach an automated external defibrillator (AED) as soon as possible.
Ataxia
lack of muscle coordination
Dura
leathery covering over the brain, next to the skull
You arrive at a local grocery store approximately 5 minutes after a 21-year-old female stopped seizing. She is confused and disoriented; she keeps asking you what happened and tells you that she is thirsty. Her brother, who witnessed the seizure, tells you that she takes phenytoin (Dilantin) for her seizures, but has not taken it in a few days. He also tells you that she has diabetes. In addition to applying high-flow oxygen, you should:
monitor her airway and breathing status and assess her blood glucose level.
Tonic-clonic seizure
patient may exhibit bilateral movement characterized by muscle rigidity and relaxation usually lasting 1-3 minutes. Paitnet may experience tachycardia, hyperventilation, sweating, intense salivation
Medications to control epilepsy
phenytoin (Dilantin), phenobarbital, carbamazepine (Tegretol)
You are caring for a 68-year-old man with sudden onset of left-sided paralysis and slurred speech. His airway is patent, his respirations are 14 breaths/min with adequate depth, and his oxygen saturation is 98%. Treatment for this patient should include:
recovery position and transport.
Dysarthria
slurred speech
Life threatening conditions that cause headaches
stroke, tumor, infection of the CNS, or hypertension
Sign of hermorrhagic stroke
sudden severe headache, often described as worst pain patient has ever had. May initially be localized then become more diffuse as irritation in the meninges spread.
Aneurism
swelling or enlargement of part of an artery resulting from weakening of the arterial wall. They will have sudden onset of a severe headache. When it occurs in healthy young person, it is usually due to weakness in the blood vessel called a berry aneurism. When in is overstretched or ruptured, blood spurts into an area between 2 of the coverings of the brain called subarachnoid space (subarachnoid Hemorrhage).
If right hemisphere is effected by stroke
trouble moving muscles on left side of body. Usually they can understand language and speak, but words can be slurred and hard to understand. They may be completely oblivious to problem. If you ask patient to lift left arm and they can't, they will lift their right arm instead (they seem to have forgotten that left arm even exists- neglect)
Subdural and epidural bleeding
usually occurs as result of trauma. Onset of stroke like symptoms may be subtle.
When you are obtaining medical history from the family of a suspected stroke patient, it is most important to determine:
when the patient last appeared normal.
