Ch.17 neurological emergencies

Partial Seizure (2 of 2) •Complex partial seizure

-Altered mental status -Results from abnormal discharges from the temporal lobe of the brain -Lip smacking, eye blinking, isolated jerking -Unpleasant smells, visual hallucinations, uncontrollable fear, repetitive physical behavior

Emergency Medical Care: Seizure (2 of 3) •It is difficult to safely prepare a patient for transport who is having a seizure.

-Assess for trauma. -Use spinal immobilization if indicated. -Never attempt to restrain a patient having a seizure.

•Tension headaches

-Caused by muscle contractions in the head and neck -Attributed to stress -Pain is usually described as squeezing, dull, or as an ache. -Usually do not require medical attention

Sinus headaches

-Caused by pressure that is the result of fluid accumulation in the sinus cavities -Patients may also have cold-like symptoms of nasal congestion, cough, and fever. -Prehospital emergency care is not required.

Emergency Medical Care: Seizure (1 of 3) •The patient may be in a postictal state upon your arrival. •The patient may still be having a seizure:

-Continue to assess and treat ABCs. -Try administering oxygen.

FAST mnemonic for stroke

-Facial droop -Arm drift -Speech -Time

•General rule:

-If a problem is caused primarily by disorders in the heart and lungs, the entire brain is affected. -If the primary problem is in the brain, only part of the brain is affected.

•Possible causes of altered mental status include:

-Intoxication -Head injury -Hypoxia -Stroke -Metabolic disturbances

Partial Seizure (1 of 2) •Simple partial seizure

-No change in the patient's level of consciousness -May have numbness, weakness, dizziness, visual changes, or unusual smells/tastes -May have some twitching or brief paralysis

The Importance of Recognizing Seizures (1 of 2) •Recognize when a seizure is occurring and whether this episode differs from previous ones.

-Patient may turn cyanotic. -Seizures may prevent the patient from breathing normally. -In a patient with diabetes, the blood glucose level may decrease. -If protocol allows, monitor blood glucose levels after a patient with diabetes has a seizure.

The Importance of Recognizing Seizures (2 of 2) •Look at other problems associated with the seizure.

-Patients who have fallen during a seizure may have a head injury. -Patients having a generalized seizure may also experience incontinence.

Ischemic Stroke (2 of 2) •Atherosclerosis

-Plaque forms inside the walls of the blood vessels and may obstruct blood flow. -Eventually, it causes complete occlusion of an artery.

Emergency Medical Care (4 of 4) •For patients who continue to have a seizure, as in status epilepticus:

-Suction the airway. -Provide positive-pressure ventilations. -Transport quickly to the hospital. -Rendezvous with ALS, if possible.

Hemorrhagic Stroke (2 of 3) •Aneurysm

-Swelling or enlargement of the wall of an artery resulting from a defect or weakening of the arterial wall

Migraine headaches

-Thought to be caused by changes in blood vessel size in the base of the brain. -Experienced by both adults and children -Pain is usually described as pounding, throbbing, and pulsating. -Often associated with nausea and vomiting, and may be preceded by visual changes -Can last for several hours or days

Review 1.A 56-year-old man experienced a sudden, severe headache and then became unresponsive. He has a history of high blood pressure. The MOST likely cause of his condition is a(n): A.hemorrhagic stroke. B.acute ischemic stroke. C.severe migraine headache. D.transient ischemic attack.

Answer: A Rationale: Hemorrhagic strokes are typically preceded by a sudden, severe headache (signals the rupture of a cerebral artery), after which the patient becomes unresponsive due to bleeding within the brain. Ischemic strokes and transient ischemic attacks generally do not cause a sudden, severe headache, and migraine headaches typically do not cause a loss of consciousness.

Review 1.Your patient opens his eyes when you say his name, is making incomprehensible sounds, and withdraws when you pinch his earlobe. What is his GCS score? A.9 B.8 C.11 D.12

Answer: A Rationale: The Glasgow Coma Scale gives a score of 3 to a patient who opens his or her eyes in response to speech. "Incomprehensible sounds" has a score of 2, and "withdraws to pain" has a score of 4. When added together, this patient's GCS score is 9.

Review 1.A 41-year-old man presents with slow, irregular breathing; hypotension; and dilated pupils. These signs MOST likely indicate dysfunction of the: A.brain stem. B.hypothalamus. C.cerebrum. D.cerebellum.

Answer: A Rationale: The brain stem is responsible for functions such as breathing, blood pressure, and pupil constriction. Brain stem dysfunction would result in abnormal findings with these functions.

Review 1.The MOST important reason for promptly transporting a stroke patient to the hospital is: A.a transient ischemic attack can be ruled out. B.medications may be given to reverse the stroke. C.the clot in the coronary artery may be dissolved. D.he or she needs close blood pressure monitoring.

Answer: B Rationale: Fibrinolytic medications (clot busters) have been shown to reverse the symptoms of a stroke by dissolving the clot that is blocking the cerebral artery. However, for the patient to be eligible for this therapy, it must be initiated within 3 hours after the onset of symptoms. For this reason, prompt transport of the stroke patient is critical.

Review 1.Unlike an ischemic stroke, a transient ischemic attack is characterized by all of the following, EXCEPT: A.symptoms that resolve within 24 hours. B.symptoms that persist for longer than 24 hours. C.weakness or paralysis to one side of the body. D.an acute onset of confusion and slurred speech.

Answer: B Rationale: Signs and symptoms of a transient ischemic attack (TIA) are usually identical to those of an acute ischemic stroke (eg, hemiparesis, slurred speech, confusion, facial droop). Unlike the ischemic stroke, however, the symptoms of a TIA usually resolve within 24 hours.

Review 1.Which of the following are components of the Cincinnati Prehospital Stroke Scale? A.Arm drift, blood pressure, speech B.Speech, pupil response, arm drift C.Facial symmetry, speech, arm drift D.Pupil response, facial droop, speech

Answer: C Rationale: The three components of the Cincinnati Prehospital Stroke Scale are facial symmetry, speech, and arm drift. Both sides of the patient's face should move symmetrically (equally) when he or she smiles. The patient's speech should be easily understandable and without slurring. The patient should be able to hold both arms out in front of his or her body—with eyes closed and palms up—without one arm drifting down to his or her side.

Review 1.If a patient complains of a severe migraine, how should she be transported? A.In a brightly lit ambulance so she can see while her vision is impaired B.With loud sirens so she can get to the hospital as soon as possible C.Without lights and sirens D.This patient should not be transported.

Answer: C Rationale: Treatment of a migraine headache is supportive; however, you should always assess the patient for other signs and symptoms that might indicate a more serious condition. Applying high-flow oxygen, if tolerated, may help ease the patient's condition. When possible, provide a darkened and quiet environment because patients are sensitive to light and sound. Do not use lights and sirens during transport.

Review 1.A patient with a suspected stroke presents with slurred speech that is difficult for you to understand. This is referred to as: A.aphasia. B.dysphasia. C.dysphagia. D.dysarthria.

Answer: D Rationale: Dysarthria is defined as slurred, poorly articulated speech; it is common in stroke patients. Dysphasia is defined as difficulty speaking; the patient's speech may or may not be slurred. Aphasia is the inability to speak. Dysphagia is defined as difficulty swallowing.

Review 1.A type of seizure that is characterized by severe twitching of all the body's muscles and lasts for several minutes or longer is called a(n): A.partial seizure. B.absence seizure. C.tonic-clonic seizure. D.generalized seizure.

Answer: D Rationale: Generalized seizures are characterized by generalized severe twitching of all of the body's muscles; they often last for several minutes or longer. An absence seizure is characterized by a blank stare; generalized muscle twitching is absent.

Review 1.An acute ischemic stroke is caused by: A.a ruptured cerebral artery. B.increased intracranial pressure. C.an acute rise in a person's blood pressure. D.a blocked cerebral artery.

Answer: D Rationale: There are two types of stroke—hemorrhagic and ischemic. A hemorrhagic stroke is caused by a ruptured cerebral artery (aneurysm), which causes bleeding within the brain and increased intracranial pressure. An ischemic stroke is caused by a blocked cerebral artery—either from a clot that grows locally (thrombus) or that travels to the brain from another part of the body (embolus).

Anatomy and Physiology (5 of 7) •In most people, speech is controlled on the

left side of the brain near the middle of the cerebrum. •Messages sent to and from the brain travel through nerves. -Twelve cranial nerves run directly from the brain to parts of the head: eyes, ears, nose, and face.

Epileptic seizures usually can be controlled by

medications. -Levetiracetam (Keppra) -Phenytoin (Dilantin) -Phenobarbital -Carbamazepine (Tegretol) -Valproate (Depakote) -Topiramate (Topamax) -Clonazepam (Klonopin)

Anatomy and Physiology (3 of 7) •The brain stem controls the •The cerebellum controls

most basic functions. -Breathing, blood pressure, swallowing, pupil constriction muscle and body coordination. -Walking, writing, picking up a coin, playing piano

Headache (1 of 6)

One of the most common complaints •Can be a symptom of another condition or a neurologic condition on its own •Only a small percentage of headaches are caused by a serious medical condition.

•The brain is the body's computer. -Controls breathing, speech, and all body functions •Three major parts:

brain stem, cerebellum, and cerebrum -The cerebrum is the largest part.

The Postictal State (2 of 2) •May be characterized by

hemiparesis, resembling a stroke. •Most commonly characterized by lethargy and confusion -Patient may be combative -Be prepared for these circumstances. •If the patient's condition does not improve, consider hypoglycemia or infection.

Serious conditions that include headache as a symptom are

hemorrhagic stroke, brain tumor, and meningitis. -Be concerned if patient complains of a sudden-onset, severe headache or a sudden headache that has associated symptoms. -Suspect stroke in patients with a severe headache, seizures, and altered mental status. -Increasing ICP may be caused by a hemorrhagic stroke, tumor, or recent head trauma.

The brain is sensitive to changes in

oxygen, glucose, and temperature.

•The cerebrum is divided into

right and left hemispheres. -Each controls activities on the opposite side of the body. -The front of the cerebrum controls emotion and thought. -The middle controls sensation and movement. -The back processes sight.

Generalized Seizure (1 of 2) •Characterized by

sudden loss of consciousness, chaotic muscle movement and tone, and apnea. •May exhibit bilateral muscle movement characterized by a cycle of muscle rigidity and relaxation, usually lasting 1 to 3 minutes. •Tachycardia, hyperventilation, sweating, and intense salivation •Most seizures last 3 to 5 minutes. •Postictal state (5 to 20 minutes) follows. -Gradual return to consciousness

Hemorrhagic Stroke (3 of 3) •Symptom may be the

sudden onset of a severe headache •When a hemorrhagic stroke occurs in an otherwise healthy young person, it is likely caused by a berry aneurysm. -Surgical repair may be possible if care is sought immediately.

Syncope •Seizures are often mistaken for

syncope, or fainting. -Fainting typically occurs while the patient is standing. -Seizures may occur in any position. -Fainting is not associated with a postictal state.

Emergency Medical Care: Seizure (3 of 3) •Not every patient who has had a seizure wants to be transported. -Your goal is

to encourage the patient to be seen by a physician. -Be prepared to discuss the situation with the hospital staff.

Seizures

•A neurologic episode caused by a surge of electrical activity in the brain •Can take the form of a convulsion and/or can be associated with a temporary alteration in consciousness. •Two basic groups: generalized and partial (focal).

Hemorrhagic Stroke (1 of 3)

•Accounts for 13% of strokes. •Results from bleeding inside the brain •Cerebral hemorrhages are often fatal. •People at high risk include those experiencing stress or exertion. •People at highest risk are those who have very high blood pressure.

The Postictal State (1 of 2)

•After a seizure, the muscles relax, becoming almost flaccid, and breathing becomes labored. -This breathing pattern helps the body balance the acidity in the bloodstream. -With normal circulation and liver function, the patient will begin to breathe more normally within minutes.

Stroke (1 of 2)

•Also called a cerebrovascular accident (CVA) •Interruption of blood flow to an area within the brain •Results in the loss of brain function •Lacking oxygen, brain cells stop functioning and begin to die within minutes. •Once the brain cells die, not much can be done.

Emergency Medical Care: Migraine

•Always assess the patient for other signs and symptoms that might indicate a more serious condition. •Apply high-flow oxygen, if tolerated. •Provide a darkened, quiet environment. •Do not use lights and sirens during transport.

Stroke (2 of 2)

•Brain cells develop ischemia, causing them to stop functioning properly. •It may take several hours or more for cell death to occur. •With prompt restoration of blood flow, the cells will not die, and function can be preserved or restored. •There are two main types of stroke: ischemic and hemorrhagic.

Signs and Symptoms of Stroke (1 of 4)

•Facial drooping •Sudden weakness or numbness in the face, arm, leg, or one side of body •Decreased or absent movement and sensation on one side of the body •Lack of muscle coordination (ataxia) or loss of balance •Sudden vision loss in one eye •Blurred and double vision •Difficulty swallowing •Decreased level of responsiveness •Speech disorders •Aphasia -Difficulty expressing thoughts or inability to use the right words (expressive aphasia) -Difficulty understanding spoken words (receptive aphasia) •Slurred speech (dysarthria) •Sudden and severe headache •Confusion •Dizziness

Absence Seizure

•Formerly called petit mal •May last for seconds •Patient fully recovers with a brief lapse of memory

Conditions That May Mimic Stroke (1 of 2)

•Hypoglycemia -Not enough blood glucose •Postictal state -Period following seizure that lasts between 5 and 30 minutes -Characterized by labored respirations and some degree of altered mental status •Subdural or epidural bleeding -Blood near the skull presses on the brain

Ischemic Stroke (1 of 2)

•Most common, accounting for more than 80% of strokes •Results from thrombosis or an embolus •Symptoms may range from nothing at all to complete paralysis. •Atherosclerosis in the blood vessels is often the cause.

Aura

•Patients may experience an aura prior to a seizure. -Can include visual changes or hallucinations •People with a history of seizures recognize their auras and usually take steps to minimize injury. •Auras do not occur prior to every seizure, and not all patients with a seizure disorder experience an aura.

Bleeding in the Brain

•Patients may have high blood pressure. -May be the cause of the bleeding -May be caused by the bleeding, as a compensatory response •Increasing blood pressure is an important sign. •Significant drops in blood pressure may occur as the patient's condition worsens. •Monitor the blood pressure for changes.

Emergency Medical Care (3 of 4) •Patients who have had a seizure require definitive evaluation and treatment. -Supplemental oxygen is strongly advised. -For patients who are having a seizure:

•Protect them from harm. •Maintain a clear airway by suctioning. •Provide oxygen as quickly as possible. •If head or neck trauma is suspected, provide spinal immobilization.

Generalized Seizure

•Results from abnormal electrical discharges from large areas of the brain •Typically characterized by unconsciousness and a generalized severe twitching of all muscles lasting several minutes or longer. •May simply be characterized by a brief lapse of consciousness. -Does not involve any changes in motor activity

Status Epilepticus

•Seizures lasting more than 5 minutes are likely to progress to status epilepticus. •Seizures that continue every few minutes without the person regaining consciousness or last longer than 30 minutes are referred to as status epilepticus.

Causes of Seizures (1 of 4)

•Some seizure disorders are congenital. •Others may be caused by high fever, structural problems in the brain, or metabolic or chemical problems.

Right Hemisphere

•Stroke may cause paralysis of the left side of the body. •Usually, patients can understand language and are able to speak -Words may be slurred •Patients may be oblivious to their problem (neglect). •Neglect and lack of pain cause many patients to delay seeking help.

Emergency Medical Care: Stroke (1 of 3)

•Support ABCs and provide rapid transport to a stroke center. •Patient may require manual airway positioning. •Use suction as needed and monitor the patient's oxygen saturation. -Maintain a SpO2 level of at least 94% •Oxygen therapy not recommended unless the patient is in respiratory distress or is hypoxic •Paralyzed extremities will require protection from harm. •Keep the patient informed. •Thrombolytic therapy may reverse stroke symptoms.

Transient Ischemic Attack (TIA) (2 of 2)

•Symptoms of a TIA can last up to 24 hours, -May not be able to differentiate between a stroke and a TIA •Every TIA is an emergency. •May be a warning sign that a more significant stroke may occur in the future •All patients with a TIA should be evaluated by a physician.

Headache (2 of 6) Most common type of headaches ?

•Tension headaches, migraines, and sinus headaches are the most common. -Not life-threatening

Transient Ischemic Attack (TIA) (1 of 2)

•When blood flow to the brain is obstructed due to atherosclerosis or a small blood clot, the patient may exhibit signs of a stroke. •When stroke-like symptoms go away on their own in less than 24 hours, the event is called a TIA. •No actual death of tissue occurs with a TIA.

•Spend as little time at the scene as possible. -Stroke is an emergency,

and "time is brain." -If possible, transport to a designated stroke center.

Left Hemisphere •Stroke in the left cerebral hemisphere may cause

aphasia. -Inability to produce or understand speech -Speech problems can vary widely. •Stroke may also cause paralysis of the right side of the body.

The rest of the nerves join in the spinal cord and exit the brain through a large opening in the

base of the skull called the foramen magnum. -At each vertebra in the neck and back, two nerves branch out (spinal nerves). -These carry signals to and from the body.

Introduction (3 of 4) •Seizures and altered mental status may also occur. •Seizures may occur as a result of:

-A recent or prior head injury -A brain tumor -A metabolic problem -Fever -A genetic disposition

Seizures from a metabolic cause can result from:

-Abnormal levels of certain blood chemicals -Hypoglycemia -Poisons -Drug overdoses -Sudden withdrawal from routine heavy alcohol or sedative drug use -Prescribed medications •Seizures can also result from sudden high fevers, particularly in children.

Causes of Altered mental state

Delirium Hypoglycemia