Emergency Care and Transportation of the Sick and Injured - Chapter 17: Neurologic Emergencies

brain stem

controls the most basic functions of the body, breathing, blood pressure, swallowing and pupil constriction

cerebellum

behind brain stem, controls muscle and body coordination

cerebrum

right and left hemispheres, front controls emotion and thought, middle controls touch and movement, back controls sight, speech usually controlled on the left side

cranial nerves

12 nerves that run to various parts fo the head

foramen magnum

A large opening at the base of the skull through which the brain connects to the spinal cord.

The brain

is the most sensitive changes in oxygen, glucose and temperature levels. a significant change in any one of these three levels will result in a neurologic change.

coma

a state of profound unconsciousness from which the patient cannot be roused

tension headaches, migraines and sinus headaches

are the most common type of headaches

Migraines headaches

are thought to be caused by changes in the blood vessel size in the base of the brain. Women are three times more likely to get it then men. described as pounding, throbbing, or pulsating.

Headache red flags

Sudden onset of symptoms

explosive/thunderclap pain

altered mental status

Age>50

depressed immune system(known to be at higher risk for infection)

neurologic deficits

neck stiffness/pain

fever

changes in vision

one sided paralysis or weakness

cerebrovascular accident (CVA) or stroke

an interruption of blood flow to the brain that results in the loss of brain function; also called a stroke. in the context of a total lack of oxygen, brain cells stop functioning and begin to die within minutes.

Spend as little time at the scene as possible.

two main types of stroke

ischemic (direct blockage) and hemorrhagic (rupture)

thrombosis

A blood clot either in the arterial or venous system. when the clot occurs in a cerebral artery . it may result in the interruption of cerebral blood flow and subsequent

embolus

a blood clot or other substance in the circulatory system that travels to a blood vessel where it causes a blockage.

ischemic stroke

a type of stroke that occurs when blood flow to a particular part of the brain is cut off by a blockage (eg a blood clot) inside a blood vessel. many patients deny or ignore their symptom and delay in seeking medical attention. this can cause devastating consequences because time is brain. Most common one

hemorrhagic stroke

a type of stroke that occurs as a result of bleeding inside the brain. accounts for 13% of all strokes. happens to people experiencing stress or excerption. highest risk are people with hypertension and a sudden severe headache.

Atherosclerosis

condition in which fatty deposits called plaque build up on the inner walls of the blood vessels

aneurysm

a swelling or enlargement of the wall of blood vessel that results from weakening of the vessel wall

berry aneurysm

resembles a tiny balloon or berry that juts out from the artery. ruptures between two of the coverings of the brain called the subarachnoid space

transient ischemic attack (TIA)

a disorder of the brain in which brain cells temporarily stop working because of insufficient oxygen, causing stroke-like symptoms that resolve completely within 24 hours of onset

signs and symptoms of stroke

facial drooping

sudden weakness or numbness in the face, arm, leg or one side of the body

loss of movement and sensation on one side of the body

speech disorders

aphasia

sudden and severe headache

trouble walking

confusion, combativeness

tongue deviation

cerebral hemorrhage

bleeding in the brain

conditions that may mimic stroke:

Hypoglycemia,

Postictal state (labored respirations, AMS),

subdural and epidural bleeding (collection of blood near skull that presses on brain)

aphasia

the inability understand and or produce speech

postictal state

the period following a seizure that lasts between 5 and 30 minutes characterized by labored respirations and some degree of altered mental status

seizure

a neurologic episode caused by a surge of electrical activity in the brain; can be a convulsion characterized by generalized uncoordinated muscular activity and can be associated with loss of consciousness. needs immediate transport

generalized (tonic-clonic) seizure

Results from abnormal electrical discharges from the large areas of the brain, usually involving both hemispheres. a seizure characterized by unconsciousness and a generalized severe twitching of all the body's muscles that may last several minutes or more; formerly known as a absence seizure or petit mal.

partial (focal) seizure

a seizure affecting a limited portion of the brain. Classified as simple or complex

aura

a sensation experienced before a seizure, serves as a warning sign that seizure is about to occur

status epilepticus

a condition in which seizures recur every few minutes or last more than 30 minutes

medications for seizure disorders

Levetiracetam(Keppra)

Phenytoin(Dilantin)

Phenobarbital

Carbamazepine(Tegretol)

Valproate(Depakote)

Topiramate(Topamax)

Clonazepam(Klonopin)

cause of epileptic seizure

congenital origin

causes of structural seizure

tumor

infection

scar tissue from injury

head trauma

stroke

causes of metabolic seizure

hypoxia

abnormal blood chemical values

hypoglycemia

poisoning

drug overdose

sudden withdrawal from alcohol, medications

febrile seizure

seizure that results from sudden high fevers; most often seen in children

hemiparesis

weakness on one side of the body

T I P S

Trauma

Infection

Psychogenic causes

Seizure, syncope

possible causes of altered mental status

dysarthria

slurred speech

A E I O U

Alcohol

epilepsy, endocrine, electrolytes

Insulin

Opiates

Uremia (kidney failure)

possible causes of altered mental status

the right side of the brain controls?

the left side of the brain

the left side of the brain controls?

the right side of the brain

the front side of the brain controls?

emotions and thoughts

the middle side of the brain controls?

sensation and movement

the back side of the brain

processes sight

Cushing's triage

decrease in heart rate

increase in blood pressure

irregular respirations

aphagia

eating disorders, swallowing and eating issues

receptive

can understand speech

expletive

cant speak properly

Dura matter

outer layer / next to the skull

aracnoid

middle layer

apia

near the bottom of the brain

altered mental status

any deviation from alert and oriented to person, place, time and event or any deviation from a patients normal baseline mental status

delirium

a temporary change in mental status characterized by disorganized thoughts inattention memory loss disorientation striking changes in personality and affect hallucinations delusions or a decreased level of consciousness

epilepsy

a disorder in which abnormal electrical discharges occur in the brain causing seizure and possible loss of consciousness

hypoglycemia

an abnormally low blood glucose level. has altered or decrease level of consciousness

incontinence

loss of bowel and or bladder control; may be the result of a generalize seizure

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

syncope

a fainting spell or transient loss of consciousness

these are associated with altered mental status

coma, seizure, intoxication, body temperature abnormalities, hypoxia, hypoglycemia

an ischemic stroke

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

untreated hypertension

patients who are at the highest risk of hemorrhagic stroke are those who have

headache

patients with a subarachnoid hemorrhage typically complain of a sudden severe

stroke

hypoglycemia can mimic conditions such as a

dilate

the platque that builds up in atherosclerosis obstructs blood flow and interferes with the vessels ability to

possible seizure activity

altered mental status, incontinence, muscle rigidity and twitching are signs and symptoms of...

migraine headaches

this is the second most common type of headache and are thought to be caused by changes in blood vessel size in the base of the brain

increased intracranial pressure

headache, vomiting, altered mental status and seizures are all considered early signs of

hemorrhagic

people with uncontrolled hypertension have a higher risk of what kind of stroke

tension headaches

headaches caused by muscle contractions in the head and neck are typically associated with?

the airway

when assessing a patient with a possible cerebrovascular accident (CVA) you should check what first

Transient ischemic attack (TIA)

what is usually a warning sign that a larger significant stroke may occur in the future

12

there are how many cranial nerves?

cerebellum

playing the piano is coordinated by which part of the brain

carbon monoxide poisoning

an incident to where you have more than one patient complaining of a headache may indicate

simple partial seizure

this may cause twitching of the extremity muscles that may spread slowly to another body part

complex partial seizures

these result from abnormal discharges from the temporal lobe of the brain

foreign body obstruction

a person who was eating prior to having a seizure may have a

glaskow coma scale score calculated

all patients with an altered mental status should have a

thrombolytic therapy

this may reverse stroke symptoms and even stop the stroke if given within 3 to 6 hours of the onset of symptoms

Cincinnati Pre-hospital Stroke Scale

-facial droop

-arm drift

-difficulty speaking

Los Angeles Prehospital Stroke Screen (LAPSS)

Age (>45)

seizure history

duration of symptoms

wheelchair bound

BGL within 60-400

Unilateral asymmetry

Facial Droop, Arm Drift, Speech, Time

F.A.S.T.

when was the last time seen normal

Hospitals will ask for stroke patients...

3-Item Stroke Severity Scale (LAG)

Blood clot-dissolving medication(Thrombolytic therapy)

in most patients with a suspected stroke, the physicians in the emergency department (ED) will need to determine whether there is bleeding in the brain. if there is no bleeding then the patient will receive __________________

A.brain stem.

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.

D.a blocked cerebral artery.

2.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.

A.hemorrhagic stroke

3.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.

B.symptoms that persist for longer than 24 hours.

4.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.

D.dysarthria.

5.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.

D.generalized seizure.

6.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.

B.medications may be given to reverse the stroke.

7.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.

C.Facial symmetry, speech, arm drift

8.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

C.Without lights and sirens

10.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.