Ch.18 Neurological Emergencies

seizures may occur as a result of:

• recent or prior head injury

• brain tumor

• metabolic problems

• fever

• a genetic disposition

possible causes of altered mental status:

• intoxication

• head injury

• hypoxia

• stroke

• metabolic disturbances

brainstem

• controls breathing, BP, swallowing, and pupil constriction

cerebellum

• controls muscle and body coordination

cerebrum

• divided into right and left hemispheres - each controls the activities on the opposite side of the body

• front - controls emotion and thought

• middle - controls sensation and movement

• back - processes sight

• speech is usually controlled on the left side of the brain near the middle of the cerebrum

how many cranial nerves are there?

12

at each vertebra in the neck and back, ___ nerves branch out from the spinal cord and carry signals to and from the body

2

the brain is most sensitive to changes in ____, ____, and ____ levels

oxygen, glucose, and temperature

tension headache

• cause: muscle contractions in the head/neck and attributed to stress

• pain: usually described as squeezing, dull, or as an ache

• severity: usually does not require medical attention

migraine headaches

• cause: changes in the blood vessel size in the base of the brain

• pain: usually describes as pounding, throbbing, and pulsating

• often associated with nausea and vomiting and may be preceded by visual warning signs such as flashing lights or partial vision loss

• duration: several hours to days

sinus headaches

• cause: pressure that results from accumulated fluid in the sinuses

• severity: prehospital care is not needed

• pts may have cold-like signs and symptoms of nasal congestion, cough, and fever

serious conditions that include headache as a symptom are _____, _____, and _____

hemorrhagic stroke, brain tumors, and meningitis

stroke (cerebrovascular accident; CVA)

an interruption of blood flow to an area within the brain that results in the loss of brain function

ischemic stroke

• most common

• results from: thrombosis or an embolus

• symptoms: may range from nothing at all to complete paralysis

• cause: atherosclerosis in the blood vessels is usually the cause

hemorrhagic stroke

• accounts for 13% of strokes

• occurs: when a blood vessel ruptures, and the accumulated blood forms a blood clot which compresses brain tissue

• often massive and fatal

• high risk: people experiencing stress, exertion, pts with extremely high BP, and pts with long-term untreated hypertension

• common cause: berry aneurysms in healthy, young people

aneurysm

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

berry aneurysms

• common cause of hemorrhagic strokes in healthy, young people

• presents as the “worst headache of their life”

• causes a subarachnoid hemorrhage

transient ischemic attack (TIA)

• symptoms: stroke-like symptoms go away on their own in < 24 hrs

• may be a warning sign of a larger stroke to come

• all pts should be evaluated by a physician

signs and symptoms of a stroke

• facial drooping

• sudden weakness or numbess in the face, arm, leg, or one side of the 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

• slurred speech (dysarthria)

• sudden and severe headache

• confusion

• dizziness

• weakness

• combativeness

• restlessness

• tongue deviation

• coma

stroke in the left hemisphere

• may cause aphasia (inability to produce or understand speech)

• can cause paralysis of the right side of the body

stroke in the right hemisphere

• can cause paralysis of the left side of the body

• usually, pts will understand language and be able to speak, but their words may be slurred

• pts may be oblivious to their problems (neglect)

bleeding in the brain

• pts may have a very high BP

• significant drops may occur as the pt’s condition worsens

conditions that may mimic a stroke

• hypoglycemia

• postictal state

• subdural or epidural bleeding

seizure

a neurological episode caused by a surge of electrical activity in the brain

generalized (tonic-clonic) seizure

• cause: abnormal electrical discharges from large areas of he brain, usually involving both hemispheres

• typically characterized by unconsciousness and severe twitching of all muscles that lasts several minutes or longer

absence seizure

• does not involve any changes in motor activity

• characterized by a brief lapse of consciousness in which the pt seems to stare and not respond

partial (focal) seizure

• no change in the pt’s LOC

• symptoms: numbness, weakness, dizziness, visual changes, unusual smells and tastes

• may cause some twitching or brief paralysis

focal-onset, impaired-awareness seizure

• pt has an altered mental status and does not interact normally with his or her environment

• cause: abnormal discharges from the temporal lobe of the brain

• characteristics: lip smacking, eye blinking, isolated jerking

• symptoms: unpleasant smells, visual hallucinations, pts may exhibit uncontrollable fear, or perform repetitive physical behavior

status epilepticus

seizures that continues every few minutes without the person regaining consciousness or last longer than 30 minutes

causes of seizures

• congenital

• structural

• metabolic

• febrile

• epileptic seizures

medications commonly used to treat seizures

• Levetiracetam (Keppra)

• Phenytoin (Dilantin)

• Phenobarbital

• Carbamazepine (Tegretol)

• Valproate (Depakote)

• Topiramate (Topamax)

• Clonazepam (Klonopin)

postictal state

• following the seizure, a pt’s muscles relax, and the breathing becomes labored

• may be characterized by hemiparesis, or weakness on one side of the body

• commonly characterized by lethargy and confusion

• if pt’s condition does not improve, you should consider other possible underlying conditions

differences between seizures and syncope

• fainting typically occurs while the pt is standing

• seizures may occur in any position

• fainting is not associated with a postictal state

emergencies that could present with altered mental status

• hypoglycemia

• hypoxemia

• intoxication

• delirium

• drug overdose

• unrecognized head injury

• brain infection

• body temperature abnormality

• brain tumor

• overdose and/or poisoning

treatment for migraine

1. appt high-flow oxygen

2. provide a darkened and quiet environment

3. do not use light and sirens

treatment for a stroke

1. support the XABCs

2. maintain a SpO2 level of at least 94%

3. routine use of oxygen is not recommended unless the pt is showing signs of respiratory distress or hypoxia

4. fibrinolytic therapy and other methods may reverse stroke symptoms and even stop the stroke if given within 3 - 6 hrs

5. if possible, transport to a designated stroke center

treatment for a seizure

1. continue to assess and treat the XABCs

2. protect the pt from harm

3. if pt refuses transport after seizure, contact online medical control and ask them to speak directly with the pt

treatment for altered mental status

1. determine the cause

2. provide spinal motion restriction, airway, and ventilatory support as indicated

3. transport to appropriate facility