EMT ch 18 notes
Chapter 18
Neurological Emergencies
Anatomy and Physiology
Brain is the body’s computer
Controls breathing, speech and all other body functions
Three parts: brainstem, cerebellum, cerebrum
Brainstem: controls most basic functions of the body
Breathing, blood pressure, swallowing, pupil constriction
Cerebellum: coordinating complex tasks that involve many muscles
Standing, falling, walking, writing, picking up a coin
Cerebrum: divided into right and left hemispheres. Each hemisphere controls activities on the opposite side of the body
Left hemisphere controls right side of body
right hemisphere controls left side of body
Front part controls emotion and thought
Middle part controls sensation and movement
Back part processes sight
Speech is usually controlled by left side of the brain near the middle of the cerebrum
Messages to and from brain travel through nerves
12 pairs of cranial nerves runs directly from brian to body parts
To eyes, ears, nose, face
Remaining nerves join the the spinal cord and exit brain through foreamen magnum
At each vertebrae two nerves (spinal nerves) branch out, one on each side, and carry signals to and from the body
Pathophysiology
Most sensitive to change in oxygen, glucose, and temperature levels
Significant change in either will cause neurological change
If there is a problem with the heart or lungs the brain will be effected.
When blood flow stops (cardiac arrest), patient will go into coma
Permanent brain damage can result within minutes
If there is poor blood supply to the brain patient may have signs/symptoms affecting only one side of the body
Low oxygen level: anxiety, restlessness, and confusion
Low blood glucose levels (hypoglycemia): mild confusion to stroke symptoms
Headache
Most common complatint
Headache is subjective
Only small percentage of headaches are caused by serious medical condition
Brain and skull do not sense pain
They don't have pain receptors
Pain for headache is felt from surround areas of the face
Pain is felt from
Scalp
meninges (membrane that cover the brain and spinal cord)
Larger blood vessels
Muscles of the head, neck, and face
Tension headaches, migraines and sinus headaches at most common type
Not life threatening
Tension headaches: caused by muscle contractions in the head and neck attributed to stress
Squeezing, dull or aching pain
Does not require medical attention.
Migraine headaches: caused by changes in blood vessel size in the base of the brain
Both adults and children can experience it.
Women 3 times more likely to experience
Patient likely have history of migraine
Pounding, throbbing, or pulsating pain
associated with nausea and vomiting
Warning signs: flashing lights or partial vision loss
Can last for several hours to days
Sinus Headaches: result of fluid accumulation in the sinus cavities
Cold Like signs and symptoms
Nasal congestion, cough, fever
May have increase pain when they bend over or when their heads move forward
Self-limiting EMS is not required.
Most headache are not life threatening but some will require medical attention
Serious neurologic condition that may include headache
Hemorrhagic stroke (bleeding in the brain)
Brain tumor
Meningitis
Headache should be concerned when:
Sudden-onset of symptoms, severe headache or sudden-onset headache that has associated symptoms
Fever
stiff neck
Seizures
altered mental status
following head trauma
Changes in vision
One-side paralysis or weakness
“Worst headache of my life”
Altered mental status
explosive/thunderclap pain
Age older than 50
Incident with multiple patients reporting a headache may indicate carbon monoxide poisoning
Hemorrhagic stroke: sudden severe headache, “worst pain”, vomiting, altered mental status, seizures
Blood from ruptured irritates brain tissues and cause intracranial pressure (ICP)
Pain may be localized and diffuse as irritation in meninges spreads
Early signs of ICP: headache, vomiting, altered mental status, seizures
Increasing ICP may be caused by hemorrhagic stroke
Ask if patient has any recent trauma
Bacterial meningitis: inflammation of the meninges caused by bacterial infection. Central nervous system infection
Common symptoms:
Headache
Stiff neck
Fever
Sensitivity to light
Need medical attention and highly contagious
Provide quiet dark environment, avoid using lights and siren
Stroke
Cerebrovascular accident (CVA): interruption of blood flow to an area of the brain that results in loss of brain function.
From lack of oxygen brain stops functioning
Brain cells begin to die within minutes of no oxygen
Decreased oxygen levels may also damage brain cells but slowly
May take several hours or days for brain cells to die in this situation
Several disability result when brain cells die
Two main types of stroke: ischemic stroke and hemorrhagic
Ischemia - reduction in blood supply that results in not enough oxygen being supplies to brain
Most common type of stroke
Cause cells to stop functioning properly
If normal blood flow is restored cells will not die and may regain full function
Stroke patients who receive treatment within the first few hours have greater chance of surviving and avoiding long-term brain damage
Ischemic Stroke - blood flow to specific part of the brain is stopped by a blockage (blood clot) inside a blood vessel
Most common type of stroke, 87%
Symptoms: Loss of movement on one side of body, opposite to where occlusion occurred
Causes:
Thrombosis - clot forms at sight of blockage
Embolus - blood clot forms somewhere else and travels to the site of the blockage.
Atrial fibrillation - atria quivers and stirs blood in heart. Stirring of blood forms clots
Atherosclerosis - calcium and cholesterol buildup, forms plaque inside blood vessel walls, obstructs blood flow and interferes with vessels’ ability to dilate. May eventually obstruct blood flow completely
Other cases: atherosclerotic plaque in carotid artery ruptures then blood clot forms over the crack in the plaque and grows large enough to block blood flow.
Even if carotid artery is not completely blocked, smaller pieces of blood clot may embolize break off and be carried away
Depending on location of clot symptoms varies
Hemorrhagic Stroke
Hemorrhagic stroke - blood clot from bleeding inside the brain due to rupture of blood vessel
The clos compresses brain tissue and the compression prevents oxygenated blood from getting to the area
13% of all strokes
Cerebral hemorrhages are massive and rapidly fatal
Common in people experiencing stress or exertion
Those with high BP and long-term untreated elevated BP at most at risk
Some people are born with weak artery walls
Aneurysm - swelling or enlargement of the wall of an artery
Symptoms:
Sudden-onset severe headache
“Worst headache ever”
Causes:
Irritation of blood on the brain tissue after artery swells and rupture
Often caused by weakness in a blood vessel (berry aneurysm)
Berry aneurysm - tiny balloon that juts out from artery
Subarachnoid hemorrhage - When aneurysm is overstretched and sculptures, blood spurts into subarachnoid space (between two coverings of the brain)
Can be surgically repaired but brain bleed and cerebral hemorrhage is often fatal
Transient Ischemic Attack
Transient ischemic attack - when stroke-like symptoms resolve on their own in 24 hours. Aka mini strokes
No actual death of tissue (infraction) occurs
Hard to differentiate between actual stroke and TIA
⅓ patients experience actual stroke after TIA
Signs and Symptoms of Stroke
Facial drooping
Sudden weakness or numbness in face, arm, leg, or one side of body
Decreased or absent movement and sensation on one side of body
Lack of muscle coordination (ataxia)
Loss of balance
Sudden vision loss in one eye; blurred, double vision, abnormal eye movements
Difficulty swallowing
Decreased level of responsiveness
Speech disorders
Aphasia; difficulty express thoughts or inability to use right words
Slurred speech (dysarthria)
Sudden and severe headache
Confusion
Dizziness
Weakness
Combativeness
Restlessness
Tongue deviation
Coma
Left Hemisphere Stroke
If affected by stroke may exhibit aphasia
Aphasia - inability to produce or understand speech
Trouble understanding speech but will speak
Speech is clear but does not make sense
Some understand the question but cant produce right sound to produce answer
Stroke on left can cause paralysis of right side of body
Right Hemisphere Stroke
If lacking oxygen, pt have trouble moving left side of body
Understand language and be able to speak but words are slurred and hard to understand
Oblivious to their problems
Will lift right arm when asked to lift left
Forgets their left arm exists
Conditions affecting back part of cerebrum may neglect certain parts of their vision
Bleeding in the Brain
Cerebral hemorrhage - bleeding in the brain
May have very high BP
Can be the cause or compensatory response to bleeding
Trend of increasing blood pressure is important sigh
Significant drop in BP may also occur as condition worsens
BP may taper off and return to normal
Conditions that may Mimic stroke
Hypoglycemia - blood sugar drops too low
Because brain needs oxygen and glucose for brain metabolism, with inadequate sugar may mimic stroke
Always check glucose level
Postictal state - period following seizure, last between 5 - 30 mins. Labored respirations and altered mental status
May look like experiencing stroke but will recover rapidly within several minutes
Subdural or epidural bleeding - collection of blood dear the skill pressing on the brain
Occurs as result of trauma
Dura - leathery covering of the brain next to the skull.
Onset of epidural bleeding is very rapid after injury
Subdural bleeding - bleeding just below the dura but outside the brain
Slower than epidural bleeding
Epidural bleeding - bleeding outside the dura and under the skull
Seizures
Seizures - neurologic episode caused by surge of electrical activity in the brain
Can look like generalized uncoordinated muscle activity and/or temporary alteration in consciousness
Epilepsy - common cause of seizures
General underlying cause is unknown
Generalized seizure - results from abnormal electrical discharges from large areas of the brain, involving both hemispheres
characterized by: unconsciousness and generalized severe twitching of body
Tonic-clonic - almost all of the muscles in the body are contracting at the same time
Tonic phase lasts few seconds
Clonic phase lasts much longer
Bilateral movement cycle of muscle rigidity and relaxation
Exhibits: tachycardia, hyperventilation, sweating, intense salication
Lasts less than 5 minutes
Postictal state - generalized seizure lasting 5 - 30 mins
Patient recovers themselves
Seizures longer than 5 minutes risks progressing status epilepticus
Status epilepticus - seizures that continue every few minutes without peron regaining consciousness or seizures that last longer than 30 mins
Focal seizure - begins in one part of the brain. Either aware or impaired-awareness of motor or non motor (absence)
Focal-onset aware seizure
no change in consciousness
Numbness
Weakness
Dizziness
Visual changes
Unusual smells or tastes
Twitching may spread from one extremities to another part of the body
Not dramatic severe twitching
Brief paralysis
Focal-onset, impaired-awarened seizure
Results from abnormal discharges from temporal lobe
Altered mental status
Does not interact normally with environment
Lip smacking
Eye blinking
Isolated convulsions
Jerking of the body
Smells and visual hallucinations
Uncontrollable fear
Repetitive physical behavior
Some remain only on one side of the body
Some begin on one side and spreads
Aura - warning sign prior to seizure
Flashing lights
Blind spots
Hallucinations
Seeing, hearing, or smelling things not present
If patient does not regain consciousness or seizure continues call ALS
Causes of Seizures
Medication used to treat seizures
Levetiracetam (Kreppa)
Phenytoin (dilantin)
Phenobarbital
Carbamazepine (Tegretol)
Valproate (depakote)
Topiramate (Topamax)
Clonazepam (klonopin)
Patients with epilepsy will have seizure if they stop taking their medications
Seizures from metabolic cause may result from abnormal levels of certain blood chemicals
ex) extremely low sodium levels, hypoglycemia, hyperglycemia, poison
The importance of Recognizing Seizures
Determine if this episode differs from previous one
Recognize postictal state of seizures
Excessive demand of oxygen from muscle use builds up acid in bloodstream
Pt may turn cyanotic
Seizures may prevent patient from breathing normally
Blood glucose level in patient may decrease in patient with diabetes
Monitor the glucose level
Look for problems associated with seizure
Head injuries
Incontinence - loss of bladder/bowel control
The Postictal State
After seizure pt muscle relax, becoming almost flaccid and floppy
Labored breathing
Lethargy and confusion
The longer the seizure is the longer the recovery be
Once patient regains consciousness postictal state is over
Hemiparesis - weakness on one side of body resembling stroke in postictal state
If patient condition does not improve consider hypoglycemia or infection
Syncope
Syncope (fainting)
Occurs when pt is standing, seizure occurs in any position
Faint not associated with postictal state
Altered Mental status
Altered mental status - pt is not thinking clearly or is incapable of being awakened.
Common causes: hypoglycemia, hypoxemia, intoxication, delirium, drug overdose, unrecognized head injury, brain infection, body temperature abnormalities, brain tumors, and overdoses and/or poisonings.
Some may be unconscious
Come may be alert but confused
Cause of Altered Mental Status
Hypoglycemia - deprives the brain of glucose, which is its primary fuel, leading to altered mental status and sometimes motor deficits like hemiparesis.
Similarly, a stroke disrupts blood flow and oxygen to the brain, which causes weakness or paralysis on one side of the body (hemiparesis).
Overlap in symptoms can be difficult to differentiate between the two without proper testing, like blood glucose measurement.
Patient with hypoglycemia always has an altered or decreased level of consciousness
Stroke pt may be alert and attempt to communicate with
Pt appears to have s/s of stroke and altered mental status report to medical control
Pt with decreased LOC should not be given anything by mouth
May also experience seizures
Mental status may not improve after seizure
Consider hypoglycemia for seizing patient with history of diabetes
AEIOU TIPS (possible causes of altered mental status
A - alcohol
E - Epilepsy, Endocrine, electrolytes
I - Insulin
O - Opiates and other drugs
U - Uremia (kidney failure)
T - Trauma, temperature
I - Infection
P - poisoning
S - shock, stroke, seizure, syncope, space-occupying lesion, subarachnoid hemorrhage.
Delirium - temporary state that often has physical state or mental cause and may be observed with proper treatment.
Symptom, not a disease
Signs and symptoms include
confusion and disorientation, disorganized thoughts, inattention, memory loss, striking changes in personality and affect, hallucinations, delusions, or a decreased level of consciousness
Pt may experience rapid alternations between mental states like lethargy and agitation.
Symptoms of delirium may mimic:
intoxication, drug abuse, or severe psychological disorders such as schizophrenia
Other causes or Altered Mental Status
Unrecognized head injury
Severe alcohol intoxication
Psychological disorders
Infections of brain or bloodstream
Drug overdose
Poisoning
Special Populations
Hemorrhagic strokes in children ares usually caused by congenital defects in blood vessels like berry aneurysms
Ischemic strokes can be cause like sickle cell anemia
Treat stroke and altered mental status in children same way you do in adults
Febrile seizures in children must be transported to hospital to find underlying cause
Patient Assessment
Scene Size-up
Neurologic emergency benefits from ALS assistance
Call for additional resources early
Look for clues to determine nature of illness
Potential trauma from environment?
Diabetic supplies?
Medical alert tags?
Evidence of seizure?
Did anyone witness what happened?
When was the last time the patient appeared normal?
Is the patient’s bed or furniture in disarray?
Most patients with a neurologic emergency display a change in their level of consciousness and their ability to interact with their environment and others.
Primary Assessment
Initial Approach and Assessment
Prioritize life-threatening conditions: airway, breathing, circulation, and bleeding.
Perform a rapid exam to assess severity.
Gather scene information: Is it medical or trauma-related?
Note patient’s body position and level of consciousness.
A patient in an unnatural position may have a life-threatening condition.
Seizure Considerations
Determine if the seizure is ongoing or if the patient is postictal.
If seizure continues, consider status epilepticus.
If postictal, patient may be unresponsive or slowly regaining awareness.
Use AVPU scale to assess level of consciousness.
Check for foreign body obstruction, especially if patient was eating or chewing gum.
Airway and Breathing Management
Ensure the patient’s airway is open and patent.
Consider oropharyngeal or nasopharyngeal airway if necessary.
Be prepared to suction and position to prevent aspiration.
If the airway is compromised, place patient in the recovery position.
In cases of altered mental status from opioid overdose or hypoxia, assess airway and breathing.
Monitor for rapid, deep breathing post-seizure (may normalize in minutes).
Do not hyperventilate the patient.
Hyperventilation can impair cardiac output, increase regurgitation risk, and decrease cerebral perfusion (especially in cases of brain injury).
Circulation Management
Check pulse if patient is unresponsive.
If no pulse, start CPR and attach AED.
If pulse present, assess rate (fast/slow) and strength (weak/strong).
Administer oxygen if needed to support cerebral perfusion.
Evaluate for external bleeding, especially if a seizure is involved.
Stroke patients are less likely to have trauma-related injuries.
Transport and Treatment Decisions
Establish priorities of care based on level of consciousness and XABCs (airway, breathing, circulation).
Guide decision on whether to stay for further assessment or proceed with transport.
For suspected stroke, provide rapid transport to appropriate facility.
Prompt treatment is critical to minimize disability from ischemic stroke
History Taking
Gathering History for Unresponsive Patient
Look for signs of trauma, medical alert tags, track marks, or environmental clues (e.g., empty alcohol or medication containers).
If no bystanders, search for possible explanations of altered mental status.
If patient is responsive, ask what happened to identify the cause (e.g., stroke signs, seizure evidence).
Evaluate speech for clarity or slurring.
For a postictal patient, look for trauma or seizure-related clues.
SAMPLE History for Responsive Patients
Obtain SAMPLE history:
Signs & symptoms
Allergies
Medications
Past medical history
Last oral intake
Events leading up to the illness/injury.
Time of last normal state is crucial, especially for stroke patients (critical for treatment timelines).
If patient was healthy before sleep, the last known healthy time is bedtime.
List all medications taken, including those related to seizure disorders or diabetes.
Identify any recent changes (e.g., missing medications, skipped doses).
Communication with Unconscious/Non-verbal Patients
Even if unconscious or unable to speak, patients may still understand.
Avoid making unnecessary comments; use non-verbal cues like hand pressure, eye movement, or nodding to gauge understanding.
Reassure the patient about your care, providing continuous updates on actions being taken.
Recognize that the patient may experience anxiety or frustration, which can affect communication.
Seizure-Related History
For seizure patients, determine if seizures are a recurring issue and any differences in the current episode.
Ask about seizure medication, adherence, or any recent changes (e.g., running out of medication).
In diabetic patients, seizures can deplete glucose levels, worsening the situation.
For new-onset seizures in a previously healthy patient, suspect serious conditions like brain tumors, intracranial bleeding, or infection.
Investigate potential causes like medications that lower blood glucose (insulin, hypoglycemic agents) or exposure to illicit drugs or toxins.
Secondary Assessment
General Secondary Assessment
Perform a full body assessment, focusing on the system involved (neurologic assessment if stroke is suspected).
Always obtain a complete set of vital signs using available monitoring devices.
Neurologic Focus in Stroke Suspected
Intracranial Bleeding (Hemorrhagic Stroke):
High blood pressure (to compensate for poor brain perfusion).
Slow pulse and erratic respirations due to brain compression.
Unequal pupil size/reactivity indicates significant bleeding and pressure on the brain.
Altered Mental Status:
If altered mental status is present, check blood glucose if local protocol allows (using portable glucometer).
Blood glucose monitoring (capillary or venous sample) provides valuable information.
Vital Signs During Seizures and Postictal State
During Active Seizures:
Do not prioritize vital signs during active seizures.
Postictal State:
Vital signs typically return to normal after the seizure.
Assess pulse (rate, rhythm, quality), respiratory rate (rhythm, quality), blood pressure, skin condition (color, temperature), oxygen saturation, and pupil reactivity.
Observing Skin Color and Condition
Paleness (hypoperfusion) can be hard to detect in dark-skinned patients.
Examine mucous membranes: inner lower eyelids, lips, nail beds.
On general observation, the patient may appear ashen or gray.
Blood Pressure Measurement
First blood pressure reading should be taken manually with a sphygmomanometer and stethoscope.
Automated non-invasive blood pressure devices may be used if available and approved.
Stroke Assessment Tool (BE-FAST)
Incorporate Stroke Scale:
A stroke assessment tool should be part of your secondary assessment in patients with neurologic disorders.
Many EMS units use stroke scales to quickly identify stroke in the field.
BE-FAST Mnemonic:
Balance: Check for signs of dizziness or lack of coordination.
Eyes: Evaluate for vision changes or loss of vision.
Face: Look for facial drooping or asymmetry.
Arms: Ask the patient to raise both arms—check for weakness or drooping.
Speech: Assess for slurred or abnormal speech.
Time: Determine the time of onset of symptoms (critical for treatment).
If Abnormal Responses:
If any part of the BE-FAST assessment is abnormal, strongly suspect a stroke.
Immediate Action: Rapid transport to a designated stroke center is indicated.
1. Cincinnati Prehospital Stroke Scale (CPSS)
This scale is used in the field to help identify potential strokes quickly.
Facial Droop:
Ask the patient to smile or show their teeth.
Look for asymmetry or drooping of one side of the face.
Abnormal: One side of the face droops or doesn't move.
Arm Drift:
Ask the patient to close their eyes and hold both arms out in front of them.
Observe if one arm drifts downward or doesn't rise at all.
Abnormal: One arm drifts or falls, suggesting weakness or paralysis.
Speech:
Ask the patient to say a simple sentence, like "You can't teach an old dog new tricks."
Listen for slurred speech or difficulty speaking.
Abnormal: Speech is slurred, inappropriate, or difficult to understand.
If any of these are abnormal, it’s a strong indication of a stroke, and rapid transport to a stroke center should be initiated.
2. Los Angeles Prehospital Stroke Screen (LAPSS)
A more comprehensive tool, also used in the prehospital setting.
Age:
>45 years (younger patients are less likely to have a stroke).
History of Seizure:
No history of seizures (a history of seizures can indicate a different cause for symptoms).
Symptom Onset:
Symptoms must have started within 24 hours to be considered a potential stroke.
Patient’s History:
The patient must not have a history of diabetes or impaired level of consciousness (this helps rule out other causes).
Motor Function (Arm Drift):
The same as in the Cincinnati scale: Ask the patient to hold their arms out with eyes closed and look for arm drift.
Speech:
Similar to the Cincinnati scale: Ask the patient to repeat a simple sentence and listen for abnormalities.
If the patient meets the criteria, the tool helps to identify possible strokes, and the patient should be transported to a stroke center.
3. National Institutes of Health (NIH) Stroke Scale (NIHSS)
The NIHSS is used primarily in the hospital setting to assess the severity of stroke symptoms.
Consciousness:
Assess the patient’s level of consciousness (alert, drowsy, or unresponsive).
Language:
Assess the ability to understand and produce speech.
Check for aphasia (difficulty in speaking or understanding speech).
Motor Function:
Test for weakness or paralysis on each side of the body.
Includes the arm drift test and checking for limb movement.
Sensory Function:
Evaluate whether the patient can feel sensations on both sides of their body.
Pupillary Response:
Check for equal and reactive pupils.
Unequal pupils can indicate brain damage or pressure.
Gaze and Visual Field:
Check for gaze preference or vision loss (blindness in part or all of the visual field).
Coordination:
Test the patient's ability to perform tasks requiring coordination (e.g., touching nose with eyes closed).
Speech:
Assess speech quality (slurred speech or inability to form words).
The NIHSS assigns a score to each item, and the total score helps determine the severity of the stroke. A higher score indicates a more severe stroke.
Comparison Summary:
Cincinnati Prehospital Stroke Scale: Quick and simple, used in the field for rapid stroke identification.
Los Angeles Prehospital Stroke Screen: More detailed than Cincinnati, includes age, history, and symptom onset time.
NIH Stroke Scale: Comprehensive, used in hospitals to assess the severity of the stroke and guide treatment decisions.
NIH Stroke Scale (NIHSS) in the Hospital
Primary Tool in Hospitals:
The NIH Stroke Scale (NIHSS) is the most commonly used instrument for evaluating stroke in the hospital.
It is an 11-step numerical grading system that provides detailed information about the patient's condition.
Reassessment:
The NIHSS can be repeated throughout the hospital stay to track changes in the patient's condition over time.
Not Used Prehospital:
The NIHSS is rarely used in the prehospital setting due to its complexity.
Prehospital Components:
Some aspects of the NIHSS can be assessed in the prehospital setting, such as:
Identifying common objects: Ask the patient to identify everyday objects in the room.
Reading a short written passage: Evaluate the patient’s ability to read and understand a brief text.
Purpose:
The NIHSS provides critical information about the severity of the stroke and helps guide hospital treatment and care decisions.
Testing
Speech Test:
Ask the patient to repeat a simple sentence, such as:
“You can’t teach an old dog new tricks.”
Normal Response: Patient repeats the phrase correctly, indicating they can both understand and produce speech.
Abnormal Response: Patient cannot repeat the phrase, suggesting a problem with understanding speech or producing it.
Facial Movement Test:
Ask the patient to smile and show their teeth (or gums if the patient does not have teeth).
Normal Response: Both sides of the face move equally.
Abnormal Response: If one side of the face does not move or moves less, this indicates muscle control issues on the opposite side of the face.
Arm Movement Test
Test:
Ask the patient to hold both arms in front of their body, palms up toward the sky, with eyes closed and without moving.
Observe for arm drift over 10 seconds.
Normal Response: Both arms stay up and do not move.
Abnormal Response:
One arm drifts down, indicating weakness or paralysis on that side.
If both arms fall to the ground, the test may have been misunderstood—repeat the test and position the arms yourself to ensure accuracy.
3-Item Stroke Severity Scale (LAG Scale)
Items Assessed:
Level of Consciousness
Arm Drift (Motor Function)
Gaze
Scoring:
Each item scored from 0 to 2:
0: Normal
2: Severe abnormality
Score of 5 or 6: High likelihood of stroke.
Purpose:
This scale helps assess the probability of a stroke in the prehospital setting.
Familiarize yourself with the specific protocol used locally.
Los Angeles Motor Scale (LAMS) for Large Vessel Occlusion (LVO) Strokes
Used to Identify LVO Strokes:
LVO strokes are a subtype of ischemic strokes caused by an occlusion of a large blood vessel in the brain.
These strokes respond well to fibrinolytics or mechanical thrombectomy but need to be identified quickly for optimal treatment.
LAMS Scoring:
Facial Droop:
Absent = 0
Present = 1
Arm Drift:
Absent = 0
Slow Drift = 1
Rapid Fall = 2
Grip Strength:
Normal = 0
Weak Grip = 1
No Grip = 2
Interpretation:
Score of 4 or more: Strong indication of LVO stroke.
Consider transport to a comprehensive stroke center if available.
Glasgow Coma Scale (GCS)
When to Use:
Calculate the GCS score for all patients with altered mental status (e.g., stroke, TIA, seizure of unknown cause).
Purpose:
The GCS provides a numerical score to assess the patient's level of consciousness.
Refer to Table 18-7 for specific GCS scoring.
Reassessment in Stroke and Seizure Patients
Focus of Reassessment:
XABCs (Airway, Breathing, Circulation)
Vital signs
Interventions provided so far
Key Considerations for Stroke Patients:
Airway and Breathing: Stroke patients may lose their airway or stop breathing suddenly. Continuous monitoring is crucial.
Intervention Effectiveness: After providing treatments (e.g., airway adjuncts, positive pressure ventilation), observe the patient's response. If the intervention isn't working, try alternative measures.
Compare Baseline and Updated Information:
Reassess vital signs (pulse, blood pressure, respirations) and GCS score.
Any changes may indicate the effectiveness of interventions.
Monitor changes closely, especially in GCS score, which reflects neurological status.
Notify Receiving Facility:
Inform the hospital about the patient’s chief complaint and assessment findings.
Follow your local protocol on whether to notify the receiving facility for a stroke alert.
Stroke alert: Ensures the stroke team is ready to treat the patient as soon as possible.
Provide critical information:
Time last seen healthy
Neurologic exam findings
Estimated time of arrival (ETA) at the hospital
Time of Onset:
For ischemic strokes, time of onset is essential for determining eligibility for treatments like clot retrieval or clot-dissolving drugs.
Document the time the patient’s symptoms began to show.
Documentation:
Stroke Scale and GCS: Record findings and any changes after reassessment.
Airway Management: Note the positioning and interventions performed (e.g., airway adjuncts, ventilation).
Seizure Documentation:
Describe the seizure activity (type, onset, duration).
Include bystander comments if available.
Note whether the patient experienced an aura (warning sign before a seizure).
Record any evidence of trauma and the interventions provided (e.g., airway, positioning).
Seizure History:
Determine if it’s the first seizure or if there’s a history of seizures.
Note frequency of seizures and history of status epilepticus (seizures lasting >5 minutes or recurrent seizures without full recovery between them).
Detailed Documentation for Seizure Patients:
Time and Description of Seizure:
Document when the seizure started and its duration.
Aura: If the patient recalls warning signs.
Interventions: Record any interventions performed (e.g., protecting the airway, positioning).
Patient's Response:
How did the patient respond to interventions?
Any changes in mental status, airway, or breathing?
Ongoing Reassessments:
Continue to assess the patient’s condition, documenting any changes.
Key Information to Document for Stroke Patients
Time of Onset:
Critical for treatment decisions: Helps determine eligibility for blood clot-dissolving drugs or clot-retrieval therapy.
If the person who last saw the patient well isn't available:
Ask for their phone number to relay to the hospital team.
GCS Score:
Record the Glasgow Coma Scale (GCS) score to assess the patient’s level of consciousness.
Stroke Assessment Tool Results:
Document the results of a stroke assessment tool, such as:
Cincinnati Prehospital Stroke Scale
Los Angeles Prehospital Stroke Screen
LAG (3-Item Stroke Severity Scale)
BE-FAST (Balance, Eyes, Face, Arms, Speech, Time)
Changes Noted on Reassessment:
Document any changes in the patient’s condition during reassessment, including:
Vital signs
GCS score
Neurological status
Neurologic Emergencies: Stroke, Seizure, Hypoglycemia, and Hypoxia
General Considerations:
Stroke, Seizure, Hypoglycemia, Hypoxia:
These conditions typically present with easily identifiable signs/symptoms, making treatment straightforward.
Other neurologic emergencies: Causes may not be immediately obvious, requiring further testing at the hospital to determine the exact cause.
Field Treatment: Based on assessment findings, not always definitive.
Low blood glucose: Administer oral glucose (if patient is conscious and able to swallow).
Unresponsive patient: Place in recovery position to protect airway.
Do not administer oral intake to patients with altered mental status or those unable to swallow normally (risk of aspiration).
Stroke Management:
Hospital Role:
CT scan is the gold standard to determine if there’s bleeding in the brain (e.g., hemorrhagic stroke).
If bleeding is absent, the patient might be a candidate for blood clot-dissolving medication (e.g., tPA).
If bleeding is present, clot-dissolving drugs can worsen the condition.
Designated Stroke Centers:
Some EMS systems direct stroke patients to accredited stroke centers with 24-hour CT technicians and neurosurgeons.
Non-accredited hospitals may only have limited CT resources.
Early Notification:
Alert the hospital early for stroke patients so the CT technician and resources can be prepared.
Time-sensitive Treatments:
Clot-dissolving medications are most effective if given within 3 hours of symptom onset.
Notify the hospital about the last time the patient was well to help determine treatment eligibility.
Seizure Management:
Seizure Treatment:
Seizures are usually short-lived. Most patients will stop seizing by the time EMS arrives.
Protect the patient from harm:
Ensure the airway is clear (suction if necessary).
Administer oxygen as soon as possible.
If head/neck trauma is suspected, provide spinal motion restriction.
Status Epilepticus (prolonged or recurrent seizures):
Suction the airway and provide positive-pressure ventilations (e.g., bag-mask).
Transport quickly to the hospital.
If available, ALS rendezvous may be beneficial (they can administer anti-seizure medications).
Patient Interaction:
Post-seizure, patients may be confused or frightened.
Patience and kindness are essential, as some patients may be frustrated and refuse transport.
Explain the importance of transportation for definitive care.
General Tips for Neurologic Emergencies:
Continuous Monitoring:
In stroke and seizure cases, always monitor the airway, breathing, circulation, and level of consciousness.
Maintain a thorough assessment and continue interventions as needed.
Airway Assessment:
Follow standard procedures to determine airway adequacy and self-maintenance.
Do not assume:
A post-seizure patient needs an airway adjunct.
A post-seizure patient’s airway is intact.
Perform a thorough assessment before deciding.
Tips on Patient Care
TIA vs Stroke: TIA symptoms mimic stroke but resolve within minutes to 24 hours. Always transport TIA patients for evaluation.
Positioning: Secure the affected/paralyzed limb safely during transport.
Communication: Stroke patients may understand but not communicate effectively. Be mindful of this.
Urgency: Stroke therapies are time-sensitive. Minimize scene time and notify the hospital immediately.
EMS Care
Headache
Headaches:
Most are harmless and don’t need emergency care.
Red flags:
Sudden, severe headache.
Headache with fever, seizures, altered mental status, or after head trauma.
Transport Guidelines:
Perform a thorough assessment and transport if concerning signs are present.
Migraine
Migraine Treatment:
Provide supportive care.
Assess for signs of more serious conditions.
High-flow oxygen may help if tolerated.
Transport Guidelines:
Offer a dark, quiet environment (sensitivity to light/sound).
Avoid using lights and sirens during transport.
Stroke
Stroke Management:
Support XABCs and ensure rapid transport to a stroke center.
Airway: Position manually if needed; use suction for secretions.
Oxygen: Maintain SpO₂ ≥ 94%. Routine oxygen not recommended unless signs of hypoxia or respiratory distress. Err on the side of caution if unsure.
Paralyzed extremities: Protect from injury during transport.
Communication:
Patients may understand but not communicate effectively.
Provide reassurance and emotional support; explain what’s happening.
Stroke Treatments:
Fibrinolytic therapy: Effective if given within:
3 hours for drugs.
6 hours for mechanical clot removal (may extend to 24 hours in advanced centers).
Not suitable for hemorrhagic strokes.
Transport Guidelines:
Minimize scene time – "Time is brain."
Prioritize transport to a designated stroke center.
Assume salvageable brain tissue until proven otherwise.
Seizure
Seizure Management:
Most patients will be in a postictal state upon arrival.
For active seizures:
Assess and manage XABCs.
Use manual airway positioning and suction as needed.
Apply high-flow oxygen (monitor SpO₂; administer even without accurate readings).
Protect patient from harm (use padding; remove dangerous objects).
Avoid tight restraints; prevent spinal movement if trauma is suspected.
Transport Guidelines
Evaluate trauma or seizure complications during assessment.
Encourage transport to the ED for evaluation.
Refusal of Transport:
Confirm these conditions for refusal:
Fully awake and oriented (GCS 15).
No trauma or complications.
History of seizures, typical in presentation.
Patient is on seizure medications and regularly evaluated by a physician.
Release to a responsible person for monitoring.
If any question is “no”, strongly encourage transport.
Contact medical direction for refusals, and follow local protocols.
Altered Mental Status
Altered Mental Status:
Signs range from confusion to coma.
Always treat it as an emergency, regardless of apparent cause (e.g., alcohol intoxication, minor head trauma).
Management:
Identify cause (mechanism of injury vs. nature of illness).
Provide spinal motion restriction if indicated.
Support airway and ventilation.
Transport to an appropriate facility.