Neurological Emergencies

Coma, Seizures, Syncope, Stroke

Coma

State of unconsciousness from which patient cannot be aroused

Coma

Unconsciousness = Immediate Life Threat

Loss of airway Aspiration

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Coma

Management of ABCs must come before investigation of cause

Airway

Open, clear, maintain If trauma present or no history available, immediately control C-spine

Breathing

Assess presence, adequacy High concentration O2 immediately on all patients with decreased LOC Assist if respiratory rate, tidal volume inadequate

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Circulation
Pulses? Perfusion?

After ABCs stabilized. . .

Quickly investigate cause DERM

D = Depth of coma

What does patient respond to? How does he respond?

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E = Eyes

Pupils equal, dilated, constricted, Responsive to light? How?

R = Respiratory pattern

Rate? Unusually deep or shallow? Altered pattern?

M = Motor Function

Evidence of paralysis? Movement on stimulation? How?

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Vital Signs

Shock? Increased ICP? Arrhythmias?

Head to Toe Survey

Injuries causing coma? Injuries caused by fall? What do the scene, bystanders tell you?

Possible Causes

Not enough oxygen Not enough sugar Not enough blood flow to deliver O2, sugar Direct brain injury
Structural (trauma) Metabolic (toxins, infections, temperature)

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Possible Causes
Alcohol Epilepsy Insulin Overdose Uremia (and other metabolic causes)

Trauma Infection Psychiatric Stroke, syncope, seizures

Management

Secure airway Protective reflexes may be lost Immobilize spine unless absolutely certain injury not present Spinal injury not suspected - patient on left side

Management

High concentration O2 Assist ventilation as needed Monitor neurological/vital signs every 5 minutes

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Management

Protect patients eyes on long transports (tape shut, moist pads) Patient may hear, understand even though unable to respond Treat, reassure accordingly

Neurologic Emergencies

Key Term
Seizure
Sudden change in sensation, behavior, or movement caused by irregular electrical activity of the brain

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Seizures

Episodes of uncoordinated electrical activity in brain Signs/symptoms depend on area involved

Key Term
Seizure
Sudden change in sensation, behavior, or movement caused by irregular electrical activity of the brain

Causes of Seizures
Toxin (including drugs & alcohol) Brain tumor Congenital brain defects Trauma Infection/Fever (#1 cause in pediatric patients 6 months to 3 years old)

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Causes of Seizures
Epilepsy Stroke Hypoglycemia Eclampsia (complication of pregnancy) Hypoxia Unknown

Epilepsy

Tendency to have repeated episodes of seizure activity

Seizure Types

Grand mal (major motor) Petit mal (absence) Focal motor (simple partial) Psychomotor (complex partial)

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Grand Mal Seizure

Aura
Sensation coming before convulsion Patient may recognize as sign of impending seizure May help locate origin of seizure in brain

Grand Mal Seizure

Convulsion
Loss of consciousness Tonic phase - rigidity Clonic phase - rhythmic jerking, incontinence, ineffective breathing

Grand Mal Seizure

Post-ictal Phase

Exhaustion Drowsiness Headache Possible hemiparesis (Todds paralysis)

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Petit Mal Seizure

Loss of consciousness No loss of postural tone More common in children

Focal Motor Seizure

Rhythmic jerking of limb, one side of body No loss of consciousness

Psychomotor Seizure

Loss of consciousness Sterotyped movements (automatisms)

May look purposeful, but arent Lip smacking, movements of hands

May be called in as drunk, O.D., psych patient

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Generalized Seizure Management

During seizure
Remove from potential harm Do not forcibly restrain Roll on side Avoid putting anything in mouth

Generalized Seizure Management

After seizure ends

Assess ABCs Clear airway Most common cause of seizure deaths is post-ictal airway loss

Generalized Seizure Management

High concentration O2 - immediately!! Assist breathing if ventilation inadequate

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Generalized Seizure Management

Obtain history/physical
Trauma that could have caused, been caused by seizure Anti-seizure medications

Neuro/vital signs every 5 minutes If patient ventilating adequately, transport on left side

Seizures

Anything that injures brain can cause seizures (AEIOU/TIPS) Do not assume seizures are due to idiopathic epilepsy until proven otherwise

Key Term
Status Epilepticus
A life-threatening condition in which the patient has two or more convulsive seizures without regaining consciousness

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Status Epilepticus

> 2 seizures without intervening conscious period Immediate Life Threat Management
Secure airway Assist breathing with O2 Transport Request ALS intercept

Syncope
Fainting Sudden, temporary loss of consciousness Caused by lack of blood flow to brain

Causes
Stress, fright, pain (vasovagal syncope) Orthostatic hypotension (BP fall on standing)

Decreased blood volume Increased size of vascular space

Decreased cardiac output Prolonged forceful coughing

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Management
ABCs Keep

patient supine, elevate lower extremities Oxygen Assess underlying cause

CVA
Cerebrovascular Stroke

accident

CVA

Damage of portion of brain due to interruption of blood supply Mechanisms

Thrombosis Hemorrhage Embolism

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Thrombosis

Blockage of vessel by thrombus Usually forms at area narrowed by atherosclerosis Typically in older persons Frequently occurs during sleep

Hemorrhage

Vessel ruptures Associated with hypertension, aneurysms of cerebral blood vessels Usually characterized by

Sudden onset Severe signs, symptoms

Embolism

Blood clots, plaque fragments travel through vessel; lodge, block flow Often associated with:
Atherosclerosis of carotids Chronic atrial fibrillation

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Signs/Symptoms

Alterations in consciousness
Altered affect Confusion Dizziness Coma

Signs/Symptoms

Localizing signs

Paralysis Loss of sensation Difficult or loss of speech

Left Hemispheric strokes
Aphasia: Inability to speak or understand speech Receptive aphasia: Ability to speak, but unable to understand speech Expressive aphasia: Inability to speak correctly, but able to understand speech Dysarthria: Able to understand, but hard to be understood

* Right Hemispheric strokes

Signs/Symptoms

Unilateral blindness Unequal pupils Seizures Headache Stiff neck

Loss of vision in half of visual field of both eyes

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Transient Ischemic Attacks

TIAs Little strokes Produce deficits that resolve completely in <24 hours Frequently precede CVA

Management

Assess ABCs Protect airway High concentration O2 Vital signs every 5-10 minutes Note increased BP, irregular pulse

Management

Nothing by mouth Avoid rough handling Transport paralyzed side down Guard your conversation Patients who cannot speak may still understand!

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Cincinnati Prehospital Stroke Scale

Have patient attempt to smile.

Cincinnati Prehospital Stroke Scale

Have patient attempt to hold arms straight in front of them for 10 seconds.

Cincinnati Prehospital Stroke Scale

Evaluate patients speech.

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Management

CVAs caused by thrombus, embolus may be reversible with thrombolytics (clot busters) Early recognition, rapid transport to appropriate facility is critical Transport to a Stroke Center

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