Neurological Emergencies

Neurological Emergencies Coma, Seizures, Syncope, Stroke Temple College EMS Professions Coma  State of unconsciousness from which patient cannot be aroused Coma  Unconsciousness = Immediate Life Threat  Loss of airway  Aspiration Coma  Management of ABC’s 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 Circulation Pulses? Perfusion? After ABC’s stabilized. . .   Quickly investigate cause DERM D = Depth of coma   What does patient respond to? How does he respond? 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? 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) Possible Causes Alcohol  Epilepsy  Insulin  Overdose  Uremia (and other metabolic causes)  Trauma  Infection  Psychiatric  Stroke, syncope  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 Management    Protect patient’s eyes on long transports (tape shut, moist pads) Patient may hear, understand even though unable to respond Treat, reassure accordingly Seizures   Episodes of uncoordinated electrical activity in brain Signs/symptoms depend on area involved 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) 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 (Todd’s paralysis) 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 aren’t  Lip smacking, movements of hands  May be called in as “drunk”, “O.D.”, “psych patient” 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 ABC’s  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 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 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 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 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 Signs/Symptoms  Alterations in consciousness  Altered affect  Confusion  Dizziness  Coma Signs/Symptoms  Localizing signs  Paralysis  Loss of sensation  Loss of speech  Unilateral blindness  Loss of vision in half of visual field of both eyes  Unequal pupils Signs/Symptoms    Seizures Headache Stiff neck Transient Ischemic Attacks     TIAs “Little strokes” Produce deficits that resolve completely in <24 hours Frequently precede CVA Management      Assess ABC’s 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! Management   CVAs caused by thrombus, embolus may be reversible with thrombolytics (clot busters) Early recognition, rapid transport to appropriate facility is critical