13: Neurologic Emergencies

Cognitive Objectives (1 of 3)

1. Describe the causes of stroke, including the two

major types of stroke and the three conditions that
cause blockages.
2. Describe the sequence of events that occur
during a stroke.
3. Obtain and interpret the key vital signs in the
stroke patient, including the time of onset of the
symptoms.
4. State the reason stroke must be treated within the
first 3 to 6 hours.
 Cognitive Objectives (2 of 3)
5. Identify the signs and symptoms of stroke.
2. Describe the significance of a transient ischemic
attack (TIA).
3. Define seizure, including the two major types of
seizure.
4. Describe the parts of a seizure.
5. List possible causes of seizure.
6. Explain the importance of recognizing seizures.
 Cognitive Objectives (3 of 3)
• Describe characteristics of the postseizure state.
• Define altered mental status.
• List possible causes of altered mental status.
 Affective Objectives
14. Explain the importance of tolerance and patience
when caring for a patient who has had a stroke,
seizure, or who has altered mental status.
 Psychomotor Objectives
1. Demonstrate the steps in the emergency
medical care for the patient who has had a
stroke.
2. Demonstrate testing for aphasia, facial
weakness, and motor weakness.
17. Demonstrate the steps in the emergency
medical care for the patient who has had a
seizure.
18. Demonstrate the steps in the emergency
medical care for the patient who has altered
mental status.
Brain Structure and Function
The Spinal Cord
 Common Causes of Brain
Disorder (1 of 2)
• Many different disorders can cause brain
dysfunction and can affect LOC, speech,
and muscle control.
• If problem is caused by heart and lungs,
entire brain will be affected.
• If problem is in the brain, only that portion of
brain will be affected.
 Common Causes of Brain
Disorder (2 of 2)
• Stroke is a common cause of brain disorder and is
treatable.
• Seizures and altered mental status are other
causes of brain disorder.
 Cerebrovascular Accident
and Stroke
• Cerebrovascular accident
– Interruption of blood flow to the brain that results
in the loss of brain function
• Stroke
– The loss of brain function that results from a
CVA
 Potential Results of a CVA
• Thrombosis—Clotting of
cerebral arteries
• Arterial rupture—Rupture
of a cerebral artery
• Cerebral embolism—
Obstruction of a cerebral
artery caused by a clot that
was formed elsewhere and
traveled to the brain
 Hemorrhagic Stroke
• Results from bleeding in the brain
• High blood pressure is a risk factor.
• Some people are born with aneurysms.
 Ischemic Stroke
• Results when blood flow to a particular part of the
brain is cut off by a blockage inside a blood vessel
Atherosclerosis
 Transient Ischemic Attack (TIA)
• A TIA is a “mini-stroke.”
• Stroke symptoms go away within 24 hours.
• Every TIA is an emergency.
• TIA may be a warning sign of a larger stroke.
• Patients with possible TIA should be evaluated by
a physician.
 Signs and Symptoms of Stroke (1 of 2)
• Left hemisphere
– 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
Signs and Symptoms of Stroke (2 of 2)
• Right hemisphere
– Dysarthria: Able to understand, but hard to be
understood
 Stroke Mimics
• Hypoglycemia
• Postictal state
• Subdural or epidural bleeding
 You are the Provider

• You and your paramedic partner arrive to a 70-

year-old man with a severe headache and
decreased level of consciousness.
• He is seated in the kitchen with his wife standing
next to him.
 You are the Provider
continued

• When you speak to him, he stares at you blankly.

• You notice that he is drooling from the right side of
his mouth.
• His wife says, “A few minutes ago, he told me that
he had a very bad headache.”
• “When I came back from the bathroom with some
ibuprofen, I tried to hand him a glass of water and
he dropped the glass on the floor. I don’t know
what’s wrong with him.”
 You are the Provider
continued

• What do you suspect is wrong with this patient?

• What other signs and symptoms would you suspect
in this scenario?
• What tests could you use to verify your suspicions?
 Scene Size-up

• Scene safety remains a priority.

• Ensure that needed resources are requested.
• Consider spinal immobilization.
• Be aware that many serious medical conditions can
mimic stroke; consider all possibilities.
 Initial Assessment

• Chief complaint may include confusion, slurred

speech, or unresponsiveness.
• Patient may have difficulty swallowing or choke on
own saliva.
• Ensure adequate airway.
• If unresponsive, place in recovery position.
• Administer oxygen.
• Raising patient’s arms and legs may aggravate
hemorrhage.
 You are the provider
continued (1 of 2)

• You utilize a portion of the Cincinnati Stroke Scale

by asking the patient to smile.
• He attempts, but the right side of his face remains
flaccid.
• You assist the patient to the cot and place him
upright, slightly on his affected side.
• As you obtain a quick set of baseline vital signs,
your partner applies high-flow oxygen.
 You are the provider continued (2 of 2)

• What other types of disorders or conditions can

mimic a stroke?
• Can all strokes be treated with clot-busting
medications?
 Transport Decision
• Thrombolytics may
reverse stroke
symptoms or stop a
stroke if given within 2
to 3 hours of onset.
• Spend as little time on
scene as possible.
• Place paralyzed side
down and well
protected with padding.
• Elevate head
approximately 6".
Focused History and Physical Exam

• Quickly determine
when patient last
appeared normal.
• Medications may give
you a clue to the
patient’s past medical
history.
• Patient may still be
able to hear and
understand; be
careful what you say.
 Cincinnati Stroke Scale
• Speech
– Abnormal if words are slurred or confused
• Facial droop
– Abnormal if asymmetrical
• Arm drift
– Abnormal if arms do not move equally
 Baseline Vital Signs
• Excessive bleeding in the brain may slow pulse and
cause erratic respirations.
• Blood pressure is usually high.
• Excessive bleeding in the brain may cause
changes in pupil size and reactivity.
 Interventions
• Based on assessment findings
• If the patient is unresponsive, you may consider the
recovery position to protect the airway.
 Detailed Physical
Exam

• Perform when time and conditions permit.

• Generally performed en route to the hospital.
• Do not delay transport, especially due to the time
sensitivity of stroke treatment.
 Ongoing Assessment

• Reassess ABCs, interventions, vital signs.

• Stroke patients can lose airway without warning.
• Watch for changes in GCS scores.
• Relay information to the hospital as soon as
possible.
• Report any pertinent physical findings, Cincinnati
Stroke Scale, GCS score, any other changes.
 You are the provider continued (1 of 2)

• Your partner tells you that he will initiate an IV en

route. You assist the patient’s wife into the
ambulance and immediately begin transport using
lights and siren.
• You do your best to address their concerns about
the noise and driving safely. You hear the
paramedic performing the rest of the stroke
scale.
• What would this include?
 You are the provider continued (2 of 2)

• Your partner asks the patient to hold his hands out

in front of him palms up and eyes closed.
• He then asks the patient to repeat a simple
declarative statement.
• The findings indicate the presence of stroke.
• He assigns this patient a GCS score and obtains
another set of vital signs.
• What would the paramedic have seen if the
remaining tests indicated a stroke?
 Emergency Care for Stroke
• Patient needs to be evaluated by computed
tomography (CT).
• Recognizing the signs and symptoms of stroke
can shorten the delay to CT.
• Treatment needs to start as soon as possible,
within 3 to 6 hours of onset.
 Seizures
• Generalized (grand mal) seizure
– Unconsciousness and generalized severe
twitching of the body’s muscles that lasts
several minutes
• Absence (petit mal) seizure
– Seizure characterized by a brief lapse of
attention
Signs and Symptoms of Seizures
• Seizures may occur on one side or gradually
progress to a generalized seizure.
• Usually last 3 to 5 minutes and are followed by
postictal state
• Patient may experience an aura.
• Seizures recurring every few minutes are known as
status epilepticus.
 Causes of Seizures
• Congenital (epilepsy)
• High fevers
• Structural problems in the brain
• Metabolic disorders
• Chemical disorders (poison, drugs)
• Sudden high fever
 Recognizing Seizures
• Cyanosis
• Abnormal breathing
• Possible head injury
• Loss of bowel and bladder control
• Severe muscle twitching
• Postseizure state of unresponsiveness with deep
and labored respirations
 Postictal State
• Patient may have labored breathing.
• May have hemiparesis: weakness on one side of
the body.
• Patient may be lethargic, confused, or combative.
• Consider underlying conditions:
– Hypoglycemia
– Infection
 Scene Size-up

• Spinal immobilization
may be needed with a
seizure.
• Ensure that scene is safe
and wear BSI.
• Request ALS assistance
earlier rather than later.
 Initial
Assessment

• Most seizures last only a few minutes at most.

• Assess level of consciousness.
• Use AVPU scale to determine how well patient is
progressing through postictal stage.
• Focus on ABCs upon arrival.
• Expect pulse to be rapid and deep.
• Pulse should slow to normal rates after several
minutes.
 Transport Decision
• It is difficult to package a seizing patient for
transport.
• Treat ABCs while waiting for seizure to finish.
• Protect the seizing patient from his or her
surroundings.
• Never restrain an actively seizing patient.
• Not every patient who has a seizure wishes to be
transported.
• Encourage every patient to be seen and evaluated
in the emergency department.
 Focused History and Physical
Exam

• Obtain some information from family or bystanders.

• Observe patient for recurrent seizures.
• If the patient displays an altered mental status,
perform a rapid physical exam.
• If patient is responsive, begin with SAMPLE history.
• If the patient has an altered mental status, utilize
the Glasgow Coma Scale.
 Interventions
• Most seizures will be over by the time you arrive.
• Treat trauma as you would for any other patient.
• For patients who continue to seize, suction the
airway according to local protocol, provide positive
pressure ventilation, transport quickly to hospital.
• Consider rendezvous with ALS, who have
medications to stop prolonged seizures.
 Detailed Physical Exam

• If life threats are treated, consider performing

detailed physical exam.
• Check patient for injuries, including tongue.
• Assess for weakness or loss of sensation on one
side of body.
 Ongoing Assessment

• Note additional seizure activity.

• Reassess ABCs, interventions, vital signs.
• Provide complete history to receiving facility.
• Include descriptions of seizure from witnesses if
available.
• Document whether this is first seizure or whether
patient has history of seizures.
 Emergency Medical Care
for Seizure
• Most patients should be evaluated by a physician
after a seizure.
• With severe injury, suspect spinal injury.
• Attempt to lower body temperature if febrile
seizure.
• Patient and family may be frightened.
 Altered Mental Status
• Hypoglycemia • Brain infection
• Hypoxemia • Body temperature
abnormalities
• Intoxication
• Brain tumors
• Drug overdose
• Glandular abnormalities
• Unrecognized head
• Poisoning
injury
 Assessing a Patient With AMS
• Same assessment
process
• Patient cannot tell you
reliably what is wrong.
• Be vigilant in ongoing
assessment.
• Monitor for changes or
deterioration.
• Provide prompt
transport to hospital
while monitoring the
patient.