BLS-2015 Neurologic Emergencies

Introduction There is a wide variety of neurologic emergencies which we encounter in the field. Not all are treated or transported in the same way. You need to quickly and accurately determine the patient’s disease or condition so you can make the right treatment and transport decision. The key for ischemic stroke patients – clot-busting therapy within 3 hours of the onset of symptoms

Practical Skills To receive CBT or OTEP credit, a trained evaluator must evaluate your ability to perform the following practical skills: Determine whether the patient is SICK or NOT SICK on initial assessment Conduct a patient history and physical exam Recognize a variety of neurologic patients Administer the FAST exam to the appropriate patient Recognize symptoms of ischemic stroke and need for short scene times Provide emergency care for neurologic emergencies

Learning Objectives Review neurological anatomy and physiology at the Basic EMT Level Recognize common neurologic emergencies Distinguish between the two types of stroke Recognize the underlying causes of stroke Recognize the signs and symptoms of stroke Determine the reasons why an ischemic stroke patient must be assessed and transported quickly Choose the correct BLS treatments for different neurologic emergencies

Terms atherosclerosis — a condition characterized by the deposit of fatty plaques containing cholesterol and lipids on the innermost layer of the walls of arteries clot-busting therapy — dissolves blood clots in a procedure termed thrombolysis; limits the damage caused by the blockage of the blood vessel dysarthria — difficulty in pronouncing words, caused by impairment in the control of the muscles used in speech embolism — a clot that travels from one part of the body to another until it becomes lodged in an artery expressive aphasia — aphasia in which the power to communicate by writing, speaking, or using signs is diminished or lost. Also called motor aphasia.

Terms foramen magnum — the opening in the base of the skull through which spinal cord passes to cranial cavity and becomes the medulla oblongata hemiparesis — partial weakness affecting one side of the body hemiplegia — complete paralysis on one side of the body hemorrhagic stroke — a type of stroke that occurs when a blood vessel bursts inside the brain hyperlipidemia — elevated lipid (fat) levels in the blood

Terms infarction — localized area of cell death due to a lack of oxygenated blood ischemia — deficiency of oxygenated blood in a body part as a result of decreased blood flow migraine headache — migraines are thought to involve abnormal functioning of brain's blood vessels. Migraines may cause pain, visual disturbances, and stomach upset; they may be preceded by an aura receptive aphasia — inability to comprehend written or spoken words

Terms seizure — uncontrolled electrical activity in the brain, which may produce a physical convulsion or twitching of the body status epilepticus — one continuous seizure lasting longer than 30 minutes or recurrent seizures without regaining consciousness between seizures stroke — occurs when blood flow to the brain is interrupted either by a clogged or ruptured artery thrombolysis — breakup of a blood clot, typically by medicine

Terms thrombus — blood clot that typically forms over fatty plaque deposits on the inner wall of arteries transient ischemic attack (TIA) — temporary interruption of blood flow to the brain with symptoms similar to that of an ischemic stroke but with no permanent effects

Three Regions of Brain Cerebrum Cerebellum Brain Stem Graphic illustrations credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.

Cerebrum Thought Memory Personality Speech Motor function Vision Tactile impulses (touch)

Cerebellum Regulates & coordinates muscle activity & balance Receives impulses from eyes, ears, peripheral joints, muscles

Brain Stem Heart function Respiration Autonomic nervous system Digestion Glandular secretions Connects brain to spinal cord

Take a tour of the brain Stroke Association

The Nervous System The nervous system is comprised of billions of nerve cells, called neurons. Neurons sense stimuli, relay impulses, and send impulses to muscles to help the body react to stimuli. The nervous system is composed of the Central Nervous System (CNS) and Peripheral Nervous System (PNS). The CNS is comprised of the brain and the spinal cord. The PNS is comprised of rest of the nerve cells throughout the body. The PNS is literally “the eyes and ears” of the central nervous system.

The Nervous System The nervous system is composed of the Central Nervous System (CNS) and Peripheral Nervous System (PNS). CNS: brain & spinal cord PNS: the rest of the nerve cells throughout the body The peripheral nervous system is broken down into two parts: a voluntary system and an involuntary system.

The Nervous System Voluntary system – also called the Somatic Nervous System, the voluntary portion of the PNS controls muscular movement Involuntary system – also called the Autonomic Nervous System, the involuntary portion of the PNS controls everything which we cannot consciously control ourselves – heart rate, respiratory rate*, digestion, pupil dilation, and many others The Autonomic Nervous System is further broken down into the Sympathetic and Parasympathetic Nervous Systems * Respiratory Rate has both voluntary and involuntary controls

Common Neurologic Emergencies Stroke Ischemic Hemorrhagic

Types of Stroke Ischemic: A blockage caused by a clot. This is the most common type of stroke.

Types of Stroke Hemorrhagic: A rupture caused by a break in a blood vessel. Less common than ischemic stroke but often has higher mortality.

Clot-busting drugs are time sensitive Ischemic Stroke Thrombus Clot that develops at site of blockage Near area of plaque Causes a sudden occlusion Sudden onset of neurological deficits Clot-busting drugs are time sensitive

Ischemic Stroke Embolus Clot floats to site to form a blockage Circulates in bloodstream until it gets stuck in a smaller artery

Hemorrhagic Stroke Ruptured blood vessel on surface of the brain (subarachnoid) Ruptured blood vessel within brain (intracerebral) Puts pressure on the brain

Time lost is brain lost; seconds count. Types of Stroke Both types of stroke Prevent oxygenated blood from reaching the brain tissues May have only minutes to get patient to definitive treatment Time lost is brain lost; seconds count.

Transient Ischemic Attack A temporary interruption in blood supply to the brain Causes stroke-like symptoms that resolve completely within 24 hours

Risk Factors Hypertension Smoking Age Gender Heredity Prior stroke Diabetes Carotid artery disease Heart disease TIAs

Signs and Symptoms Paralysis or weakness on one side of the body Facial droop on one side Altered level of consciousness Change in personality or mood Headache or dizziness Impaired speech Blurred vision Poor coordination

Aneurysms A common cause of a ruptured artery in the brain is an abnormality or weakness in the vascular wall called an aneurysm

Altered Mental Status Any number of medical emergencies or conditions can cause an alteration in a patient’s mental status trauma disturbances in oxygen flow to the brain electrolyte imbalances presence of intoxicants or poisons, too much or too little glucose in the blood psychiatric disorders serious infections

Seizures A seizure can have many different presentations. Most often, it is a convulsion of the muscles of the body. Tonic-Clonic Partial Febrile

Seizure Disorders Seizures – electrical storm in the brain Epilepsy Tumor (benign of cancerous) Infections such as meningitis, encephalitis or AIDS Scar tissue from injury Head trauma Stroke Hypoxia Abnormal blood chemistry Hypoglycemia Poisoning Use of illegal street drugs like cocaine or amphetamines Drug overdose Alcohol/medication withdrawal Sudden high fever

Seizure Disorders Status Epilepticus – life-threatening Acute, prolonged epileptic crisis Seizure can last longer than 5 minutes and/or many seizures & does not wake up between seizures Medical emergency – requires quick medical treatment & ALS intervention Complications include: airway compromise dysfunction of the heart or lungs metabolic changes increase in body temperature irreversible brain injury

Headaches Your History and Physical Exam, including Vital Signs, will help clarify whether this a nuisance or a medical emergency

Initial Assessment Determine SICK or NOT SICK early in the call SICK

Physical Exam A SICK patient is one who can die quickly unless you initiate aggressive BLS and ALS treatment and rapid transport. A NOT SICK patient is one who can be ill or injured, but not severely enough to be life threatening right now. ABC’s Skin Signs Work of breathing The FEEL of the pt’s pulse – not the Pulse Ox. HR Reading! Overall Appearance

Physical Exam Key Clinical Indicators Relative to stroke Pulse Respirations Mental status Skin signs and color Overall Appearance Relative to stroke Baseline vital signs FAST exam Blood glucometry SICK or NOT SICK?

FAST F – Facial droop A – Arm drift S – Speech T - Time Based on Cincinnati Prehospital Stroke Scale F – Facial droop A – Arm drift S – Speech T - Time Accurate in identifying patients with stroke An abnormal finding in ANY three tests strongly suggests a stroke

FAST

Video FAST Exam

Time of Onset Determine time of onset – time patient was last known to be normal Keep scene times very short…goal is 15 minutes Be aware of time it takes for the hospital staff to assess and administer thrombolytic therapy Clot-busting drugs are time sensitive and must be given as early as possible

Patient History Stroke patients often report loss of motor function and/or a change in speech pattern Some experience altered LOC SAMPLE history to determine if there is a history of: Hypertension Blood thinners or anticoagulants Arteriovenous malformation (AVM) Cerebral aneurysm Prior stroke

Chief complaint and time of onset are key in the Patient History Chief complaint and time of onset are key in the assessment of stroke.

Care for Stroke Protect airway Ensure adequate respirations Remove secretions that can be aspirated Provide ventilation assistance Proper positioning Administer oxygen if saturation level is below 95% or there are signs of hypoxia Candidate for clot-busting therapy? Initiate immediate & rapid transport to appropriate medical facility

When possible…keep scene time to 15 minutes Short Scene Times Victims of stroke often deny or rationalize their symptoms Patients eligible for clot-busting drugs must be transported immediately Notify hospital that possible stroke patient is en route Avoid delays if patient waited before calling for help When possible…keep scene time to 15 minutes

Latest Treatments tPA FDA approved clot buster medication May reduce long-term disability Intra-atrial clot removal Does not have time limit Restores blood flow by removing blood clots View the video Revascularization of occluded vessels Uses suction to grab blood clots Effective if used within 8 hours of symptom onset

Seizures - Emergency Care Basic Life Support care includes: Once patient is awake, perform examination to determine if any injuries occurred or if any neurologic abnormalities exist During seizure, position patient on his/her side Maintain the airway Protect patient from injury During and after seizure, provide oxygen Perform blood glucometry Obtain oximetry reading after seizure Advanced Life Support indicators include: Multiple seizures (status epilepticus) Single seizure lasting longer than 5 minutes or more than 15 minutes postictal with no improvement in level of consciousness Seizure due to hypoglycemia Seizure due to hypoxia Seizure following head trauma Drug or alcohol associated seizure Pregnant female

Headaches - Primary Tension – most common type headache Causes Tight muscles in shoulders, neck, scalp, jaw Related to stress, depression, anxiety

EMS gets called – perform thorough Headaches - Migraine Pain – intense pulsing or throbbing in one area of head Aura – visual disturbance May see spots, dots, zigzag lines Temporary loss of vision Nausea, vomiting can occur EMS gets called – perform thorough exam and physical

Patients with these type symptoms Need hospital evaluation Headaches - Secondary Rare causes of headaches Brain infection Brain tumor Stroke TIA Neurologic symptoms – consider ALS Weakness Sensory Altered LOC “Worst headache of my life” Patients with these type symptoms Need hospital evaluation

Summary Three regions of the brain are cerebrum, cerebellum and brain stem Two basic types of stroke are ischemic (blockage) and hemorrhagic (rupture) Ischemic stroke can be caused by a thrombus which is a clot that forms in a cerebral artery or an embolus which is a clot that travels to the brain

Summary Signs and symptoms of stroke include: Paralysis or weakness on one side of the body Facial droop on one side Altered level of consciousness (from confusion to unconsciousness) Change in personality or mood Headache or dizziness Impaired speech Blurred vision Poor coordination

Summary Three tests of the FAST exam are facial droop, arm drift and speech with T for Time Determine last time patient was last known to be normal. This helps determine if a patient meets the time window for clot-busting therapy Short scene and transport times are vital – try to keep scene time to 15 minutes

Summary Seizures can have many causes, including medicines, high fevers, head injuries and certain diseases Most common type of headache - tension headache Migraine a very specific type of headache Pain often described as intense pulsing or throbbing pain in one area of the head Any headache with neurologic symptoms – weakness, sensory, altered LOC warrant consideration of ALS Headache usually develops suddenly & without warning Patient may say, “This is the worst headache of my life.”