Neurological Emergencies. 4 Dr. Maha Al Sedik 2015 Medical Emergency I

Neurological Emergencies Headache Stroke Coma Status epileptics seizure

is a state of unconsciousness in which a person: cannot be awakened; fails to respond normally to painful stimuli, light, or sound; and, does not initiate voluntary actions. Coma

Coma Pathophysiology:  History of present illness is vital to determine the underlying cause.  Determine when the patient was last seen normal.  Evaluate the speed of onset.

is a neurological scale that aims to give a reliable recording about the conscious state of a person. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and15. Glasgow Coma Scale (GCS)

Best eye response (E) Best verbal response (V) Best motor response (M) 4 Eyes opening spontaneously 5 Oriented 6 Obeys commands 3 Eye opening to speech 4 Confused 5 Localizes to pain 2 Eye opening in response to pain 3 Inappropriate words 4 Withdraws from pain 1 No eye opening 2 Incomprehensible sounds 3 Abnormal Flexion 1 None 2 Abnormal Extension 1 No motor response Glasgow Coma Scale (GCS)

brain injury is classified as: Severe, with GCS < 8-9. Moderate, GCS 8 –12. Minor, GCS ≥ 13. Normal :

Management  Support vital functions ( ABC ).  Special attention to the history about the cause.  Administer naloxone if you suspect narcotic overdose.  Patients may need:  Urine and blood analysis.  Radiography.  Computed tomography.  Magnetic resonance imaging.

Neurological Emergencies Headache Stroke Coma Status epileptics seizure

Seizures Incidence:  Account for up to 30% of EMS calls.  In the United States, it is estimated that 4 million people have epilepsy.

Pathophysiology  Sudden firing of neurons.  Signs and symptoms include:  Muscle spasms.  Increased secretions.  Cyanosis.

If a seizure continues for a long time:  Cerebral glucose and oxygen supplies can be depleted.  There can be serious, long term effects, including death.

Try to determine the cause of the seizure.  Medication compliance.  Fever.  Congenital.  Tumor.

Seizures Absence seizures (petit mal seizures) Pseudoseizures partial seizures generalized seizures ( grand mal seizures )

Absence seizures (petit mal seizures)  Typical patient: child.  Patient stops and freezes mid action.  Usually no longer than several seconds.

Pseudo seizures:  Cause is of psychiatric origin.  Triggered by emotional event, stress, lights, or pain.

partial seizures:  Only a limited part of the brain is involved.  Simple partial seizures involve one part of the body.

generalized seizures ( grand mal seizures ): Full body continuous strong jerking movements. It may be caused by psychological trauma. The patient is not pretending.

Other problems associated with the seizure:  Patients who have fallen during a seizure may have a head injury.  Patients having a generalized seizure may also experience incontinence.  Decrease in the oxygen and glucose demand of the brain.

Management:  Remain calm.  Prevent the patient from becoming injured.  Do not place anything in the patient’s mouth.  Loosen the tie.  Let the patient to lie in a recovery position.

 Correct hypoglycemia as needed.  Ventilatory assistance may be necessary.  All patients should be transported.  Be prepared to administer diazepam or lorazepam.

Neurological Emergencies Headache Stroke Coma Status epileptics seizure

 Pathophysiology:  Seizure that lasts longer than 4 to 5 minutes or consecutive seizures without a return to consciousness between seizures.  Refer to local guidelines regarding intervention.  Nearly 20% of patients die.  May result in neurons being damaged or killed.  Goal: stop seizure and ensure adequate ABCs. Status epileptics

Management  Administer a benzodiazepine.  Be prepared to control airway and ventilation.

Reference: AAOS Emergency Care in the Streets 7 th Edition, Caroline Jones & Bartlett, 2012; ISBN 13: Premier Online Package