Chapter 17 Neurologic Emergencies

Chapter 17 Neurologic Emergencies

National EMS Education Standard Competencies (1 of 3)
Medicine Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. National EMS Education Standard Competencies Medicine Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient.

Neurology Anatomy, presentations, and management of Decreased level of responsiveness Seizure Stroke National EMS Education Standard Competencies Neurology Anatomy, presentations, and management of • Decreased level of responsiveness • Seizure • Stroke

Neurology (cont’d) Anatomy, physiology, pathophysiology, assessment, and management of Stroke/transient ischemic attack Seizure Status epilepticus Headache National EMS Education Standard Competencies Anatomy, physiology, pathophysiology, assessment, and management of • Stroke/transient ischemic attack • Seizure • Status epilepticus • Headache

Introduction (1 of 4) Stroke is the fifth-leading cause of death and the leading cause of adult disability in the United States. Common in geriatric patients Lecture Outline I. Introduction A. Stroke is the fifth-leading cause of death and the leading cause of adult disability in the United States, according to the American Stroke Association. 1. It is common in geriatric patients.

Introduction (2 of 4) Other contributing factors for stroke include family history and race. Treatments are available for stroke. Many hospitals are certified stroke centers. Rapid transport is vital. Lecture Outline 2. Contributing factors for stroke include family history and race. a. African Americans, Hispanics, and Asians have a higher risk of stroke. 3. Treatments are available for stroke. a. Many hospitals are certified stroke centers. b. Rapid transport is vital.

Introduction (3 of 4) Seizures and altered mental status may also occur. Seizures may occur as a result of: A recent or prior head injury A brain tumor A metabolic problem Fever A genetic disposition Lecture Outline B. Seizures and altered mental status may also occur when there is a disorder in the brain. 1. Seizures may occur as a result of: a. A recent or prior head injury b. A brain tumor c. A metabolic problem d. Fever e. A genetic disposition

Introduction (4 of 4) Possible causes of altered mental status include: Intoxication Head injury Hypoxia Stroke Metabolic disturbances Treatment varies widely. Lecture Outline 2. Altered mental status is a common presentation in patients with a wide variety of medical problems. a. Possible causes include: i. Intoxication ii. Head injury iii. Hypoxia iv. Stroke v. Metabolic disturbances b. Treatment varies widely.

Anatomy and Physiology (1 of 7)
The brain is the body’s computer. Controls breathing, speech, and all body functions Three major parts: brain stem, cerebellum, and cerebrum The cerebrum is the largest part. Lecture Outline II. Anatomy and Physiology A. The brain is the body’s computer. 1. It controls breathing, speech, and all other body functions. 2. There are three major parts: brain stem, cerebellum, and cerebrum. a. The cerebrum is the largest part.

The figure on this slide illustrates the three major parts of the brain: the cerebrum, the cerebellum, and the brain stem. © Jones & Bartlett Learning.

The brain stem controls the most basic functions. Breathing, blood pressure, swallowing, pupil constriction The cerebellum controls muscle and body coordination. Walking, writing, picking up a coin, playing piano Lecture Outline b. The brain stem controls the most basic functions. i. Breathing, blood pressure, swallowing, pupil constriction c. The cerebellum controls muscle and body coordination. i. Walking, writing, picking up a coin, playing the piano

The cerebrum is divided into right and left hemispheres. Each controls activities on the opposite side of the body. The front of the cerebrum controls emotion and thought. The middle controls sensation and movement. The back processes sight. Lecture Outline d. The cerebrum, located above the cerebellum, is divided into right and left hemispheres. i. Each controls activities on the opposite side of the body. ii. The front of the cerebrum controls emotion and thought. iii. The middle part controls sensation and movement. iv. The back part processes sight.

In most people, speech is controlled on the left side of the brain near the middle of the cerebrum. Messages sent to and from the brain travel through nerves. Twelve cranial nerves run directly from the brain to parts of the head: eyes, ears, nose, and face. Lecture Outline v. In most people, speech is controlled on the left side of the brain near the middle of the cerebrum. B. Messages sent to and from the brain travel through nerves. 1. Twelve cranial nerves run directly from the brain to parts of the head. a. Eyes, ears, nose, and face

The rest of the nerves join in the spinal cord and exit the brain through a large opening in the base of the skull called the foramen magnum. At each vertebra in the neck and back, two nerves branch out (spinal nerves). These carry signals to and from the body. Lecture Outline 2. The rest of the nerves join in the spinal cord and exit the brain through a large opening in the base of the skull called the foramen magnum. 3. At each vertebra in the neck and back, two nerves branch out. a. These are called spinal nerves. b. They carry signals to and from the body.

The figure on this slide illustrates the intersection of the skull and spinal cord. The spinal cord exits the skull at the foramen magnum, and two nerves branch out of the spinal cord at each vertebra in the neck and back. © Jones & Bartlett Learning.

Pathophysiology (1 of 2) Many different disorders may cause brain dysfunction. May affect the patient’s level of consciousness, speech, and voluntary muscle control The brain is sensitive to changes in oxygen, glucose, and temperature. Lecture Outline III. Pathophysiology A. Many different disorders may cause brain dysfunction and may affect the patient’s: 1. Level of consciousness 2. Speech 3. Voluntary muscle control B. The brain is most sensitive to changes in oxygen, glucose, and temperature levels.

Pathophysiology (2 of 2) General rule:
If a problem is caused primarily by disorders in the heart and lungs, the entire brain is affected. If the primary problem is in the brain, only part of the brain is affected. Lecture Outline 1. A significant change in any one of these levels will result in a neurologic change. 2. General rule: a. If a problem is caused primarily by disorders in the heart and lungs, the entire brain will be affected. b. If the primary problem is in the brain, only part of the brain is affected.

Headache (1 of 6) One of the most common complaints
Can be a symptom of another condition or a neurologic condition on its own Only a small percentage of headaches are caused by a serious medical condition. Lecture Outline IV. Headache A. One of the most common complaints you will hear from your patients in terms of pain is headache. 1. Headache can be a symptom of another condition or it can be a neurologic condition on its own. 2. Only a small percentage of headaches are caused by a serious medical condition.

Headache (2 of 6) Tension headaches, migraines, and sinus headaches are the most common. Not life-threatening Lecture Outline B. Tension headaches, migraines, and sinus headaches are the most common types. 1. These are not life threatening.

Headache (3 of 6) Tension headaches
Caused by muscle contractions in the head and neck Attributed to stress Pain is usually described as squeezing, dull, or as an ache. Usually do not require medical attention Lecture Outline 2. Tension headaches a. These headaches are caused by muscle contractions in the head and neck and are attributed to stress. b. The pain is usually described as squeezing, dull, or as an ache. c. Usually do not require medical attention

Headache (4 of 6) Migraine headaches
Thought to be caused by changes in blood vessel size in the base of the brain. Experienced by both adults and children Pain is usually described as pounding, throbbing, and pulsating. Often associated with nausea and vomiting, and may be preceded by visual changes Can last for several hours or days Lecture Outline C. Migraine headaches 1. They are thought to be caused by changes in the blood vessel size in the base of the brain. 2. Both adults and children can experience migraines. 3. Women are three times as likely as men to experience migraines. 4. The pain is usually described as pounding, throbbing, and pulsating. 5. Migraines are often associated with nausea and vomiting and may be preceded by visual warning signs such as flashing lights or partial vision loss. 6. Migraine headaches can last for several hours to days.

Headache (5 of 6) Sinus headaches
Caused by pressure that is the result of fluid accumulation in the sinus cavities Patients may also have cold-like symptoms of nasal congestion, cough, and fever. Prehospital emergency care is not required. Lecture Outline D. Sinus headaches are caused by pressure that is the result of fluid accumulation in the sinus cavities. 1. Patients may also have cold-like signs and symptoms of nasal congestion, cough, and fever. 2. Prehospital emergency care is not required.

Headache (6 of 6) Serious conditions that include headache as a symptom are hemorrhagic stroke, brain tumor, and meningitis. Be concerned if patient complains of a sudden-onset, severe headache or a sudden headache that has associated symptoms. Suspect stroke in patients with a severe headache, seizures, and altered mental status. Increasing ICP may be caused by a hemorrhagic stroke, tumor, or recent head trauma. Lecture Outline E. Serious conditions that include headache as a symptom are hemorrhagic stroke (bleeding in the brain), brain tumor, and meningitis. 1. You should be concerned if the patient complains of a sudden-onset, severe headache or a sudden-onset headache that has associated symptoms. 2. You should suspect a stroke in patients with a severe headache, seizures, and altered mental status. 3. Signs of increased intracranial pressure (ICP) include headache, vomiting, altered mental status, and seizures. 4. Increasing ICP may be caused by a hemorrhagic stroke, tumor, or recent head trauma. 5. Your patient assessment should include asking the patient if he or she has experienced any recent head trauma. 6. Consider not using lights and siren during transport.

Stroke (1 of 2) Also called a cerebrovascular accident (CVA)
Interruption of blood flow to an area within the brain Results in the loss of brain function Lacking oxygen, brain cells stop functioning and begin to die within minutes. Once the brain cells die, not much can be done. Lecture Outline V. Stroke A. A cerebrovascular accident (CVA), or stroke, is an interruption of blood flow to an area within the brain that results in the loss of brain function. 1. Lacking oxygen, brain cells stop functioning and begin to die within minutes. 2. Once brain cells die, not much can be done.

Stroke (2 of 2) Brain cells develop ischemia, causing them to stop functioning properly. It may take several hours or more for cell death to occur. With prompt restoration of blood flow, the cells will not die, and function can be preserved or restored. There are two main types of stroke: ischemic and hemorrhagic. Lecture Outline 3. Brain cells develop ischemia, the reduction in blood supply that results in inadequate oxygen being supplied to the cells, causing those cells to stop functioning properly. 4. It may take several hours or more for cell death to occur, because small trickles of blood may be keeping ischemic cells alive. 5. With prompt restoration of blood flow, the cells will not die, and function can be preserved or restored. B. Types of stroke 1. There are two main types of stroke: ischemic and hemorrhagic. a. An ischemic stroke occurs when blood flow through the cerebral arteries is blocked. b. In hemorrhagic stroke, a blood vessel ruptures and the accumulated blood causes increased pressure in the brain.

Ischemic Stroke (1 of 2) Most common, accounting for more than 80% of strokes Results from thrombosis or an embolus Symptoms may range from nothing at all to complete paralysis. Atherosclerosis in the blood vessels is often the cause. Lecture Outline 2. Ischemic stroke a. Most common, according to the American Stroke Association, accounting for more than 80% of strokes b. When blood flow to a particular part of the brain is stopped by a blockage (blood clot) inside a blood vessel c. This blockage can be due to thrombosis, where a clot forms at the site of blockage, or due to an embolus, where the clot forms in a remote area and then travels to the site of blockage. d. Symptoms may range from nothing at all to complete paralysis. e. Atherosclerosis in the blood vessels is often the cause of ischemic stroke.

Ischemic Stroke (2 of 2) Atherosclerosis
Plaque forms inside the walls of the blood vessels and may obstruct blood flow. Eventually, it causes complete occlusion of an artery. Lecture Outline i. Disorder in which calcium and cholesterol build up, forming a plaque inside the walls of the blood vessels ii. This plaque may obstruct blood flow and interfere with the vessel’s ability to dilate. iii. Eventually, it causes complete occlusion of an artery. iv. Even if the blockage in the carotid artery is not complete, smaller pieces of the clot may embolize deep into the brain and become lodged in a smaller branch of a blood vessel, blocking blood flow. © Jones & Bartlett Learning.

Hemorrhagic Stroke (1 of 3)
Accounts for 13% of strokes. Results from bleeding inside the brain Cerebral hemorrhages are often fatal. People at high risk include those experiencing stress or exertion. People at highest risk are those who have very high blood pressure. Lecture Outline 3. Hemorrhagic stroke a. Accounts for 13% of strokes, according to the American Stroke Association. b. Results from bleeding inside the brain i. Blood forms a clot, which compresses the brain tissue next to it. ii. This compression prevents oxygenated blood from getting into the area, and the brain cells begin to die. c. Cerebral hemorrhages are often fatal. d. People at high risk include those experiencing stress or exertion. e. People at highest risk are those who have very high blood pressure or long-term elevated blood pressure that is not treated. i. Blood vessels in the brain weaken. ii. If a vessel ruptures, the bleeding in the brain will increase the pressure inside the cranium.

Aneurysm Swelling or enlargement of the wall of an artery resulting from a defect or weakening of the arterial wall Lecture Outline f. An aneurysm is a swelling or enlargement of the wall of an artery resulting from a defect or weakening of the arterial wall. © Jones & Bartlett Learning.

Symptom may be the sudden onset of a severe headache When a hemorrhagic stroke occurs in an otherwise healthy young person, it is likely caused by a berry aneurysm. Surgical repair may be possible if care is sought immediately. Lecture Outline g. A symptom may be the sudden onset of a severe headache. h. When a hemorrhagic stroke occurs in an otherwise healthy young person, it is likely caused by a weakness in a blood vessel called a berry aneurysm. i. Surgical repair may be possible if care is sought immediately.

Transient Ischemic Attack (TIA) (1 of 2)
When blood flow to the brain is obstructed due to atherosclerosis or a small blood clot, the patient may exhibit signs of a stroke. When stroke-like symptoms go away on their own in less than 24 hours, the event is called a TIA. No actual death of tissue occurs with a TIA. Lecture Outline 4. Transient ischemic attack (TIA) a. When blood flow to the brain is obstructed due to atherosclerosis or a small blood clot, the patient may exhibit signs of a stroke. b. When stroke-like symptoms go away on their own in less than 24 hours, the event is called a transient ischemic attack. i. Some patients call these mini-strokes. c. No actual death of tissue occurs with a TIA.

Transient Ischemic Attack (TIA) (2 of 2)
Symptoms of a TIA can last up to 24 hours, May not be able to differentiate between a stroke and a TIA Every TIA is an emergency. May be a warning sign that a more significant stroke may occur in the future All patients with a TIA should be evaluated by a physician. Lecture Outline d. Because symptoms of a TIA can last up to 24 hours, you may not be able to differentiate between a stroke and a TIA. e. Although most patients with TIAs do well, every TIA is an emergency. f. It may be a warning sign that a more significant stroke may occur in the future. i. About one third of patients who have a TIA will experience a stroke soon after. ii. All patients with a TIA should be evaluated by a physician.

Signs and Symptoms of Stroke (1 of 4)
Facial drooping Sudden weakness or numbness in the face, arm, leg, or one side of body Decreased or absent movement and sensation on one side of the body Lack of muscle coordination (ataxia) or loss of balance Lecture Outline C. Signs and symptoms of stroke 1. General signs and symptoms include the following: a. Facial drooping b. Sudden weakness or numbness in the face, arm, leg, or one side of the body c. Decreased or absent movement and sensation on one side of the body d. Lack of muscle coordination (ataxia) or loss of balance

Sudden vision loss in one eye Blurred and double vision Difficulty swallowing Decreased level of responsiveness Speech disorders Lecture Outline e. Sudden vision loss in one eye, or blurred and double vision f. Difficulty swallowing g. Decreased level of responsiveness h. Speech disorders

Aphasia Difficulty expressing thoughts or inability to use the right words (expressive aphasia) Difficulty understanding spoken words (receptive aphasia) Slurred speech (dysarthria) Sudden and severe headache Confusion Dizziness Lecture Outline i. Aphasia: difficulty expressing thoughts or inability to use the right words (expressive aphasia) or difficulty understanding spoken words (receptive aphasia) j. Slurred speech (dysarthria) k. Sudden and severe headache l. Confusion m. Dizziness

Weakness Combativeness Restlessness Tongue deviation Coma Lecture Outline n. Weakness o. Combativeness p. Restlessness q. Tongue deviation r. Coma

Left Hemisphere Stroke in the left cerebral hemisphere may cause aphasia. Inability to produce or understand speech Speech problems can vary widely. Stroke may also cause paralysis of the right side of the body. Lecture Outline 2. Left hemisphere a. Stroke in the left cerebral hemisphere may cause aphasia. i. Aphasia is the inability to produce or understand speech. ii. Speech problems can vary widely. b. Strokes that affect the left side of the brain can also cause paralysis of the right side of the body.

Right Hemisphere Stroke may cause paralysis of the left side of the body. Usually, patients can understand language and are able to speak Words may be slurred Patients may be oblivious to their problem (neglect). Neglect and lack of pain cause many patients to delay seeking help. Lecture Outline 3. Right hemisphere a. Strokes that affect the right side of the brain can cause paralysis of the left side of the body. b. Usually, patients will understand language and be able to speak, but their words may be slurred and hard to understand. c. Patients may be oblivious to their problem; this symptom is called neglect. i. Patients with a problem affecting the back part of the cerebrum may neglect certain parts of their vision. d. Neglect and lack of pain cause many patients to delay seeking help.

Bleeding in the Brain Patients may have high blood pressure.
May be the cause of the bleeding May be caused by the bleeding, as a compensatory response Increasing blood pressure is an important sign. Significant drops in blood pressure may occur as the patient’s condition worsens. Monitor the blood pressure for changes. Lecture Outline 4. Bleeding in the brain a. Patients may have very high blood pressure. i. May be the cause of the bleeding ii. May be caused by the bleeding, as a compensatory response b. A trend of increasing blood pressure is an important sign, as the body must increase the blood pressure to get blood to the brain’s tissues. c. Significant drops in blood pressure may occur as the patient’s condition worsens. d. Monitoring the blood pressure for changes in these patients is very important.

Conditions That May Mimic Stroke (1 of 2)
Hypoglycemia Not enough blood glucose Postictal state Period following seizure that lasts between 5 and 30 minutes Characterized by labored respirations and some degree of altered mental status Subdural or epidural bleeding Blood near the skull presses on the brain Lecture Outline D. Conditions that may mimic stroke 1. Hypoglycemia a. Not enough blood glucose 2. Postictal state a. Period following seizure that lasts between 5 and 30 minutes, characterized by labored respirations and some degree of altered mental status 3. Subdural or epidural bleeding a. A collection of blood near the skull that presses on the brain

Conditions That May Mimic Stroke (2 of 2)
The figure on this slide illustrates intracranial bleeding. Trauma to the head may result in intracranial bleeding. Bleeding outside the dura and under the skull is called epidural bleeding, and bleeding beneath the dura but outside the brain is called subdural bleeding. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Seizures A neurologic episode caused by a surge of electrical activity in the brain Can take the form of a convulsion and/or can be associated with a temporary alteration in consciousness. Two basic groups: generalized and partial (focal). Lecture Outline VI. Seizures A. A seizure is a neurologic episode caused by a surge of electrical activity in the brain. 1. Can take the form of a convulsion, characterized by generalized uncoordinated muscle activity, and/or can be associated with a temporary alteration in consciousness. 2. In the United States, it is estimated that 2 to 3 million people have epilepsy, a common cause of seizures. 3. Seizures are classified into two basic groups: generalized and partial (focal).

Generalized Seizure Results from abnormal electrical discharges from large areas of the brain Typically characterized by unconsciousness and a generalized severe twitching of all muscles lasting several minutes or longer. May simply be characterized by a brief lapse of consciousness. Does not involve any changes in motor activity Lecture Outline 4. Generalized (tonic-clonic) seizure a. This type of seizure results from abnormal electrical discharges from large areas of the brain, usually involving both hemispheres. b. Typically characterized by unconsciousness and a generalized severe twitching of all muscles that lasts several minutes or longer. c. In other cases, the seizure may simply be characterized by a brief lapse of consciousness in which the patient seems to stare and not respond to anyone. i. This type of seizure does not involve any changes in motor activity. ii. Called a petit mal or absence seizure

Partial Seizure (1 of 2) Simple partial seizure
No change in the patient’s level of consciousness May have numbness, weakness, dizziness, visual changes, or unusual smells/tastes May have some twitching or brief paralysis Lecture Outline 5. Partial (focal) seizure a. Begins in one part of the brain and is classified as simple or complex b. Simple partial seizure i. No change in the patient’s level of consciousness ii. Patients may have numbness, weakness, dizziness, visual changes, or unusual smells and tastes iii. May also cause some twitching or brief paralysis

Partial Seizure (2 of 2) Complex partial seizure Altered mental status
Results from abnormal discharges from the temporal lobe of the brain Lip smacking, eye blinking, isolated jerking Unpleasant smells, visual hallucinations, uncontrollable fear, repetitive physical behavior Lecture Outline c. Complex partial seizure i. The patient has an altered mental status and does not interact normally with his or her environment. ii. Results from abnormal discharges from the temporal lobe of the brain iii. Other characteristics may be lip smacking, eye blinking, and isolated jerking. iv. Patients also may experience unpleasant smells and visual hallucinations, exhibit uncontrollable fear, or perform repetitive physical behavior.

Aura Patients may experience an aura prior to a seizure.
Can include visual changes or hallucinations People with a history of seizures recognize their auras and usually take steps to minimize injury. Auras do not occur prior to every seizure, and not all patients with a seizure disorder experience an aura. Lecture Outline 6. Patients may experience an aura prior to a seizure. a. Can include visual changes (flashing lights or blind spots in the field of vision) or hallucinations (seeing, hearing, or smelling things that are not actually present). b. People with a history of seizures recognize their auras and usually take steps to minimize injury, such as sitting or lying down. c. Auras do not occur prior to every seizure, and not all patients with a seizure disorder experience an aura.

Generalized Seizure (1 of 2)
Characterized by sudden loss of consciousness, chaotic muscle movement and tone, and apnea. May exhibit bilateral muscle movement characterized by a cycle of muscle rigidity and relaxation, usually lasting 1 to 3 minutes. Lecture Outline 7. Generalized seizure a. Characterized by sudden loss of consciousness followed by chaotic muscle movement and tone, and apnea. b. During a generalized seizure, a patient may exhibit bilateral muscle movement characterized by a cycle of muscle rigidity and relaxation usually lasting 1 to 3 minutes.

Generalized Seizure (2 of 2)
Tachycardia, hyperventilation, sweating, and intense salivation Most seizures last 3 to 5 minutes. Postictal state (5 to 20 minutes) follows. Gradual return to consciousness Lecture Outline i. The patient exhibits tachycardia, hyperventilation, sweating, and intense salivation. ii. Most seizures last 3 to 5 minutes. iii. A postictal state (5 to 30 minutes) follows, in which the patient is unresponsive at first and gradually regains consciousness.

Absence Seizure Formerly called petit mal May last for seconds
Patient fully recovers with a brief lapse of memory Lecture Outline 8. In contrast, an absence (formerly called petit mal) seizure may last for just seconds, after which the patient fully recovers with only a brief lapse of memory of the event.

Status Epilepticus Seizures lasting more than 5 minutes are likely to progress to status epilepticus. Seizures that continue every few minutes without the person regaining consciousness or last longer than 30 minutes are referred to as status epilepticus. Lecture Outline 9. Seizures lasting more than 5 minutes are likely to progress to status epilepticus. a. Seizures that continue every few minutes without the person regaining consciousness or last longer than 30 minutes are referred to as status epilepticus.

Causes of Seizures (1 of 4)
Some seizure disorders are congenital. Others may be caused by high fever, structural problems in the brain, or metabolic or chemical problems. Lecture Outline B. Causes of seizures 1. Some seizure disorders, such as epilepsy, are congenital. 2. Others may be caused by: a. High fever b. Structural problems in the brain c. Metabolic or chemical problems in the body d. Idiopathic (cause cannot be determined) © Jones & Bartlett Learning.

Epileptic seizures usually can be controlled by medications. Levetiracetam (Keppra) Phenytoin (Dilantin) Phenobarbital Carbamazepine (Tegretol) Valproate (Depakote) Topiramate (Topamax) Clonazepam (Klonopin) Lecture Outline 3. Epileptic seizures usually can be controlled with medications. a. Medications used most often to treat seizures include: i. Levetiracetam (Keppra) ii. Phenytoin (Dilantin) iii. Phenobarbital iv. Carbamazepine (Tegretol) v. Valproate (Depakote) vi. Topiramate (Topamax) vii. Clonazepam (Klonopin)

Seizures may be caused by an abnormal area in the brain (structural cause), such as: A benign or cancerous tumor An infection (brain abscess, meningitis) Scar tissue from some type of injury Lecture Outline 4. Seizures may also be caused by an abnormal area in the brain (structural cause), such as: a. A benign or cancerous tumor b. An infection (brain abscess, meningitis) c. Scar tissue from some type of injury

Seizures from a metabolic cause can result from: Abnormal levels of certain blood chemicals Hypoglycemia Poisons Drug overdoses Sudden withdrawal from routine heavy alcohol or sedative drug use Prescribed medications Seizures can also result from sudden high fevers, particularly in children. Lecture Outline 5. Seizures from a metabolic cause can result from: a. Abnormal levels of certain blood chemicals b. Hypoglycemia c. Poisons d. Drug overdoses e. Sudden withdrawal from routine heavy alcohol or sedative drug use f. Prescribed medications 6. Seizures can also result from sudden high fevers, particularly in children. a. Known as febrile seizures b. Always transport a child who has had a febrile seizure for evaluation at a hospital; it is possible a second seizure may occur.

The Importance of Recognizing Seizures (1 of 2)
Recognize when a seizure is occurring and whether this episode differs from previous ones. Patient may turn cyanotic. Seizures may prevent the patient from breathing normally. In a patient with diabetes, the blood glucose level may decrease. If protocol allows, monitor blood glucose levels after a patient with diabetes has a seizure. Lecture Outline C. The importance of recognizing seizures 1. You must recognize when a seizure is occurring and whether this episode differs from previous ones. a. Patient may turn cyanotic from a lack of oxygen in the blood. b. Seizures may prevent the patient from breathing normally. c. In a patient with diabetes, the blood glucose level may decrease. i. If your local protocol allows, closely monitor blood glucose levels after a patient with diabetes has a seizure.

The Importance of Recognizing Seizures (2 of 2)
Look at 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. Lecture Outline 2. You must look at other problems associated with the seizure. a. Patients who have fallen during a seizure may have a head injury. b. Patients having a generalized seizure also may experience incontinence.

The Postictal State (1 of 2)
After a seizure, the muscles relax, becoming almost flaccid, and breathing becomes labored. This breathing pattern helps the body balance the acidity in the bloodstream. With normal circulation and liver function, the patient will begin to breathe more normally within minutes. Lecture Outline D. The postictal state 1. Once a seizure has stopped, the patient’s muscles relax, becoming almost flaccid, or floppy, and the breathing becomes labored (fast and deep). a. This breathing pattern helps the body balance the acidity in the bloodstream. b. With normal circulation and liver function, the patient will begin to breathe more normally within minutes.

The Postictal State (2 of 2)
May be characterized by hemiparesis, resembling a stroke. Most commonly characterized by lethargy and confusion Patient may be combative Be prepared for these circumstances. If the patient’s condition does not improve, consider hypoglycemia or infection. Lecture Outline 2. In some situations, the postictal state may be characterized by hemiparesis, or weakness on one side of the body, resembling a stroke. 3. The postictal state is most commonly characterized by lethargy and confusion. a. The patient may be combative. b. You must be prepared for these circumstances. 4. If the patient’s condition does not improve, you should consider other possible underlying conditions. a. Hypoglycemia b. Infection

Syncope Seizures are often mistaken for syncope, or fainting.
Fainting typically occurs while the patient is standing. Seizures may occur in any position. Fainting is not associated with a postictal state. Lecture Outline E. Syncope 1. Seizures are often mistaken for syncope (fainting). a. Fainting typically occurs while the patient is standing. b. Seizures may occur in any position. c. Fainting is not associated with a postictal state.

Altered Mental Status Aside from stroke and seizures, the most common neurologic emergency Patient is not thinking clearly or is incapable of being aroused In some cases, the patient will be unconscious; in others, the patient may be alert but confused. Lecture Outline VII. Altered Mental Status A. Aside from stroke and seizures, the most common type of neurologic emergency that you will encounter is a patient with an altered mental status. 1. The patient is not thinking clearly or is incapable of being aroused. 2. In some cases, the patient will be unconscious; in others, the patient may be alert but confused.

Causes of AMS (1 of 5) Hypoglycemia
Patients can have signs and symptoms that mimic stroke and seizures. May have hemiparesis A patient who has had a stroke may be alert and attempting to communicate. A patient with hypoglycemia almost always has an altered or decreased LOC. Lecture Outline 3. Causes include: a. Hypoglycemia b. Hypoxemia c. Intoxication d. Delirium e. Drug overdose f. Unrecognized head injury g. Brain infection h. Body temperature abnormality i. Brain tumor j. Overdose and/or poisoning B. Causes of altered mental status 1. Hypoglycemia a. Patients can have signs and symptoms that mimic stroke and seizures. i. In these cases, the patient may have hemiparesis, similar to what occurs as a result of a stroke. ii. The principal difference is that a patient who has had a stroke may be alert and attempting to communicate normally, whereas a patient with hypoglycemia almost always has an altered or decreased level of consciousness.

Causes of AMS (2 of 5) Hypoglycemia (cont’d)
Patients commonly take medications that lower blood glucose level. Patients can also experience seizures. The mental status is not likely to improve, even after several minutes. Consider hypoglycemia in a patient who has AMS after an injury such as a motor vehicle crash. Lecture Outline b. Patients with hypoglycemia commonly, but not always, take medications that lower the blood glucose level. c. Patients with hypoglycemia can also experience seizures. i. The mental status of a patient with hypoglycemia is not likely to improve, even after several minutes. d. Consider hypoglycemia in a patient who has altered mental status after an injury such as a motor vehicle crash.

Causes of AMS (3 of 5) Delirium A symptom, not a disease
Presents as a new complaint Temporary state that may have a physical or mental cause, such as: Infection Changes in medication Hypoxia May be reversed with treatment Lecture Outline 2. Delirium a. Delirium is a symptom, not a disease. b. Presents as a new complaint, rather than a long-standing alteration in behavior. c. Temporary state that often has a physical or mental cause i. Infection ii. Changes in medications iii. Hypoxia d. May be reversed with proper treatment

Causes of AMS (4 of 5) Delirium (cont’d) Signs and symptoms
Rapid alteration between mental states Symptoms may mimic intoxication, drug abuse, or severe psychological disorders. Lecture Outline e. Signs and symptoms include: i. Confusion and disorientation ii. Disorganized thoughts iii. Inattention iv. Memory loss v. Striking changes in personality and affect vi. Hallucinations vii. Delusions viii. Decreased level of consciousness f. The patient may experience rapid alteration between mental states such as lethargy and agitation. g. Symptoms of delirium may mimic intoxication, drug abuse, or severe psychological disorders such as schizophrenia. h. Delirium is discussed in detail in Chapter 35, Geriatric Emergencies.

Causes of AMS (5 of 5) Other causes of AMS
Consideration of other possibilities becomes important because a patient with AMS may be combative and refuse treatment/transport. In most cases, a patient who appears intoxicated is just that. Psychological disorders and medication complications are possible causes. Infections, particularly those involving the brain or bloodstream, may cause AMS. Lecture Outline 3. Other causes of altered mental status a. Consideration of other possibilities becomes important because a patient with altered mental status may be combative and refuse treatment and transport. b. Unrecognized head injury c. In most cases, a patient who appears intoxicated is just that; however, you must consider other problems. d. Psychological disorders and medication complications are also possible causes. e. Infections may cause altered mental status, particularly those involving the brain or bloodstream.

Scene Size-up (1 of 2) Scene safety
Dispatcher may be able to provide a description of the patient’s problem. Patients with AMS may exhibit a wide range of signs, symptoms, and behaviors. Do not be distracted by the seriousness of the situation or frightened family members. Consider the need for spinal immobilization. Lecture Outline VIII. Patient Assessment A. Scene size-up 1. Scene safety a. In some calls to the dispatcher, the description of the patient’s signs and symptoms will provide a fairly good idea of what the problem may be and the dispatcher will be able to convey this information to the responding crew. b. Patients with altered mental status may exhibit a wide range of signs and symptoms and behaviors. c. The most significant difference between an altered mental status and other emergencies is that your patient cannot tell you reliably what is wrong. d. Do not be distracted by the seriousness of the situation or by frightened family members. e. Look first for threats to your safety, and follow standard precautions. f. Consider the need for spinal immobilization based on dispatch information and your assessment of the scene. g. Call for additional resources early.

Scene Size-up (2 of 2) Mechanism of injury/nature of illness
Look for clues to determine the NOI. Special considerations for a patient with a suspected neurologic emergency: An evaluation of the environment for signs of potential trauma Indications of a previous medical condition Evidence of a seizure Ask family when was the last time the patient appeared normal Lecture Outline 2. Mechanism of injury/nature of illness a. Look for clues to help you determine the nature of illness. b. There are special considerations for a patient with a suspected neurologic emergency: i. An evaluation of the environment, assessing for any signs of potential trauma ii. Indications of a previous medical condition iii. Evidence of a seizure iv. Ask family when was the last time the patient appeared normal.

Primary Assessment (1 of 5)
Look for and treat life-threatening conditions. Perform a rapid exam. As you approach the patient: Gather information from the scene. Note the patient’s body position and LOC. Initial impression will help you determine the severity of the situation. You should be able to tell if a seizure took place. Use the AVPU scale. Lecture Outline B. Primary assessment 1. Remember that your first priority is to look for and treat life-threatening conditions. 2. Perform a rapid exam. 3. As you approach the patient: a. Gather information from the scene. b. Note the patient’s body position and level of consciousness. c. This initial impression will help you determine the severity of the situation d. You should be able to tell if a seizure is still taking place. i. Unless you are stationed extremely close to the scene, most seizures will be over by the time you arrive. ii. If the seizure is still occurring, status epilepticus may be present. e. Use the AVPU scale.

Airway and breathing Patients may have difficulty swallowing and choke on their own saliva. Be prepared to provide suction. Position the patient to prevent aspiration. Check for foreign body obstruction. Assess the patient’s breathing. All patients with an AMS, regardless of the cause, should receive high-flow oxygen. Lecture Outline 4. Airway and breathing a. Stroke patients may have difficulty swallowing and are at risk for choking on their own saliva. b. Evaluate the airway of an unresponsive patient to make sure it is patent and will remain so. c. Be prepared to provide suction. d. Position the patient to prevent aspiration. e. Check for foreign body obstruction. f. Assess the patient’s breathing. i. All patients with an altered mental status, regardless of the cause, should receive high-flow oxygen.

Airway and breathing (cont’d) Ventilate the patient at proper rate with proper volume. Deliver each breath during a period of 1 second at a rate of 10 to 12 breaths/min. Do not hyperventilate the patient. Hyperventilation may have negative consequences. Decrease in cardiac output Risk of regurgitation and aspiration Further injury to the brain in patients with intracerebral bleeding and increased intracranial pressure Lecture Outline g. It is important to ventilate the patient at the appropriate rate with the proper volume. i. Deliver each breath during a period of 1 second at a rate of 10 to 12 breaths/min. ii. Do not hyperventilate the patient. h. Hyperventilation may have several negative consequences. i. Overinflates the lungs, which can impair blood return to the right atrium and cause a decrease in cardiac output ii. Increases the risks of regurgitation and aspiration. iii. May cause severe injury in patients with intracerebral bleeding and increased intracranial pressure, causing cerebral vasoconstriction, which shunts blood (and oxygen) away from the brain, causing further injury to the brain.

Circulation Check the pulse if the patient is unresponsive. If no pulse is found, immediately begin CPR and attach an AED. If the patient is responsive, determine if the pulse is fast or slow, weak or strong. Evaluate the patient quickly for external bleeding. Lecture Outline 5. Circulation a. Begin by checking the pulse if the patient is unresponsive. b. If no pulse is found, immediately begin CPR and attach an AED. c. If the patient is responsive, determine if the pulse is fast or slow, weak or strong. d. Evaluate the patient quickly for external bleeding.

Transport decision Establish priorities based on your assessment of the patient’s LOC and ABCs. If the patient is experiencing a stroke, rapidly transport to an appropriate facility. Lecture Outline 6. Transport decision a. Establish your priorities based on your assessment of the patient’s level of consciousness and ABCs. b. If you suspect the patient is having a stroke, you should rapidly transport the patient to an appropriate facility.

History Taking (1 of 2) Investigate the chief complaint.
For unresponsive patients, gather any history from family or bystanders. If no one is around, quickly look for explanations for the AMS. Stroke (hemiparalysis or one-sided weakness) Seizure (incontinence or bitten tongue) Ask a responsive patient what happened. Evaluate a responsive patient’s speech. Lecture Outline C. History taking 1. Investigate the chief complaint. a. If the patient is unresponsive, gather any history of the present illness from family or bystanders. b. If no one is around, quickly look for explanations for the altered mental status, such as a stroke (hemiparalysis or one-sided weakness) or seizure (incontinence or bitten tongue). c. In a responsive patient, ask him or her what happened. d. Evaluate the patient’s speech.

History Taking (2 of 2) Gather a SAMPLE history. Time is critical.
Try to determine the exact time the patient last appeared healthy. Collect or list all medications. Ask if the patient has a history of seizures. Ask if this episode differs from previous episodes and what medications the patient takes. If not, a serious condition should be suspected. Lecture Outline e. Gather a SAMPLE history. i. Remember that time can be critical in a neurologic emergency. ii. Make a special effort to determine the exact time that the patient last appeared to be healthy. iii. Collect or list all medications the patient has taken. iv. Patients who have had a stroke may appear to be unconscious and unable to speak, but they may still be able to hear and understand what is taking place. v. Try to establish effective communication. vi. Your history should reveal if the patient has a history of seizures. vii. Find out if this episode differs from previous episodes and what medications the patient takes. a. Note medications used to treat a seizure disorder. viii. If the patient does not have a history, a serious condition should be suspected.

Secondary Assessment (1 of 10)
Physical examinations Full-body secondary assessment, paying special attention to the system involved If you suspect your patient is having a stroke, direct particular attention to your neurologic assessment. Lecture Outline D. Secondary assessment 1. Physical examinations a. Your assessment should continue with a secondary assessment of the entire body, paying special attention to the system involved. b. If you suspect your patient is having a stroke, direct particular attention to your neurologic assessment.

Vital signs Significant intracranial bleeding leads to a great deal of pressure in the skull, compressing the brain. Slows the pulse and causes erratic respirations Blood pressure is usually high to compensate for poor perfusion. Unequal pupil size and reactivity indicate significant bleeding and pressure on the brain. Lecture Outline 2. Vital signs a. Patients with significant intracranial bleeding may have a great deal of pressure in the skull that is compressing the brain. i. This slows the pulse and causes respirations to be erratic. ii. Blood pressure is usually high to compensate for poor perfusion in the brain. iii. Unequal pupil size and reactivity indicate significant bleeding and pressure on the brain.

Vital signs (cont’d) If the patient has an AMS, check the blood glucose level. During most active seizures, it is impossible to evaluate vital signs and this should not be your priority In most cases, vital signs of a patient in a postictal state will be close to normal limits. Lecture Outline b. If the patient has an altered mental status, you should check the glucose level if you have the equipment available. c. During most active seizures, it is impossible to evaluate vital signs and this should not be your priority. d. In most cases, vital signs of a patient in a postictal state will be close to normal limits. e. Monitoring devices i. Use a portable blood glucose monitor to check blood glucose levels. ii. You may also use noninvasive blood pressure methods to monitor blood pressure.

Stroke Assessment Rapidly identify stroke in the field with a stroke scale. Stroke scales evaluate the face, arms, and speech. Cincinnati Prehospital Stroke Scale Los Angeles Prehospital Stroke Screen 3-Item Stroke Severity Scale (LAG) Looks at level of consciousness, arm drift (motor function), and gaze. Lecture Outline 3. Stroke assessment a. Rapidly identify stroke in the field with a stroke scale. b. Stroke scales evaluate the face, arms, and speech. c. The Cincinnati Prehospital Stroke Scale and the Los Angeles Prehospital Stroke Screen are commonly used. i. To test speech, ask the patient to repeat a simple phrase. ii. To test facial movement, ask the patient to smile, showing his or her teeth. iii. To test arm movement, ask the patient to hold both arms in front of his or her body, palms up toward the sky, with eyes closed and without moving. d. 3-Item Stroke Severity Scale (LAG) i. Looks specifically at three items—level of consciousness, arm drift (motor function), and gaze.

FAST mnemonic Facial droop Arm drift Speech Time Lecture Outline e. FAST mnemonic i. Facial droop ii. Arm drift iii. Speech iv. Time (the time the patient last acted normally)

The table on this slide displays the Cincinnati Prehospital Stroke Scale. © Jones & Bartlett Learning.

The table on this slide displays the Los Angeles Prehospital Stroke Screen. © Jones & Bartlett Learning.

The table on this slide displays the 3-Item Stroke Severity Scale (LAG). © Jones & Bartlett Learning.

All patients with an AMS should also have a Glasgow Coma Scale (GCS) score calculated. Lecture Outline f. All patients with an altered mental status should also have a Glasgow Coma Scale (GCS) score calculated.

The table on this slide displays the Glasgow Coma Scale (GCS). © Jones & Bartlett Learning.

Reassessment (1 of 4) Focus on reassessing the ABCs, vital signs, and interventions. Stroke patients can lose airway or stop breathing without warning. Interventions Multiple interventions may be necessary. Lecture Outline E. Reassessment 1. Focus on reassessing the ABCs, vital signs, and interventions provided so far. a. Patients who have had a stroke can lose their airway or stop breathing without warning. 2. Interventions a. Multiple interventions may be necessary.

Reassessment (2 of 4) Interventions (cont’d)
Airway adjuncts Positive-pressure ventilations Other treatments Compare baseline information with updated information. Notify the receiving facility of patient’s chief complaint and assessment findings. Lecture Outline i. Airway adjuncts ii. Positive-pressure ventilations iii. Other treatments iv. If an intervention is not working, try something else. b. Compare baseline information with updated information. c. Notify the receiving facility of your patient’s chief complaint and your assessment findings.

Reassessment (3 of 4) Communication and documentation
Call a “stroke alert” to designated stroke centers. Be sure to communicate: Time that the patient was last seen healthy Findings of your neurologic examination Time you anticipate arriving at the hospital Lecture Outline i. Local protocol will tell you if the designated stroke centers in your call area want you to call in a “stroke alert” for patients you have assessed and found to be having a stroke. ii. Report the time the patient last appeared to be healthy. iii. Report the findings of your neurologic examination and the time you anticipate arriving at the hospital.

Reassessment (4 of 4) Communication and documentation (cont’d)
For patients who have had a seizure, give a description of the seizure activity if known. If the patient has a history of seizure activity, determine how often the seizures occur and if there is any history of status epilepticus. Document interventions and the patient’s response. Lecture Outline d. For patients who have had a seizure, give a description of the seizure activity if known. i. If the patient has a history of seizure activity, determine how often the seizures occur and if there is any history of status epilepticus. e. Document interventions and the patient’s response.

Emergency Medical Care (1 of 4)
Some conditions are easier to identify. Cause of other neurologic emergencies may not always be obvious ED physicians determine if there is bleeding in the brain for patients with a suspected stroke with a CT scan of the head Blood clot–dissolving medication may be given if there is no bleeding Lecture Outline IX. Emergency Medical Care A. General 1. Some conditions are easier to identify with treatment options that are readily available. 2. The cause of other neurologic emergencies may not always be obvious to you. a. This may make it difficult for you to provide definitive treatment in the field. 3. In most patients with a suspected stroke, physicians in the emergency department need to determine whether there is bleeding in the brain. a. The only reliable way to tell is with a CT scan of the head. i. If there is no bleeding, the patient may be a candidate for blood clot–dissolving medication. ii. If bleeding is present, this medication will increase bleeding with disastrous consequences.

Notify hospital staff. Treatments are available if started right away. Communicate the last time the patient was known to be well. Lecture Outline b. Some EMS systems designate specific hospitals, typically accredited stroke hospitals, for patients who may be having a stroke. c. Notify the hospital staff as early as possible if you have a “stroke alert” patient. d. Only a limited number of treatments are available that are effective if started more than 3 hours after the stroke began. i. Notify the hospital regarding the last time the patient was known to be without their current signs and symptoms of stroke. © Jones & Bartlett Learning.

Patients who have had a seizure require definitive evaluation and treatment. Supplemental oxygen is strongly advised. For patients who are having a seizure: Protect them from harm. Maintain a clear airway by suctioning. Provide oxygen as quickly as possible. If head or neck trauma is suspected, provide spinal immobilization. Lecture Outline 4. Patients who have had a seizure require definitive evaluation and treatment in the hospital. a. Supplemental oxygen is strongly advised. b. Most seizures will not require a significant amount of intervention on your part. c. For patients who are having a seizure: i. Protect them from harm. ii. Maintain a clear airway by suctioning. iii. Provide oxygen as quickly as possible. iv. If head or neck trauma is suspected, provide spinal immobilization

For patients who continue to have a seizure, as in status epilepticus: Suction the airway. Provide positive-pressure ventilations. Transport quickly to the hospital. Rendezvous with ALS, if possible. Lecture Outline d. For patients who continue to have a seizure, as in status epilepticus: i. Suction the airway. ii. Provide positive-pressure ventilations. iii. Transport quickly to the hospital. iv. Rendezvous with ALS, if possible.

Emergency Medical Care: Headache
Most headaches are harmless and do not require emergency medical care. You should be concerned if the patient complains of: A sudden-onset, severe headache A sudden headache with fever, seizures, AMS, or following trauma Lecture Outline B. Headache 1. Most headaches are harmless and do not require emergency medical care. 2. You should be concerned if the patient complains of: a. A sudden-onset, severe headache b. A sudden headache with fever, seizures, altered mental status, or following trauma

Emergency Medical Care: Migraine
Always assess the patient for other signs and symptoms that might indicate a more serious condition. Apply high-flow oxygen, if tolerated. Provide a darkened, quiet environment. Do not use lights and sirens during transport. Lecture Outline 3. Migraine a. Always assess the patient for other signs and symptoms that might indicate a more serious condition. b. Apply high-flow oxygen, if tolerated. c. Provide a darkened and quiet environment. d. Do not use lights and sirens during transport.

Emergency Medical Care: Stroke (1 of 3)
Support ABCs and provide rapid transport to a stroke center. Patient may require manual airway positioning. Use suction as needed and monitor the patient’s oxygen saturation. Maintain a SpO2 level of at least 94% Oxygen therapy not recommended unless the patient is in respiratory distress or is hypoxic Lecture Outline B. Stroke 1. Support the ABCs and provide rapid transport to a stroke center. 2. The patient may require manual airway positioning. 3. Use suction as needed and monitor the patient’s oxygen saturation with a pulse oximeter. a. Maintain a Spo2 level of at least 94%. 4. Routine use of oxygen therapy is not recommended unless the patient is experiencing respiratory distress or is showing signs of hypoxia.

Paralyzed extremities will require protection from harm. Keep the patient informed. Thrombolytic therapy may reverse stroke symptoms. Lecture Outline 5. A patient’s paralyzed extremities will require protection from harm. 6. Continuously talk to the patient and inform him or her of what is going on. 7. Thrombolytic therapy (blood clot–dissolving drugs) and methods to mechanically remove the blood clot may reverse stroke symptoms and even stop the stroke if given within 3 hours (drugs) or 6 hours (mechanical methods). 8. Comprehensive stroke centers are able to offer advanced stroke care and in some cases may be able to provide thrombolytic therapy even after the 3- and 6-hour window. a. Proceed under the assumption that an area of the brain can still be saved. b. The sooner the treatment is done, the better the patient’s prognosis.

Spend as little time at the scene as possible. Stroke is an emergency, and “time is brain.” If possible, transport to a designated stroke center. Lecture Outline 9. Spend as little time at the scene as possible. a. Stroke is an emergency, and “time is brain.” b. If possible, transport to a designated stroke center.

Emergency Medical Care: Seizure (1 of 3)
The patient may be in a postictal state upon your arrival. The patient may still be having a seizure: Continue to assess and treat ABCs. Try administering oxygen. Lecture Outline C. Seizure 1. The patient may be in postictal state upon your arrival. 2. Alternatively, the patient may still be having the seizure. a. Continue to assess and treat ABCs. b. Try administering oxygen.

It is difficult to safely prepare a patient for transport who is having a seizure. Assess for trauma. Use spinal immobilization if indicated. Never attempt to restrain a patient having a seizure. Lecture Outline c. It is difficult to safely prepare a patient for transport who is having a seizure. i. Assess for trauma. ii. Use spinal immobilization if indicated. iii. Never attempt to restrain a patient having a seizure.

Not every patient who has had a seizure wants to be transported. Your goal is to encourage the patient to be seen by a physician. Be prepared to discuss the situation with the hospital staff. Lecture Outline 3. Not every patient who has had a seizure wants to be transported. a. It is usually in the patient’s best interest to be evaluated by a physician. b. Your goal is to encourage the patient to be seen by a physician. c. Be prepared to discuss the situation with the hospital staff. d. If the patient still refuses transport, ask yourself the following questions: i. Is the patient awake and completely oriented after a seizure (GCS score of 15)? ii. Does your assessment reveal no indication of trauma or complications from the seizure? iii. Has the patient ever had a seizure before? iv. Was this seizure the “usual” seizure in every way (length, activity, recovery)? v. Is the patient currently being treated with medications and receiving regular evaluations by a physician?

Emergency Medical Care: Altered Mental Status
Signs and symptoms vary from simple confusion to coma. AMS is always an emergency that requires immediate attention. Even if the cause appears to be intoxication or minor head trauma Lecture Outline D. Altered mental status 1. Signs and symptoms vary from simple confusion to coma. 2. Regardless of the signs and symptoms, altered mental status is always an emergency that requires immediate attention, even if the cause appears to be intoxication or minor head trauma.

Review A 41-year-old man presents with slow, irregular breathing; hypotension; and dilated pupils. These signs MOST likely indicate dysfunction of the: brain stem. hypothalamus. cerebrum. cerebellum.

Review Answer: A Rationale: The brain stem is responsible for functions such as breathing, blood pressure, and pupil constriction. Brain stem dysfunction would result in abnormal findings with these functions.

Review (1 of 2) A 41-year-old man presents with slow, irregular breathing; hypotension; and dilated pupils. These signs MOST likely indicate dysfunction of the: brain stem. Rationale: Correct answer hypothalamus. Rationale: The hypothalamus causes changes to occur in the heart rate, body temperature, and thirst.

Review (2 of 2) A 41-year-old man presents with slow, irregular breathing; hypotension; and dilated pupils. These signs MOST likely indicate dysfunction of the: cerebrum. Rationale: The cerebrum causes changes to occur in emotion, thought, touch, and movement. cerebellum. Rationale: The cerebellum causes changes to occur in muscle control, body coordination, standing, walking, and writing.

Review An acute ischemic stroke is caused by:
a ruptured cerebral artery. increased intracranial pressure. an acute rise in a person’s blood pressure. a blocked cerebral artery.

Review Answer: D Rationale: There are two types of stroke—hemorrhagic and ischemic. A hemorrhagic stroke is caused by a ruptured cerebral artery (aneurysm), which causes bleeding within the brain and increased intracranial pressure. An ischemic stroke is caused by a blocked cerebral artery—either from a clot that grows locally (thrombus) or that travels to the brain from another part of the body (embolus).

Review (1 of 2) An acute ischemic stroke is caused by:
a ruptured cerebral artery. Rationale: This is known as a hemorrhagic stroke. increased intracranial pressure. Rationale: This can be caused by swelling, bleeding, or tumors.

Review (2 of 2) An acute ischemic stroke is caused by:
an acute rise in a person’s blood pressure. Rationale: This is known as a hypertensive crisis. a blocked cerebral artery. Rationale: Correct answer

Review A 56-year-old man experienced a sudden, severe headache and then became unresponsive. He has a history of high blood pressure. The MOST likely cause of his condition is a(n): hemorrhagic stroke. acute ischemic stroke. severe migraine headache. transient ischemic attack.

Review Answer: A Rationale: Hemorrhagic strokes are typically preceded by a sudden, severe headache (signals the rupture of a cerebral artery), after which the patient becomes unresponsive due to bleeding within the brain. Ischemic strokes and transient ischemic attacks generally do not cause a sudden, severe headache, and migraine headaches typically do not cause a loss of consciousness.

Review (1 of 2) A 56-year-old man experienced a sudden, severe headache and then became unresponsive. He has a history of high blood pressure. The MOST likely cause of his condition is a(n): hemorrhagic stroke. Rationale: Correct answer acute ischemic stroke. Rationale: This generally does not cause a sudden, severe headache.

Review (2 of 2) A 56-year-old man experienced a sudden, severe headache and then became unresponsive. He has a history of high blood pressure. The MOST likely cause of his condition is a(n): severe migraine headache. Rationale: This generally does not cause a loss of consciousness. transient ischemic attack. Rationale: This generally does not cause a sudden, severe headache.

Review Unlike an ischemic stroke, a transient ischemic attack is characterized by all of the following, EXCEPT: symptoms that resolve within 24 hours. symptoms that persist for longer than 24 hours. weakness or paralysis to one side of the body. an acute onset of confusion and slurred speech.

Review Answer: B Rationale: Signs and symptoms of a transient ischemic attack (TIA) are usually identical to those of an acute ischemic stroke (eg, hemiparesis, slurred speech, confusion, facial droop). Unlike the ischemic stroke, however, the symptoms of a TIA usually resolve within 24 hours.

Review (1 of 2) Unlike an ischemic stroke, a transient ischemic attack is characterized by all of the following EXCEPT: symptoms that resolve within 24 hours. Rationale: This is a sign of a transient ischemic attack. symptoms that persist for longer than 24 hours. Rationale: Correct answer

Review (2 of 2) Unlike an ischemic stroke, a transient ischemic attack is characterized by all of the following EXCEPT: weakness or paralysis to one side of the body. Rationale: This is a sign of a transient ischemic attack. an acute onset of confusion and slurred speech. Rationale: This is a sign of a transient ischemic attack.

Review A patient with a suspected stroke presents with slurred speech that is difficult for you to understand. This is referred to as: aphasia. dysphasia. dysphagia. dysarthria.

Review Answer: D Rationale: Dysarthria is defined as slurred, poorly articulated speech; it is common in stroke patients. Dysphasia is defined as difficulty speaking; the patient’s speech may or may not be slurred. Aphasia is the inability to speak. Dysphagia is defined as difficulty swallowing.

Review (1 of 2) A patient with a suspected stroke presents with slurred speech that is difficult for you to understand. This is referred to as: aphasia. Rationale: Aphasia is the inability to produce or understand speech. dysphasia. Rationale: Dysphasia is difficulty in speaking.

Review (2 of 2) A patient with a suspected stroke presents with slurred speech that is difficult for you to understand. This is referred to as: dysphagia. Rationale: Dysphagia is difficulty in swallowing. dysarthria. Rationale: Correct answer

Review A type of seizure that is characterized by severe twitching of all the body’s muscles and lasts for several minutes or longer is called a(n): partial seizure. absence seizure. tonic-clonic seizure. generalized seizure.

Review Answer: D Rationale: Generalized seizures are characterized by generalized severe twitching of all of the body’s muscles; they often last for several minutes or longer. An absence seizure is characterized by a blank stare; generalized muscle twitching is absent.

Review (1 of 2) A type of seizure that is characterized by severe twitching of all the body’s muscles and lasts for several minutes or longer is called a(n): partial seizure. Rationale: A partial seizure is broken down into simple (jerking of one part of the body) and complex (changes in behavior and emotion). absence seizure. Rationale: An absence seizure does not involve any changes in motor activity.

Review (2 of 2) A type of seizure that is characterized by severe twitching of all the body’s muscles and lasts for several minutes or longer is called a(n): tonic-clonic seizure. Rationale: A tonic-clonic seizure exhibits muscle contraction and incontinence. generalized seizure. Rationale: Correct answer

Review The MOST important reason for promptly transporting a stroke patient to the hospital is: a transient ischemic attack can be ruled out. medications may be given to reverse the stroke. the clot in the coronary artery may be dissolved. he or she needs close blood pressure monitoring.

Review Answer: B Rationale: Fibrinolytic medications (clot busters) have been shown to reverse the symptoms of a stroke by dissolving the clot that is blocking the cerebral artery. However, for the patient to be eligible for this therapy, it must be initiated within 3 hours after the onset of symptoms. For this reason, prompt transport of the stroke patient is critical.

Review (1 of 2) The MOST important reason for promptly transporting a stroke patient to the hospital is because: a transient ischemic attack can be ruled out. Rationale: In a TIA, stroke symptoms resolve (on their own), usually in less than 24 hours with no neurologic deficits. medications may be given to reverse the stroke. Rationale: Correct answer

Review (2 of 2) The MOST important reason for promptly transporting a stroke patient to the hospital is because: the clot in the coronary artery may be dissolved. Rationale: The coronary artery is in the heart and not the brain. he or she needs close blood pressure monitoring. Rationale: Monitoring of a patient’s blood pressure is important, but dissolving the clot and stopping the progression of damage is more important.

Review Which of the following are components of the Cincinnati Prehospital Stroke Scale? Arm drift, blood pressure, speech Speech, pupil response, arm drift Facial symmetry, speech, arm drift Pupil response, facial droop, speech

Review Answer: C Rationale: The three components of the Cincinnati Prehospital Stroke Scale are facial symmetry, speech, and arm drift. Both sides of the patient’s face should move symmetrically (equally) when he or she smiles. The patient’s speech should be easily understandable and without slurring. The patient should be able to hold both arms out in front of his or her body—with eyes closed and palms up—without one arm drifting down to his or her side.

Review Which of the following are components of the Cincinnati Prehospital Stroke Scale? Arm drift, blood pressure, speech Rationale: The scale does not use blood pressure. Speech, pupil response, arm drift Rationale: The scale does not use pupil response. Facial symmetry, speech, arm drift Rationale: Correct answer Pupil response, facial droop, speech Rationale: The scale does not use pupil response.

Review Your patient opens his eyes when you say his name, is making incomprehensible sounds, and withdraws when you pinch his earlobe. What is his GCS score? 9 8 11 12

Review Answer: A Rationale: The Glasgow Coma Scale gives a score of 3 to a patient who opens his or her eyes in response to speech. “Incomprehensible sounds” has a score of 2, and “withdraws to pain” has a score of 4. When added together, this patient’s GCS score is 9.

Review Your patient opens his eyes when you say his name, is making incomprehensible sounds, and withdraws when you pinch his earlobe. What is his GCS score? 9 Rationale: Correct answer 8 Rationale: This is not the right score. 11 Rationale: This is not the right score. 12 Rationale: This is not the right score.

Review If a patient complains of a severe migraine, how should she be transported? In a brightly lit ambulance so she can see while her vision is impaired With loud sirens so she can get to the hospital as soon as possible Without lights and sirens This patient should not be transported.

Review Answer: C Rationale: Treatment of a migraine headache is supportive; however, you should always assess the patient for other signs and symptoms that might indicate a more serious condition. Applying high-flow oxygen, if tolerated, may help ease the patient’s condition. When possible, provide a darkened and quiet environment because patients are sensitive to light and sound. Do not use lights and sirens during transport.

Review (1 of 2) If a patient complains of a severe migraine, how should she be transported? In a brightly lit ambulance so she can see while her vision is impaired Rationale: Migraine patients are sensitive to light. With loud sirens so she can get to the hospital as soon as possible Rationale: Migraine patients are sensitive to loud noises.

Review (2 of 2) If a patient complains of a severe migraine, how should she be transported? Without lights and sirens Rationale: Correct answer This patient should not be transported. Rationale: A migraine could indicate a more serious condition.

Chapter 17 Neurologic Emergencies

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Chapter 17 Neurologic Emergencies

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