1. BLS-2015 Neurologic Emergencies

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

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

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

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

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

14. Take a tour of the brain
Stroke Association

15. 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.

16. 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.

17. 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

18. Common Neurologic Emergencies
Stroke
Ischemic
Hemorrhagic

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

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

21. 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

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

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

24. 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.

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

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

27. 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

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

29. 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

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

31. 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

32. 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

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

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

35. 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

36. 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?

37. 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

38. FAST

39. Video FAST Exam

40. 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

41. 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

42. 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.

43. 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

44. 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

45. 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

46. 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

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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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.”