1. Neurological Emergencies Coma, Seizures, Syncope, Stroke

2. Coma H State of unconsciousness from which patient cannot be aroused

3. Coma H Unconsciousness = Immediate Life Threat HLoss of airway HAspiration

4. Coma H Management of ABC’s must come before investigation of cause

5. Airway H Open, clear, maintain H If trauma present or no history available, immediately control C-spine

6. Breathing H Assess presence, adequacy H High concentration O 2 immediately on all patients with decreased LOC H Assist if respiratory rate, tidal volume inadequate

7. Circulation Pulses? Perfusion?

8. After ABC’s stabilized... H Quickly investigate cause H DERM

9. D = Depth of coma H What does patient respond to? H How does he respond?

10. E = Eyes H Pupils equal, dilated, constricted, H Responsive to light? H How?

11. R = Respiratory pattern H Rate? H Unusually deep or shallow? H Altered pattern?

12. M = Motor Function H Evidence of paralysis? H Movement on stimulation? H How?

13. Vital Signs H Shock? H Increased ICP? H Arrhythmias?

14. Head to Toe Survey H Injuries causing coma? H Injuries caused by fall? H What do the scene, bystanders tell you?

15. Possible Causes H Not enough oxygen H Not enough sugar H Not enough blood flow to deliver O 2, sugar H Direct brain injury HStructural (trauma) HMetabolic (toxins, infections, temperature)

16. Possible Causes J Alcohol J Epilepsy J Insulin J Overdose J Uremia (and other metabolic causes) J Trauma J Infection J Psychiatric J Stroke, syncope

17. Management H Secure airway H Protective reflexes may be lost H Immobilize spine unless absolutely certain injury not present H Spinal injury not suspected - patient on left side

18. Management H High concentration O 2 H Assist ventilation as needed H Monitor neurological/vital signs every 5 minutes

19. Management H Protect patient’s eyes on long transports (tape shut, moist pads) H Patient may hear, understand even though unable to respond H Treat, reassure accordingly

20. Seizures H Episodes of uncoordinated electrical activity in brain H Signs/symptoms depend on area involved

21. Epilepsy H Tendency to have repeated episodes of seizure activity

22. Seizure Types H Grand mal (major motor) H Petit mal (absence) H Focal motor (simple partial) H Psychomotor (complex partial)

23. Grand Mal Seizure H Aura HSensation coming before convulsion HPatient may recognize as sign of impending seizure HMay help locate origin of seizure in brain

24. Grand Mal Seizure H Convulsion HLoss of consciousness HTonic phase - rigidity HClonic phase - rhythmic jerking, incontinence, ineffective breathing

25. Grand Mal Seizure H Post-ictal Phase H Exhaustion H Drowsiness H Headache H Possible hemiparesis (Todd’s paralysis)

26. Petit Mal Seizure H Loss of consciousness H No loss of postural tone H More common in children

27. Focal Motor Seizure H Rhythmic jerking of limb, one side of body H No loss of consciousness

28. Psychomotor Seizure H Loss of consciousness H Sterotyped movements (automatisms) HMay look purposeful, but aren’t HLip smacking, movements of hands H May be called in as “drunk”, “O.D.”, “psych patient ”

29. Generalized Seizure Management H During seizure HRemove from potential harm HDo not forcibly restrain HRoll on side HAvoid putting anything in mouth

30. Generalized Seizure Management H After seizure ends HAssess ABC’s HClear airway Most common cause of seizure deaths is post-ictal airway loss

31. Generalized Seizure Management HHigh concentration O 2 - immediately!! HAssist breathing if ventilation inadequate

32. Generalized Seizure Management HObtain history/physical HTrauma that could have caused, been caused by seizure HAnti-seizure medications HNeuro/vital signs every 5 minutes HIf patient ventilating adequately, transport on left side

33. Seizures H Anything that injures brain can cause seizures (AEIOU/TIPS) H Do not assume seizures are due to idiopathic epilepsy until proven otherwise

34. Status Epilepticus H > 2 seizures without intervening conscious period H Immediate Life Threat H Management HSecure airway HAssist breathing with O 2 HTransport HRequest ALS intercept

35. Syncope J Fainting J Sudden, temporary loss of consciousness J Caused by lack of blood flow to brain

36. Causes J Stress, fright, pain (vasovagal syncope) JOrthostatic hypotension (BP fall on standing) J Decreased blood volume J Increased size of vascular space JDecreased cardiac output JProlonged forceful coughing

37. Management J ABCs J Keep patient supine, elevate lower extremities J Oxygen J Assess underlying cause

38. CVA J Cerebrovascular accident J Stroke

39. CVA H Damage of portion of brain due to interruption of blood supply H Mechanisms HThrombosis HHemorrhage HEmbolism

40. Thrombosis H Blockage of vessel by thrombus H Usually forms at area narrowed by atherosclerosis H Typically in older persons H Frequently occurs during sleep

41. Hemorrhage H Vessel ruptures H Associated with hypertension, aneurysms of cerebral blood vessels H Usually characterized by H Sudden onset H Severe signs, symptoms

42. Embolism H Blood clots, plaque fragments travel through vessel; lodge, block flow H Often associated with: HAtherosclerosis of carotids HChronic atrial fibrillation

43. Signs/Symptoms H Alterations in consciousness HAltered affect HConfusion HDizziness HComa

44. Signs/Symptoms H Localizing signs HParalysis HLoss of sensation HLoss of speech HUnilateral blindness HLoss of vision in half of visual field of both eyes HUnequal pupils

45. Signs/Symptoms H Seizures H Headache H Stiff neck

46. Transient Ischemic Attacks H TIAs H “Little strokes” H Produce deficits that resolve completely in <24 hours H Frequently precede CVA

47. Management H Assess ABC’s H Protect airway H High concentration O 2 H Vital signs every 5-10 minutes H Note increased BP, irregular pulse

48. Management H Nothing by mouth H Avoid rough handling H Transport paralyzed side down H Guard your conversation H Patients who cannot speak may still understand!

49. Management H CVAs caused by thrombus, embolus may be reversible with thrombolytics (clot busters) H Early recognition, rapid transport to appropriate facility is critical