Neurological Emergencies Coma, Seizures, Syncope, Stroke

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Neurological EmergenciesComa, Seizures, Syncope,
Stroke

• Temple College
• EMS Professions

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Coma

• State of unconsciousness from which patient
  cannot be aroused

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Coma

• Unconsciousness Immediate Life Threat
• Loss of airway
• Aspiration

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Coma

• Management of ABCs must come before
  investigation of cause

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Airway

• Open, clear, maintain
• If trauma present or no history available,
  immediately control C-spine

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Breathing

• Assess presence, adequacy
• High concentration O2 immediately on all patients
  with decreased LOC
• Assist if respiratory rate, tidal volume
  inadequate

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Circulation

• Pulses?
• Perfusion?

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After ABCs stabilized. . .

• Quickly investigate cause
• DERM

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D Depth of coma

• What does patient respond to?
• How does he respond?

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E Eyes

• Pupils equal, dilated, constricted,
• Responsive to light?
• How?

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R Respiratory pattern

• Rate?
• Unusually deep or shallow?
• Altered pattern?

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M Motor Function

• Evidence of paralysis?
• Movement on stimulation?
• How?

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Vital Signs

• Shock?
• Increased ICP?
• Arrhythmias?

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Head to Toe Survey

• Injuries causing coma?
• Injuries caused by fall?
• What do the scene, bystanders tell you?

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Possible Causes

• Not enough oxygen
• Not enough sugar
• Not enough blood flow to deliver O2, sugar
• Direct brain injury
• Structural (trauma)
• Metabolic (toxins, infections, temperature)

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Possible Causes

• Alcohol
• Epilepsy
• Insulin
• Overdose
• Uremia (and other metabolic causes)

• Trauma
• Infection
• Psychiatric
• Stroke, syncope

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Management

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

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Management

• High concentration O2
• Assist ventilation as needed
• Monitor neurological/vital signs every 5 minutes

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Management

• Protect patients eyes on long transports (tape
  shut, moist pads)
• Patient may hear, understand even though unable
  to respond
• Treat, reassure accordingly

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Seizures

• Episodes of uncoordinated electrical activity in
  brain
• Signs/symptoms depend on area involved

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Epilepsy

• Tendency to have repeated episodes of seizure
  activity

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Seizure Types

• Grand mal (major motor)
• Petit mal (absence)
• Focal motor (simple partial)
• Psychomotor (complex partial)

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Grand Mal Seizure

• Aura
• Sensation coming before convulsion
• Patient may recognize as sign of impending
  seizure
• May help locate origin of seizure in brain

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Grand Mal Seizure

• Convulsion
• Loss of consciousness
• Tonic phase - rigidity
• Clonic phase - rhythmic jerking, incontinence,
  ineffective breathing

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Grand Mal Seizure

• Post-ictal Phase
• Exhaustion
• Drowsiness
• Headache
• Possible hemiparesis (Todds paralysis)

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Petit Mal Seizure

• Loss of consciousness
• No loss of postural tone
• More common in children

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Focal Motor Seizure

• Rhythmic jerking of limb, one side of body
• No loss of consciousness

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Psychomotor Seizure

• Loss of consciousness
• Sterotyped movements (automatisms)
• May look purposeful, but arent
• Lip smacking, movements of hands
• May be called in as drunk, O.D., psych
  patient

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Generalized Seizure Management

• During seizure
• Remove from potential harm
• Do not forcibly restrain
• Roll on side
• Avoid putting anything in mouth

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Generalized Seizure Management

• After seizure ends
• Assess ABCs
• Clear airway

• Most common cause of seizure deaths is post-ictal
  airway loss

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Generalized Seizure Management

• High concentration O2 - immediately!!
• Assist breathing if ventilation inadequate

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Generalized Seizure Management

• Obtain history/physical
• Trauma that could have caused, been caused by
  seizure
• Anti-seizure medications
• Neuro/vital signs every 5 minutes
• If patient ventilating adequately, transport on
  left side

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Seizures

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

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Status Epilepticus

• gt 2 seizures without intervening conscious period
• Immediate Life Threat
• Management
• Secure airway
• Assist breathing with O2
• Transport
• Request ALS intercept

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Syncope

• Fainting
• Sudden, temporary loss of consciousness
• Caused by lack of blood flow to brain

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Causes

• Stress, fright, pain (vasovagal syncope)
• Orthostatic hypotension (BP fall on standing)
• Decreased blood volume
• Increased size of vascular space
• Decreased cardiac output
• Prolonged forceful coughing

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Management

• ABCs
• Keep patient supine, elevate lower extremities
• Oxygen
• Assess underlying cause

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CVA

• Cerebrovascular accident
• Stroke

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CVA

• Damage of portion of brain due to interruption of
  blood supply
• Mechanisms
• Thrombosis
• Hemorrhage
• Embolism

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Thrombosis

• Blockage of vessel by thrombus
• Usually forms at area narrowed by atherosclerosis
• Typically in older persons
• Frequently occurs during sleep

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Hemorrhage

• Vessel ruptures
• Associated with hypertension, aneurysms of
  cerebral blood vessels
• Usually characterized by
• Sudden onset
• Severe signs, symptoms

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Embolism

• Blood clots, plaque fragments travel through
  vessel lodge, block flow
• Often associated with
• Atherosclerosis of carotids
• Chronic atrial fibrillation

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Signs/Symptoms

• Alterations in consciousness
• Altered affect
• Confusion
• Dizziness
• Coma

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Signs/Symptoms

• Localizing signs
• Paralysis
• Loss of sensation
• Loss of speech
• Unilateral blindness
• Loss of vision in half of visual field of both
  eyes
• Unequal pupils

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Signs/Symptoms

• Seizures
• Headache
• Stiff neck

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Transient Ischemic Attacks

• TIAs
• Little strokes
• Produce deficits that resolve completely in lt24
  hours
• Frequently precede CVA

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Management

• Assess ABCs
• Protect airway
• High concentration O2
• Vital signs every 5-10 minutes
• Note increased BP, irregular pulse

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Management

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

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Management

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