Neurologic Emergencies
Chapter 13
Brain Structure
The Spinal Cord
Common Causes of Brain Disorder
• Many different disorders can cause brain
dysfunction and can affect LOC, speech, and
muscle control.
• If problem is caused by heart and lungs, entire
brain will be affected.
• If problem is in the brain, only that portion of
brain will be affected.
• Stroke is a common cause of brain disorder and is
treatable.
• Seizures and altered mental status are other
causes of brain disorder.
Cerebrovascular Accident and Stroke
• Cerebrovascular accident
– Interruption of blood flow to the brain that results
in the loss of brain function
• Stroke
– The loss of brain function that results from a CVA
Potential Results of a CVA
• Thrombosis—Clotting of
cerebral arteries
• Arterial rupture—
Rupture of a cerebral
artery
• Cerebral embolism —
Obstruction of a cerebral
artery caused by a clot
that was formed
elsewhere and traveled
to the brain
Hemorrhagic Stroke
• Results from bleeding in
the brain
• High blood pressure is a
risk factor.
• Some people are born
with aneurysms
Ischemic Stroke
• Results when blood
flow to a particular part
of the brain is cut off by
a blockage inside a
blood vessel
Atherosclerosis
• Atherosclerosis is a
condition in which
fatty material collects
along the walls of
arteries. This fatty
material thickens,
hardens (forms
calcium deposits),
and may eventually
block the arteries
Transient Ischemic Attack (TIA)
• A TIA is a “mini-stroke.”
• Stroke symptoms go away within 24 hours.
• Every TIA is an emergency.
• TIA may be a warning sign of a larger stroke.
• Patients with possible TIA should be evaluated
by a physician.
Signs and Symptoms of Stroke
• Left hemisphere
– Aphasia: Inability to speak or understand speech
– Receptive aphasia: Ability to speak, but unable to
understand speech
– Expressive aphasia: Inability to speak correctly,
but able to understand speech
• Right hemisphere
– Dysarthria: Able to understand, but hard to be
understood
Stroke Mimics
• Hypoglycemia
• Postictal state
• Subdural or epidural bleeding
You Are The Provider
• You and your paramedic partner arrive to a 70-year-old man
with a severe headache and decreased level of consciousness.
• He is seated in the kitchen with his wife standing next to him.
• When you speak to him, he stares at you blankly.
• You notice that he is drooling from the right side of his
mouth.
• His wife says, “A few minutes ago, he told me that he had a
very bad headache.”
• “When I came back from the bathroom with some ibuprofen,
I tried to hand him a glass of water and he dropped the glass
on the floor. I don’t know what’s wrong with him.”
Continued…
• What do you suspect is wrong with this
patient?
• What other signs and symptoms would you
suspect in this scenario?
• What tests could you use to verify your
suspicions?
Scene Size up:
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Scene safety remains a priority.
Ensure that needed resources are requested.
Consider spinal immobilization.
Be aware that many serious medical
conditions can mimic stroke; consider all
possibilities.
Initial Assessment
• Chief complaint may include confusion,
slurred speech, or unresponsiveness.
• Patient may have difficulty swallowing or
choke on own saliva.
• Ensure adequate airway.
• If unresponsive, place in recovery position.
• Administer oxygen.
• Raising patient’s arms and legs may aggravate
hemorrhage.
You are the Provider
• You utilize a portion of the Cincinnati Stroke
Scale by asking the patient to smile.
• He attempts, but the right side of his face
remains flaccid.
• You assist the patient to the cot and place him
upright, slightly on his affected side.
• As you obtain a quick set of baseline vital
signs, your partner applies high-flow oxygen.
Transport Decision
• Thrombolytics may
reverse stroke
symptoms or stop a
stroke if given within 2
to 3 hours of onset.
• Spend as little time on
scene as possible.
• Place paralyzed side
down and well
protected with padding.
• Elevate head
approximately 6".
Focused History and Physical Exam
• Quickly determine
when patient last
appeared normal.
• Medications may give
you a clue to the
patient’s past medical
history.
• Patient may still be
able to hear and
understand; be careful
what you say.
Cincinnati Stroke Scale
• Speech
– Abnormal if words are slurred or confused
• Facial droop
– Abnormal if asymmetrical
• Arm drift
– Abnormal if arms do not move equally
Baseline Vital Signs
• Excessive bleeding in the brain may slow pulse
and cause erratic respirations.
• Blood pressure is usually high.
• Excessive bleeding in the brain may cause
changes in pupil size and reactivity.
Interventions
• Based on assessment findings
• If the patient is unresponsive, you may
consider the recovery position to protect the
airway.
Detailed Physical Exam
• Perform when time and conditions permit.
• Generally performed en route to the hospital.
• Do not delay transport, especially due to the
time sensitivity of stroke treatment.
Ongoing Assessment
• Reassess ABCs, interventions, vital signs.
• Stroke patients can lose airway without
warning.
• Watch for changes in GCS scores.
• Relay information to the hospital as soon as
possible.
• Report any pertinent physical findings,
Cincinnati Stroke Scale, GCS score, any other
changes.
Emergency Care for Stroke
• Patient needs to be evaluated by computed
tomography (CT).
• Recognizing the signs and symptoms of stroke
can shorten the delay to CT.
• Treatment needs to start as soon as possible,
within 3 to 6 hours of onset.
Seizures
• Generalized (grand mal) seizure
– Unconsciousness and generalized severe twitching
of the body’s muscles that lasts several minutes
• Absence (petit mal) seizure
– Seizure characterized by a brief lapse of attention
Signs and Symptoms of Seizures
• Seizures may occur on one side or gradually
progress to a generalized seizure.
• Usually last 3 to 5 minutes and are followed by
postictal state
• Patient may experience an aura.
• Seizures recurring every few minutes are
known as status epilepticus.
Causes of Seizures
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Congenital (epilepsy)
High fevers
Structural problems in the brain
Metabolic disorders
Chemical disorders (poison, drugs)
Sudden high fever
Recognizing Seizures
• Cyanosis
• Abnormal breathing
• Possible head injury
• Loss of bowel and bladder control
• Severe muscle twitching
• Postseizure state of unresponsiveness with
deep and labored respirations
Postictal State
• Patient may have labored breathing.
• May have hemiparesis: weakness on one side
of the body.
• Patient may be lethargic, confused, or
combative.
• Consider underlying conditions:
– Hypoglycemia
– Infection
Scene Size Up
• Spinal immobilization
may be needed with a
seizure.
• Ensure that scene is
safe and wear BSI.
• Request ALS
assistance earlier
rather than later
Initial Assessment
• Most seizures last only a few minutes at most.
• Assess level of consciousness.
• Use AVPU scale to determine how well patient
is progressing through postictal stage.
• Focus on ABCs upon arrival.
• Expect pulse to be rapid and deep.
• Pulse should slow to normal rates after several
minutes.
Transport Decision
• It is difficult to package a seizing patient for
transport.
• Treat ABCs while waiting for seizure to finish.
• Protect the seizing patient from his or her
surroundings.
• Never restrain an actively seizing patient.
• Not every patient who has a seizure wishes to
be transported.
• Encourage every patient to be seen and
evaluated in the emergency department.
Focused History and Physical Exam
• Obtain some information from family or
bystanders.
• Observe patient for recurrent seizures.
• If the patient displays an altered mental
status, perform a rapid physical exam.
• If patient is responsive, begin with SAMPLE
history.
• If the patient has an altered mental status,
utilize the Glasgow Coma Scale.
Interventions
• Most seizures will be over by the time you
arrive.
• Treat trauma as you would for any other
patient.
• For patients who continue to seize, suction
the airway according to local protocol, provide
positive pressure ventilation, transport quickly
to hospital.
• Consider rendezvous with ALS, who have
medications to stop prolonged seizures.
Detailed Physical Exam
• If life threats are treated, consider performing
detailed physical exam.
• Check patient for injuries, including tongue.
• Assess for weakness or loss of sensation on
one side of body.
Ongoing Assessment
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Note additional seizure activity.
Reassess ABCs, interventions, vital signs.
Provide complete history to receiving facility.
Include descriptions of seizure from witnesses
if available.
• Document whether this is first seizure or
whether patient has history of seizures.
Emergency Medical Care for Seizure
• Most patients should be evaluated by a
physician after a seizure.
• With severe injury, suspect spinal injury.
• Attempt to lower body temperature if febrile
seizure.
• Patient and family may be frightened.
Altered Mental Status
• Hypoglycemia
• Hypoxemia
• Intoxication
• Drug overdose
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Unrecognized head injury
Brain infection
Body temperature abnormalities
Brain tumors
Glandular abnormalities
Poisoning
Assessing a Patient With AMS
• Same assessment
process
• Patient cannot tell you
reliably what is wrong.
• Be vigilant in ongoing
assessment.
• Monitor for changes or
deterioration.
• Provide prompt
transport to hospital
while monitoring the
patient.