2IntroductionThere 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
3Practical SkillsTo 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 assessmentConduct a patient history and physical examRecognize a variety of neurologic patientsAdminister the FAST exam to the appropriate patientRecognize symptoms of ischemic stroke and need for short scene timesProvide emergency care for neurologic emergencies
4Learning ObjectivesReview neurological anatomy and physiology at the Basic EMT LevelRecognize common neurologic emergenciesDistinguish between the two types of strokeRecognize the underlying causes of strokeRecognize the signs and symptoms of strokeDetermine the reasons why an ischemic stroke patient must be assessed and transported quicklyChoose the correct BLS treatments for different neurologic emergencies
5Termsatherosclerosis — a condition characterized by the deposit of fatty plaques containing cholesterol and lipids on the innermost layer of the walls of arteriesclot-busting therapy — dissolves blood clots in a procedure termed thrombolysis; limits the damage caused by the blockage of the blood vesseldysarthria — difficulty in pronouncing words, caused by impairment in the control of the muscles used in speechembolism — a clot that travels from one part of the body to another until it becomes lodged in an arteryexpressive aphasia — aphasia in which the power to communicate by writing, speaking, or using signs is diminished or lost. Also called motor aphasia.
6Termsforamen magnum — the opening in the base of the skull through which spinal cord passes to cranial cavity and becomes the medulla oblongatahemiparesis — partial weakness affecting one side of the bodyhemiplegia — complete paralysis on one side of the bodyhemorrhagic stroke — a type of stroke that occurs when a blood vessel bursts inside the brainhyperlipidemia — elevated lipid (fat) levels in the blood
7Termsinfarction — 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
8Termsseizure — 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
9Termsthrombus — 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
10Three Regions of Brain Cerebrum Cerebellum Brain Stem Graphic illustrations credit: LifeART(R) image, Copyright 1998,Lippincott Williams & Wilkins. All rights reserved.
11Cerebrum Thought Memory Personality Speech Motor function Vision Tactile impulses (touch)
15The Nervous SystemThe 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.
16The Nervous SystemThe nervous system is composed of the Central Nervous System (CNS) and Peripheral Nervous System (PNS).CNS: brain & spinal cordPNS: the rest of the nerve cells throughout the bodyThe peripheral nervous system is broken down into two parts: a voluntary system and an involuntary system.
17The Nervous SystemVoluntary system – also called the Somatic Nervous System, the voluntary portion of the PNS controls muscular movementInvoluntary 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 othersThe Autonomic Nervous System is further broken down into the Sympathetic and Parasympathetic Nervous Systems* Respiratory Rate has both voluntary and involuntary controls
19Types of StrokeIschemic: A blockage caused by a clot. This is the most common type of stroke.
20Types of StrokeHemorrhagic: A rupture caused by a break in a blood vessel. Less common than ischemic stroke but often has higher mortality.
21Clot-busting drugs are time sensitive Ischemic StrokeThrombusClot that develops at site of blockageNear area of plaqueCauses a sudden occlusionSudden onset of neurological deficitsClot-busting drugs are time sensitive
22Ischemic Stroke Embolus Clot floats to site to form a blockage Circulates in bloodstream until it gets stuck in a smaller artery
23Hemorrhagic StrokeRuptured blood vessel on surface of the brain (subarachnoid)Ruptured blood vessel within brain (intracerebral)Puts pressure on the brain
24Time lost is brain lost; seconds count. Types of StrokeBoth types of strokePrevent oxygenated blood from reaching the brain tissuesMay have only minutes to get patient to definitive treatmentTime lost is brain lost; seconds count.
25Transient Ischemic Attack A temporary interruption in blood supply to the brainCauses stroke-like symptoms that resolve completely within 24 hours
27Signs and Symptoms Paralysis or weakness on one side of the body Facial droop on one sideAltered level of consciousnessChange in personality or moodHeadache or dizzinessImpaired speechBlurred visionPoor coordination
28AneurysmsA common cause of a ruptured artery in the brain is an abnormality or weakness in the vascular wall called an aneurysm
29Altered Mental Status Any number of medical emergencies or conditions can cause an alteration in a patient’s mental statustraumadisturbances in oxygen flow to the brainelectrolyte imbalancespresence of intoxicants or poisons, too much or too little glucose in the bloodpsychiatric disordersserious infections
30Seizures A seizure can have many different presentations. Most often, it is a convulsionof the muscles of the body.Tonic-ClonicPartialFebrile
31Seizure Disorders Seizures – electrical storm in the brain Epilepsy Tumor (benign of cancerous)Infections such as meningitis, encephalitis or AIDSScar tissue from injuryHead traumaStrokeHypoxiaAbnormal blood chemistryHypoglycemiaPoisoningUse of illegal street drugs like cocaine or amphetaminesDrug overdoseAlcohol/medication withdrawalSudden high fever
32Seizure Disorders Status Epilepticus – life-threatening Acute, prolonged epileptic crisisSeizure can last longer than 5 minutes and/or many seizures & does not wake up between seizuresMedical emergency – requires quick medical treatment & ALS interventionComplications include:airway compromisedysfunction of the heart or lungsmetabolic changesincrease in body temperatureirreversible brain injury
33HeadachesYour History and Physical Exam, including Vital Signs, will help clarify whether this a nuisance or a medical emergency
34Initial Assessment Determine SICK or NOT SICK early in the call SICK
35Physical ExamA 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’sSkin SignsWork of breathingThe FEEL of the pt’s pulse – not the Pulse Ox. HR Reading!Overall Appearance
36Physical Exam Key Clinical Indicators Relative to stroke Pulse RespirationsMental statusSkin signs and colorOverall AppearanceRelative to strokeBaseline vital signsFAST examBlood glucometrySICKorNOT SICK?
37FAST F – Facial droop A – Arm drift S – Speech T - Time Based on Cincinnati Prehospital Stroke ScaleF – Facial droopA – Arm driftS – SpeechT - TimeAccurate in identifying patients with strokeAn abnormal finding in ANY three tests strongly suggests a stroke
40Time of OnsetDetermine time of onset – time patient was last known to be normalKeep scene times very short…goal is 15 minutesBe aware of time it takes for the hospital staff to assess and administer thrombolytic therapyClot-busting drugs are time sensitiveand must be given as early as possible
41Patient HistoryStroke patients often report loss of motor function and/or a change in speech patternSome experience altered LOCSAMPLE history to determine if there is a history of:HypertensionBlood thinners or anticoagulantsArteriovenous malformation (AVM)Cerebral aneurysmPrior stroke
42Chief complaint and time of onset are key in the Patient HistoryChief complaint and time of onset are key in theassessment of stroke.
43Care for Stroke Protect airway Ensure adequate respirations Remove secretions that can be aspiratedProvide ventilation assistanceProper positioningAdminister oxygen if saturation level is below 95% or there are signs of hypoxiaCandidate for clot-busting therapy?Initiate immediate & rapid transport to appropriate medical facility
44When possible…keep scene time to 15 minutes Short Scene TimesVictims of stroke often deny or rationalize their symptomsPatients eligible for clot-busting drugs must be transported immediatelyNotify hospital that possible stroke patient is en routeAvoid delays if patient waited before calling for helpWhen possible…keep scene time to 15 minutes
45Latest Treatments tPA FDA approved clot buster medication May reduce long-term disabilityIntra-atrial clot removalDoes not have time limitRestores blood flow by removing blood clotsView the videoRevascularization of occluded vesselsUses suction to grab blood clotsEffective if used within 8 hours of symptom onset
46Seizures - Emergency Care Basic Life Support care includes:Once patient is awake, perform examination to determine if any injuries occurred or if any neurologic abnormalities existDuring seizure, position patient on his/her sideMaintain the airwayProtect patient from injuryDuring and after seizure, provide oxygenPerform blood glucometryObtain oximetry reading after seizureAdvanced 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 consciousnessSeizure due to hypoglycemiaSeizure due to hypoxiaSeizure following head traumaDrug or alcohol associated seizurePregnant female
47Headaches - Primary Tension – most common type headache Causes Tight muscles in shoulders, neck, scalp, jawRelated to stress, depression, anxiety
48EMS gets called – perform thorough Headaches - MigrainePain – intense pulsing or throbbing in one area of headAura – visual disturbanceMay see spots, dots, zigzag linesTemporary loss of visionNausea, vomiting can occurEMS gets called – perform thoroughexam and physical
49Patients with these type symptoms Need hospital evaluation Headaches - SecondaryRare causes of headachesBrain infectionBrain tumorStrokeTIANeurologic symptoms – consider ALSWeaknessSensoryAltered LOC“Worst headache of my life”Patients with these type symptomsNeed hospital evaluation
50SummaryThree regions of the brain are cerebrum, cerebellum and brain stemTwo 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
51Summary Signs and symptoms of stroke include: Paralysis or weakness on one side of the bodyFacial droop on one sideAltered level of consciousness (from confusion to unconsciousness)Change in personality or moodHeadache or dizzinessImpaired speechBlurred visionPoor coordination
52SummaryThree tests of the FAST exam are facial droop, arm drift and speech with T for TimeDetermine last time patient was last known to be normal. This helps determine if a patient meets the time window for clot-busting therapyShort scene and transport times are vital – try to keep scene time to 15 minutes
53SummarySeizures can have many causes, including medicines, high fevers, head injuries and certain diseasesMost common type of headache - tension headacheMigraine a very specific type of headachePain often described as intense pulsing or throbbing pain in one area of the headAny headache with neurologic symptoms – weakness, sensory, altered LOC warrant consideration of ALSHeadache usually develops suddenly & without warningPatient may say, “This is the worst headache of my life.”