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BLS-2015 Neurologic Emergencies. Introduction  There is a wide variety of neurologic emergencies which we encounter in the field.  Not all are treated.

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Presentation on theme: "BLS-2015 Neurologic Emergencies. Introduction  There is a wide variety of neurologic emergencies which we encounter in the field.  Not all are treated."— Presentation transcript:

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 Ischemic Stroke Clot-busting drugs are time sensitive  Thrombus  Clot that develops at site of blockage  Near area of plaque  Causes a sudden occlusion  Sudden onset of neurological deficits

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 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 or NOT SICK? SICK or NOT SICK?

35 Physical Exam ABC’s Skin SignsWork of breathing Overall Appearance The FEEL of the pt’s pulse – not the Pulse Ox. HR Reading!  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.

36 Physical Exam SICK or NOT SICK? SICK or NOT SICK?  Key Clinical Indicators  Pulse  Respirations  Mental status  Skin signs and color  Overall Appearance  Relative to stroke  Baseline vital signs  FAST exam  Blood glucometry

37 FAST 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 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 Short Scene Times When possible…keep scene time to 15 minutes  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

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 View the video  Revascularization of occluded vessels  Uses suction to grab blood clots  Effective if used within 8 hours of symptom onset  View the video View the video

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 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 Headaches - Secondary Rare causes of headaches Brain infection  Brain tumor  Stroke  TIA Patients with these type symptoms Need hospital evaluation Neurologic symptoms – consider ALS  Weakness  Sensory  Altered LOC  “Worst headache of my life”

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.”


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