Neurological Emergencies Joshua B. Yellen, M.A. A.T.C., L.A.T. © Copyright 2005 Joshua B. Yellen. All Rights Reserved

Objectives Brain Structure and Function Common Causes of Brain Disorder Signs and Symptoms of Brain Disorder Emergency Medical Care Conclusions

Stroke Third most common cause of death behind Heart Disease and Cancer Seizures may develop as a result of a recent or old head injury, brain tumor, metabolic problem or genetic condition Altered mental status may develop due to a range of conditions

Brain Structure and Function Brain controls: –Breathing –Speech –Wants, desires –Receive input from senses Hearing, sight, taste, smell and touch –Muscle and movements

Brain Structure and Function Brain is divided into 3 major parts: Brain Stem –breathing, blood pressure, swallowing, pupil constriction Cerebellum –Muscle and body coordination Cerebrum –Divided into hemispheres –Each hemisphere is responsible for the opposite side of the body and the same side of the face Front: emotion & thought Middle: touch & movement Back: processes sight

Brain Structure and Function Cranial Nerves I: Olfactory –(On) II: Optic –(Old) III: Occulomotor –(Olympus) IV: Trochlear –(Towering) V: Trigeminal –(Tops) VI: Abducens –(A) VII: Facial –(Fin) VIII: Acoustic (Vestibulo-Cochlear) –(And) IX: Glossopharyngeal –(German) X: Vagus –(Viewed) XI: Spinal Accessory –(Some) XII: Hypoglossal –(Hops)

Cranial Nerves I: Olfactory: –Smell II: Optic: –Vision III: Occulomotor: –Eye mvmnt; open eyelid; constriction of pupil; focusing IV: Trochlear: –Inferior & lateral movement of eyeV:Trigeminal: –Sensation to the face; masticationVI:Abducens: –Lateral movement of the eye

Cranial Nerves VII: Facial: –Motor nerve of facial expression; taste; control of tear, nasal, sublingual & submaxillary glands VIII: Acoustic (vestibulocochlear): –Hearing & equilibrium IX: Glossopharyngeal: –swallowing; salivation; gag reflex; sensation from tongue to ear X: Vagus: –swallowing; speech; regulation of pulmonary, cardiovascular and gastrointestinal functions XI: Spinal Accessory: –swallowing; innervation of the SCM XII: Hypoglossal: –tongue movement; speech; swallowing

Concussion Grading Scales 19 different concussion grading scales 3 most common scales used on the field –Cantu (1986) –Colorado Medical Society (1991) –American Academy of Neurology (1997)

Cantu (1986) Grade 1: –Normal consciousness; no LOC or PTA < 30 min. RTP in selected circumstances Grade 2: –LOC < 5 min or PTA 30 min-24 hr; no RTP; evaluate in medical facility Grade 3: –LOC > 5 min; transport to emergency medical facility in full neck injury precautions

Cantu (1986) RTP Guidelines After Head Injury Grade 1: –May RTP if asymptomatic for 1 wk Grade 2: –May RTP if asymptomatic for 1 wk Grade 3: –Should not be allowed to play for 1 month; may then return to play if asymptomatic for 1 wk.

Colorado Medical Society (1991) Grade 1: –No LOC; confusion w/o amnesia; RTP within 20 min with normal exam Grade 2: –No LOC; confusion w/ amnesia; no RTP that day Grade 3: –LOC; transport to emergency medical facility in full neck injury precautions

Colorado Medical Society RTP Guidelines After Head Injury Grade 1: –RTP if asymptomatic at rest & exertion after at least 20 minutes of observation Grade 2: –RTP if asymptomatic for 1 week Grade 3: –Should not be allowed to play for at least 1 month; may then RTP after asymptomatic for 2 wks

American Academy of Neurology (1997) Grade 1: –No LOC; transient confusion; symptoms & mental status abnormalities resolve < 15 min. Grade 2: –No LOC; transient confusion; symptoms & mental status abnormalities resolve > 15 min. Grade 3: –Any LOC (seconds- minutes)

Common Causes of Brain Disorder Common causes of brain disorder include: –Stroke –Infection –Tumor –Concussion

Stroke Cerebral Vascular Accident (CVA) –Interruption of blood flow to the brain that results in the loss of brain function Stroke –Loss of brain function that results from a CVA and occurs when blood flow to a part of the brain in cut off –Results in infarcted cells Dead cells

Stroke Interruption of cerebral blood flow may result from –Thrombosis –Arterial rupture –Cerebral embolism

Stroke Two types of stroke: –Hemorrhagic stroke Occurs as a result of bleeding in the brain Forms a clot which squeezes the brain tissue next to it –Ischemic stroke Blood flow to the brain is cut off by a blockage inside a blood vessel

Transient Ischemic Attack Some patients have the ability to break up clots on their own Blood flow is restored quickly to the area and patient regains function of area Stroke symptoms will go away on their own in less than 24 hours –Also called “mini-strokes” May be a warning sign for a larger event and should be evaluated by a physician

Seizure Typically characterized by unconsciousness and a generalized severe twitching of all of the body’s muscles Will last for several minutes or longer –Called a Grand Mal or generalized seizure

Seizure Seizure that is characterized by a brief lapse of attention in which the patient seems to stare and not respond to stimuli Called Petit Mal Seizure or absence seizure

Characteristics of Seizure Some will occur on one side of the body Some will begin one side of the body and progress to a generalized seizure that affects the entire body Most seizures will last 3-5 minutes Followed by postictal state –Patient remains unconscious or unresponsive –Patients with petit mal seizures will usually recover with no complications

Characteristics of Seizure Seizures that recur every few minutes Called status epilepticus –Should be considered serious and evaluated by a qualified physician –Also known as status seizures

Causes of Seizures Epileptic: –Congenital in origin Structural: –Tumor (benign or malignant) –Infection (brain abscess) Metabolic: –Abnormal blood chemistry –Hypoglycemia –Poisoning –Drug overdose –Sudden withdrawal from drugs or alcoholFebrile –Sudden high fever

Altered Mental Status Aside from stroke and seizures is the most common type of neurological emergency Patient is not thinking clearly and is unable to be aroused Common causes: –Hypoglycemia –Hypoxemia –Drug overdose –Unrecognized head injury –Brain infection –Body temperature abnormalities –Brain tumor –Glandular abnormality –Chronic poisoning

Signs & Symptoms of a Brain Disorder If the disorder originates in the heart and lungs the entire brain will be affected If the disorder originates in the brain only a part of the brain will be affected Bleeding in the brain will usually present with an elevated blood pressure –Brain is raising the blood pressure in an attempt to force more oxygen into its injured parts

Emergency Medical Care (Stroke) Patient will need definitive evaluation in hospital CT scan to reveal if there is bleeding in the brain Administer medication to break up clot Most treatments need to be started as soon as possible –Usually within the first 3 hours

Emergency Medical Care (Seizures) Patient will need definitive evaluation in hospital Patient will be confused and frustrated with condition –Be tolerant and patient Treat for possible causes of seizure –Hypoglycemia –Severe head injury –Febrile seizures

Conclusions Brain Structure and Function Common Causes of Brain Disorder Signs and Symptoms of Brain Disorder Emergency Medical Care