Chapter 18 Neurologic Emergencies

Part 1 You are dispatched to 1600 Courage Court for an older man who has fallen. You arrive to find Mr. Hishari, an 81-year-old man, lying on the floor. His two sons explain that they visited their father last night and left around 7:00 PM. When they returned this morning, they found the patient lying on the floor next his chair. He is unable to explain what happened and, because he lives alone, no one is sure how long he’s been on the floor.

Part 1 (cont’d) The patient is awake and responding to his sons, but they say he is “not acting right.” They describe him as “very sharp,” but today he keeps getting their names confused. They say this only happens when his blood glucose level is low. The patient has type 2 diabetes.

Part 1 (cont’d) Primary AssessmentRecording Time: 0 minutes Appearance Lying on the floor, appears clean Level of consciousness V (Responsive to verbal stimuli), oriented to person and place, but not day Airway Patent Breathing Nonlabored Circulation Strong radial pulse

Part 1 (cont’d) 1.What are some possible causes that may have resulted in Mr. Hishari being on the floor? 2.How would you prioritize those causes?

Part 2 You obtain the patient’s vital signs. As your partner obtains his blood glucose level, you continue your assessment and determine that he is quite confused. He is alert and oriented to person and place, but is unsure as to what day it is and cannot describe the events leading up to your arrival.

Part 2 (cont’d) The patient shows no signs of trauma. While assessing his pupils he takes your penlight and tries to shave his face with it. He also seems to use inappropriate words for common, household objects and appears frustrated that you can’t understand him.

Part 2 (cont’d) Vital SignsRecording Time: 5 minutes Level of Consciousness Verbal, oriented to person and place, but not day, with a Glasgow Coma Scale score of 14 Skin Pale, warm, and dry Pulse 90 beats/min and irregular Blood Pressure 142/86 mm Hg Respirations 26 breaths/min SaO 2 98% on 4 L/min via NC Blood Glucose 100 mg/dL

Part 2 (cont’d) 3.Given the information you have now, what do you think could be this patient’s underlying illness, injury, or condition? 4.Do your assessment and treatment priorities ever change? 5.What are appropriate interventions?

Part 3 In the interest of time, you place your patient on the gurney, obtain IV access, administer normal saline TKO, draw blood, and perform an ECG. You also complete a fibrinolytic screen while en route to the hospital. You ask one of the patient’s sons to accompany you and provide more information regarding his medical history.

Part 3 (cont’d) The patient’s son tells you that his medical history includes atrial fibrillation (which you confirm on the monitor) and that the patient takes aspirin, diltiazem, Coumadin, and glucophage. The patient has no known drug allergies, has no recent history of illness, and has been compliant with his medications and diet.

Part 3 (cont’d) ReassessmentRecording Time: 10 minutes Level of Consciousness Alert, with a Glasgow Coma Scale score of 14 Skin Pale, warm, and dry Pulse 92 beats/min, strong and irregular Blood Pressure 140/84 mm Hg Respirations 24 breaths/min SaO 2 98% on 4 L/min via NC

Part 3 (cont’d) 6.Would you choose to place this patient in manual in-line spinal precautions? 7.What places this patient at greater risk for cerebrovascular accident?

Part 4 During transport, the patient’s condition did not change. You continue to monitor his mentation, vital signs, and deficits while en route to the hospital. You provide a prompt radio report to the receiving facility, and deliver your patient to the emergency department without incident.

Part 4 (cont’d) ReassessmentRecording Time: 15 minutes Level of Consciousness Alert, with a Glasgow Coma Scale score of 14 Skin Pale, warm, and dry Pulse 88 beats/min, strong and irregular Blood Pressure 140 by palpation Respirations 24 breaths/min SaO 2 100% on 15 L/min via nonrebreathing mask

Part 4 (cont’d) 8.What other important considerations relate to total patient care?

Part 5 A CT scan showed a mild stroke in the parietal lobe. The patient was not a candidate for fibrinolytics because the onset of his stroke couldn’t be determined. He soon returned home with the support of his family and full-time nursing care. Because you rapidly recognized his stroke and transported him with the appropriate sense of urgency, the emergency department nurses and doctors were able to promptly confirm the type of stroke and begin appropriate care.