13: Neurologic Emergencies

Cognitive Objectives (1 of 3) Describe the causes of stroke, including the two major types of stroke and the three conditions that cause blockages. Describe the sequence of events that occur during a stroke. Obtain and interpret the key vital signs in the stroke patient, including the time of onset of the symptoms. State the reason stroke must be treated within the first 3 to 6 hours.

Cognitive Objectives (2 of 3) 5. Identify the signs and symptoms of stroke. Describe the significance of a transient ischemic attack (TIA). Define seizure, including the two major types of seizure. Describe the parts of a seizure. List possible causes of seizure. Explain the importance of recognizing seizures.

Cognitive Objectives (3 of 3) Describe characteristics of the postseizure state. Define altered mental status. List possible causes of altered mental status.

Affective Objectives 14. Explain the importance of tolerance and patience when caring for a patient who has had a stroke, seizure, or who has altered mental status.

Psychomotor Objectives Demonstrate the steps in the emergency medical care for the patient who has had a stroke. Demonstrate testing for aphasia, facial weakness, and motor weakness. 17. Demonstrate the steps in the emergency medical care for the patient who has had a seizure. 18. Demonstrate the steps in the emergency medical care for the patient who has altered mental status.

Brain Structure and Function

The Spinal Cord

Common Causes of Brain Disorder (1 of 2) 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.

Common Causes of Brain Disorder (2 of 2) 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 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

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 (1 of 2) 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

Signs and Symptoms of Stroke (2 of 2) Right hemisphere Dysarthria: Able to understand, but hard to be understood

Stroke Mimics Hypoglycemia Postictal state Subdural or epidural bleeding

He is seated in the kitchen with his wife standing next to him. 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. 

You are the Provider continued 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.”

You are the Provider 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 safety remains a priority. Scene Size-up 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.

Patient may have difficulty swallowing or choke on own saliva. 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 continued (1 of 2) 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. 

You are the provider continued (2 of 2) What other types of disorders or conditions can mimic a stroke? Can all strokes be treated with clot-busting medications? 

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. 

Reassess ABCs, interventions, vital signs. 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.

You are the provider continued (1 of 2) Your partner tells you that he will initiate an IV en route. You assist the patient’s wife into the ambulance and immediately begin transport using lights and siren.  You do your best to address their concerns about the noise and driving safely. You hear the paramedic performing the rest of the stroke scale.  What would this include?

You are the provider continued (2 of 2) Your partner asks the patient to hold his hands out in front of him palms up and eyes closed.  He then asks the patient to repeat a simple declarative statement. The findings indicate the presence of stroke.  He assigns this patient a GCS score and obtains another set of vital signs.  What would the paramedic have seen if the remaining tests indicated a stroke?

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 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

Spinal immobilization may be needed with a seizure. 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.

Most seizures last only a few minutes at most. 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.

Note additional seizure activity. Ongoing Assessment 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 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.

Review A 41-year-old man presents with slow, irregular breathing; hypotension; and dilated pupils. These signs MOST likely indicate dysfunction of the: A. brain stem. B. hypothalamus. C. cerebrum. D. cerebellum.

Review Answer: A Rationale: The brain stem is responsible for functions such as breathing, blood pressure and heart rate regulation, and pupil constriction. Brain stem dysfunction would result in abnormal findings with these functions.

Review A 41-year-old man presents with slow, irregular breathing; hypotension; and dilated pupils. These signs MOST likely indicate dysfunction of the: brain stem. Rationale: Correct answer B. hypothalamus. Rationale: The hypothalamus causes changes to occur in the heart rate, body temperature, and thirst. C. cerebrum. Rationale: The cerebrum causes changes to occur in emotion, thought, touch, and movement. D. cerebellum. Rationale: The cerebellum causes changes to occur in muscle control, body coordination, standing, walking, and writing.

Review 2. An acute ischemic stroke is caused by: A. a ruptured cerebral artery. B. increased intracranial pressure. C. an acute rise in a person’s BP. D. a blocked cerebral artery.

Review Answer: D Rationale: There are two types of stroke—hemorrhagic and ischemic. A hemorrhagic stroke is caused by ruptured cerebral artery (aneurysm), which causes bleeding within the brain and increased intracranial pressure. An ischemic stroke is caused by a blocked cerebral artery—either from a clot that grows locally (thrombus) or travels to the brain from another part of the body (embolus).

Review 2. An acute ischemic stroke is caused by: a ruptured cerebral artery. Rationale: This is known as a hemorrhagic stroke (bleed). B. increased intracranial pressure. Rationale: This can be caused by swelling, bleeding, or tumors. C. an acute rise in a person’s BP. Rationale: This is known as a hypertensive crisis. D. a blocked cerebral artery. Rationale: Correct answer

Review 3. The MOST important reason for promptly transporting a stroke patient to the hospital is because: A. a transient ischemic attack can be ruled out. B. medications may be given to reverse the stroke. C. the clot in the coronary artery may be dissolved. D. he or she needs close blood pressure monitoring.

Review Answer: B Rationale: Fibrinolytic medications (clot busters) have been shown to reverse the symptoms of a stroke by dissolving the clot that is blocking the cerebral artery. However, for the patient to be eligible for this therapy, it must be initiated within 3 hours after the onset of symptoms. For this reason, prompt transport of the stroke patient is critical.

Review 3. The MOST important reason for promptly transporting a stroke patient to the hospital is because: a transient ischemic attack can be ruled out. Rationale: Stroke symptoms that have resolved (on their own) usually in less than 24 hours with no neurological deficits. B. medications may be given to reverse the stroke. Rationale: Correct answer C. the clot in the coronary artery may be dissolved. Rationale: The coronary artery is in the heart and not the brain. D. he or she needs close blood pressure monitoring. Rationale: Monitoring of a patient’s blood pressure is important, but dissolving the clot and stopping the progression of damage is more important.

Review 4. Unlike an ischemic stroke, a transient ischemic attack is characterized by all of the following EXCEPT: A. symptoms that resolve within 24 hours. B. symptoms that persist for longer than 24 hours. C. weakness or paralysis to one side of the body. D. an acute onset of confusion and slurred speech.

Review Answer: B Rationale: Signs and symptoms of a transient ischemic attack (TIA) are usually identical to that of an acute ischemic stroke (eg, hemiparesis, slurred speech, confusion, facial droop). Unlike the ischemic stroke, however, the symptoms of a TIA usually resolve within 24 hours.

Review 4. Unlike an ischemic stroke, a transient ischemic attack is characterized by all of the following EXCEPT: symptoms that resolve within 24 hours. Rationale: This is a sign of a transient ischemic attack. B. symptoms that persist for longer than 24 hours. Rationale: Correct answer C. weakness or paralysis to one side of the body. D. an acute onset of confusion and slurred speech.

Review 5. A type of seizure that is characterized by severe twitching of all the body's muscles and lasts for several minutes or longer is called a/an: A. partial seizure. B. absence seizure. C. petit mal seizure. D. grand mal seizure.

Review Answer: D Rationale: Grand mal seizures—a type of generalized seizure—are characterized by generalized severe twitching of all of the body's muscles; they often last for several minutes or longer. A petit mal (absence) seizure—also a type of generalized seizure—is characterized by a blank stare; generalized muscle twitching is absent.

Review 5. A type of seizure that is characterized by severe twitching of all the body's muscles and lasts for several minutes or longer is called a/an: partial seizure. Rationale: A partial seizure is broken down into simple (jerking of one part of the body) and complex (see changes in behavior and emotion). B. absence seizure. Rationale: An absence seizure is the same as a petit mal seizure or blank stare. C. petit mal seizure. Rationale: A petit mal seizure is the same as an absence seizure or blank stare. D. grand mal seizure. Rationale: Correct answer

Review 6. You are caring for a 2-year-old girl who apparently experienced a febrile seizure. She is awake and alert and her skin is hot and flushed. During transport to the hospital, you should: A. use the lights and siren. B. keep her warm with blankets. C. give blow-by oxygen as tolerated. D. lower her fever with chemical ice packs.

Review Answer: C Rationale: Febrile seizures commonly affect children, and are caused by an acute increase in body temperature. If the child is not actively seizing, simply transport him or her to the hospital, offer blow-by oxygen, and allow the parent or caregiver to accompany him or her. Removing clothing will help release body heat. However, attempting to lower the child’s fever may cause shivering, resulting in an acute spike in body temperature and another seizure, and should be avoided. Lights and siren should also be avoided; loud sounds or bright lights may also cause another seizure.

Review 6. You are caring for a 2-year-old girl who apparently experienced a febrile seizure. She is awake and alert and her skin is hot and flushed. During transport to the hospital, you should: use the lights and siren. Rationale: This could cause another seizure. B. keep her warm with blankets. Rationale: Remove clothing and blankets from the patient to allow the release of body heat. C. give blow-by oxygen as tolerated. Rationale: Correct answer D. lower her fever with chemical ice packs. Rationale: Attempt to lower the fever only if the patient is actively seizing. Use tepid water to avoid causing the patient to shiver.

Review 7. Common causes of an acutely altered mental status include all of the following, EXCEPT: A. hypoxemia. B. brain tumors. C. hypoglycemia. D. grand mal seizures.

Review Answer: B Rationale: Hypoxemia, hypoglycemia, and grand mal seizures are all acute events; therefore, they typically present with an acutely altered mental status. Brain tumors grow over time—often months to years—and usually cause a progressive decline in mental status.

Review 7. Common causes of an acutely altered mental status include all of the following, EXCEPT: hypoxemia. Rationale: Hypoxemia is a common cause of an acutely altered mental status. B. brain tumors. Rationale: Correct answer C. hypoglycemia. Rationale: Hypoglycemia is a common cause of an acutely altered mental status. D. grand mal seizures. Rationale: A grand mal seizure is a common cause of an acutely altered mental status.

Review 8. A patient with a suspected stroke presents with slurred speech that is difficult for you to understand. This is referred to as: A. aphasia. B. dysphasia. C. dysphagia. D. dysarthria.

Review Answer: D Rationale: Dysarthria is defined as slurred, poorly-articulated speech; it is common in stroke patients. Dysphasia is defined as difficulty speaking; the patient’s speech may or may not be slurred. Aphasia is the inability to speak. Dysphagia is defined as difficulty swallowing.

Review 8. A patient with a suspected stroke presents with slurred speech that is difficult for you to understand. This is referred to as: aphasia. Rationale: Aphasia is the inability to produce or understand speech. B. dysphasia. Rationale: Dysphasia is difficulty in speaking. C. dysphagia. Rationale: Dysphagia is difficulty in swallowing. D. dysarthria. Rationale: Correct answer

Review 9. A 56-year-old man experienced a sudden, severe headache and then became unresponsive. He has a history of high blood pressure. The MOST likely cause of his condition is a/an: A. hemorrhagic stroke. B. acute ischemic stroke. C. severe migraine headache. D. transient ischemic attack.

Review Answer: A Rationale: Hemorrhagic strokes are typically preceded by a sudden, severe headache (signals the rupture of a cerebral artery), after which the patient becomes unresponsive due to bleeding within the brain. Ischemic strokes and transient ischemic attacks generally do not cause a sudden, severe headache, and migraine headaches typically do not cause a loss of consciousness.

Review 9. A 56-year-old man experienced a sudden, severe headache and then became unresponsive. He has a history of high blood pressure. The MOST likely cause of his condition is a/an: hemorrhagic stroke. Rationale: Correct answer B. acute ischemic stroke. Rationale: This generally does not cause a sudden, severe headache. C. severe migraine headache. Rationale: This generally does not cause a loss of consciousness. D. transient ischemic attack.

Review 10. Which of the following are components of the Cincinnati Prehospital Stroke Scale? A. Arm drift, blood pressure, speech B. Speech, pupil response, arm drift C. Facial symmetry, speech, arm drift D. Pupil response, facial droop, speech

Review Answer: C Rationale: The three components of the Cincinnati Prehospital Stroke Scale are facial symmetry, speech, and arm drift. Both sides of the patient’s face should move symmetrically (equally) when he or she smiles. His or her speech should be easily understandable and without slurring. He or she should be able to hold both arms out in front of his or her body—with eyes closed and palms up—without one arm drifting down to his or her side.

Review 10. Which of the following are components of the Cincinnati Prehospital Stroke Scale? Arm drift, blood pressure, speech Rationale: The scale does not use blood pressure. B. Speech, pupil response, arm drift Rationale: The scale does not use pupil response. C. Facial symmetry, speech, arm drift Rationale: Correct answer D. Pupil response, facial droop, speech