1. Medical Emergencies Lecture 2 4-14

2. Syncope (cerebral ischemia)  Sudden, transient loss of consciousness and postural tone with spontaneous recovery  Possible causes  loss of cerebral oxygenation and perfusion  Often sign of another underlying condition  Often associated with a stressful condition  Most common medical emergency in the dental office  Most syncopal episodes occur during the administration of local anesthetics 4-14

3. Syncope  Affects all age groups  More susceptible in children, pregnant mothers, and the elderly.  Children (15% of children have had at least one episode of syncope before adolescence.) Causes:  Missed meal  Heat  Dehydration  Crying  Exertional activity 4-14

4. Syncope  Elderly:  Postural changes  Defecation  Coughing  Orthostatic hypotension  Medications  Diseases: coronary heart disease, heart failure, diabetes, renal insufficiency, chronic obstructive pulmonary disease  Mortality rate from syncope for patients age 60 and older is 5 times higher than patients under 60. 4-14

5. Signs and Symptoms of Pre-Syncope  Pallor  Pupil dilation  Diaphoresis: cold sweat  Excitation of piloerector muscles  Weakness, dizziness, vertigo  Nausea, tingling in toes and fingers**  Yawning or sighing  Usually occur several minutes before loss of consciousness. Table 5.1 pg 51 in book. 4-14

6. Signs and Symptoms of Pre-Syncope  Vision changes – darkening, blurring, seeing spots  Increased BP  Shortness of breath  Heart palpitations  Chest pain  Slow onset  Dental professional may see the patient become pale.  Place patient in Trendelenburg position** 4-14

7. Signs and Symptoms of Syncope Syncopal symptoms ◦Unconsciousness ◦Weak, slow pulse ◦Low heart rate ◦Pallor ◦Flaccid muscles** 4-14

8. Treatment of Syncope Remove objects from oral cavity Position supine with feet elevated Open airway Assess circulation Loosen tight clothing Administer oxygen, 4-6L/minute Monitor vital signs

9. Treatment of Syncope If unconsciousness persists summon EMS Bradycardia 0.6 mg atropine IM Longer patient in syncope more likely seizure will occur Once consciousness returns ◦Keep in supine position until patient feels well enough to be returned to upright position and pulse returns to normal

10. Treatment of Syncope Once consciousness returns ◦Suspend treatment for the day ◦Emergency contact should escort patient home as syncope can reoccur ◦If neurocardiac syncope suspected contact EMS ◦Thoroughly document syncope episode in chart

11. Figure 5.2 Patient in appropriate position for treatment of syncope

12. Types of Syncope  Cardiac syncope  Noncardiac syncope  Neurocardiac syncope

13. Preventing syncope in the dental office** Review medical history for past episodes of syncope. Help patient to relax and reduce anxiety; build a good client-provider rapport; low- stress environment. Patient’s who feel faint: recline dental chair to Trendelenburg position (head lower than legs) 4-14

14. Types of Syncope  Neurocardiac/Vasodepressor syncope: most common form encountered by dental professionals  Noncardiac syncope  Cardiac syncope 4-14

15. Types of Syncope  Neurocardiac syncope: most common type of syncope.  Vasodepressor, vasavagal, neurocardiogenic, neurally mediated (synonyms for neurocardiac syncope)  Associated with some noxious stimuli: pain, fear, exhaustion, or illness.  Dental patients who are anxious can lead to a physiological responses that produce syncope.  Activation of the autonomic nervous system: fight or flight response.  Release of catecholemines, epinephrine and norepinephrine particularly, to muscle tissues in preparation for movement with blood pumped back to heart 4-14

16. Types of Syncope Neurocardiac syncope ◦When the sympathetic system is activated pts will experience rapid, pounding heart, deep breathing, dry mouth, cold, sweaty skin, dilated pupils. (Fight or flight responses) ◦If no movement occurs (such as with dental patients) blood pools in extremities causing hypotensive response, bradycardia, and decrease in cerebral blood flow leading to syncope 4-14

17. Types of Syncope  Non-Cardiac syncope  Seizures – due to reduction of oxygen to the brain  Orthostatic hypotension – reduction in BP when assuming an upright position  Situational occurrences – coughing, urination, defecation, neck stretching, hair grooming, venipuncture, swallowing  Valsalva’s maneuver – forced expiratory effort against a closed airway  Hyperventilation – excessive breathing causing change in chemical make-up of blood  Can cause sufficient cerebral vasoconstriction which can lead to syncope  Metabolic diseases – hypoglycemia or hypoxemia 4-14

18. Types of Syncope  Cardiac syncope (2 nd most common type)  Inadequate cardiac output  Usually from underlying heart disease  Commonly from arrhythmias or obstructions of the heart  Patient’s heartbeat can be rapid and irregular(tachyarrhythmia) or slow and irregular(bradyarrhythmia)  Pacemaker malfunction  Very serious and Potentially fatal  Requires referral to medical professional 4-14

19. Figure 5.1 Types and etiologies of syncope

20. Treatment of Syncope Remove objects from oral cavity Position supine with feet elevated: presyncopal symptoms indicate a 50-70% decrease in blood flow to the brain. Open airway Assess circulation Loosen tight clothing Administer oxygen, 4-6L/minute Monitor vital signs 4-14

21. Treatment of Syncope  If unconsciousness persists summon EMS (unconsciousness can last between a few seconds to minutes).  Longer patient in syncope more likely seizure will occur due to lack of oxygen to the brain.  Ammonia inhalants are no longer recommended for use due to severe complications.  Once consciousness returns  Keep in supine position until patient feels well enough to be returned to upright position and pulse returns to normal 4-14

22. Treatment of Post-Syncope**  Once consciousness returns  Suspend treatment for the day  Emergency contact should escort patient home as syncope can reoccur within the first 24 hours of the first episode.  If neurocardiac syncope suspected contact EMS  Thoroughly document syncope episode in chart  At the next dental appointment, the patient may need anti-anxiety medications.  The patient should be evaluated by a medical doctor. 4-14

24. Chapter 6 SHOCK 4-14

25. Shock Condition produced when the cardio- vascular pulmonary system fails to deliver enough oxygenated blood to body tissues to support metabolic needs Tissues use anaerobic (without air) metabolic processes Produces acidosis (increased acidity in the blood) and harmful toxins 4-14

26. Stages of Shock  Initial  Compensatory  Progressive  Refractor 4-14

27. Stages of Shock Initial – first stage ◦Cells deprived of oxygen ◦Inhibits ability to produce energy ◦Cells not functioning properly ◦Impacts body systems 4-14

28. Stages of Shock Compensatory (2 nd stage) – body performs physiological adaptations in an attempt to overcome shock ◦Increased respiration to increase oxygen to cells ◦Increased blood pressure to compensate for hypotension (low blood pressure) ◦Reduced blood supply to peripheral organs to improve blood supply to brain ◦Reduced blood flow to kidneys with resulting oliguria (reduced urine output) 4-14

29. Stages of Shock Progressive ( 3 rd stage) – compensatory mechanisms begin to fail ◦If the problem causing shock is not treated, condition will worsen ◦Vital organs compromised and not functioning appropriately ◦Systolic hypotension (low BP) 4-14

30. Stages of Shock Refractory (4 th stage) – failure of vital organs ◦Irreversible ◦Cell death and brain damage have occurred ◦Death will occur in a few hours 4-14

31. Types of Shock Hypovolemic Cardiogenic Distributive ◦Anaphylactic ◦Septic ◦Neurogenic Obstructive 4-14

32. Hypovolemic Shock Most common form. A state of decreased blood volume. Caused by inadequate venous return to the heart Etiologies: ◦ Hemorrhage or dehydration (vomiting or diarrhea) 4-14

33. Hypovolemic Shock Initial symptoms: ◦Peripheral vasoconstriction causing an elevated diastolic BP ◦Increased heart rate ◦Rapid, thready pulse ◦Cool skin ◦Reduced urine output ◦Confusion 4-14

34. Hypovolemic Shock  Treatment  Stop the bleeding, diarrhea, or vomiting that is causing the shock.  Supine position  Call EMS  ABC’s of CPR  Monitor vital signs  Administer oxygen 4-6L/minute  IV fluids to restore circulating blood volume 4-14

35. Cardiogenic Shock Reduction in perfusion due to decreased cardiac output. Heart fails to pump enough blood to supply oxygen to the peripheral tissues and body organs. Etiologies (Can be caused by) damage to the heart due to…. ◦MI (heart attacks) ◦Cardiac arrhythmias ◦Cardiac dysfunction 4-14

36. Cardiogenic Shock  Signs and symptoms  Reduction in BP with systolic below 90 mmHg  Fast, weak pulse  Cold, clammy skin  Cyanosis: blue or purple color of skin due to the tissues receiving less oxygen  Non-specific chest pain  Shortness of breath  Reduced urine output and confusion  Mental confusion 4-14

37. Cardiogenic Shock  Treatment  Supine position (Face up)  Contact EMS  Monitor vital signs  Administer oxygen using a non-re- breather mask  Needs IV fluids: treatment provided in ER  Cardiac medications needed: beta blockers or vasodilators 4-14

38. Distributive Shock Vasogenic shock (another name for distributive shock) ◦3 types: result from vasodilation and abnormal distribution of fluids in the circulatory system. ◦Anaphylactic ◦Septic ◦Neurogenic 4-14

39. Anaphylactic Shock Sudden, massive vasodilation and circulatory collapse following exposure to an allergen Will be discussed in detail later in Allergy chapter Treatments: epinephrine, histamine blockers, or corticosteroids. 4-14

40. Septic Shock Also called: Vasodilatory shock Bacteria (particularly gram-negative bacilli) invades bloodstream and causes an inflammatory response to try to rid itself of the invader Result of a severe infection. Can cause multiple organ failure and death. 4-14

41. Septic Shock  Signs and symptoms  Fever, vasodilation (widening of blood vessels)  Increased cardiac output  Tissue edema (swelling)  Pink, warm skin  Restlessness  Tachycardia (rapid heart rate)  Thirst  Eventual respiratory failure  Vasodilation causes the patient to appear pink & warm, which differs from all other forms of shock 4-14

42. Septic Shock  Signs and symptoms  Can cause microthrombi formation (small blood clots)  Often fatal and cause multiple organ failure.  Usually seen in elderly individuals, individuals with poor nutritional status, neonates (babies), critically ill, and immunocompromised patients  hypotension, restlessness, anxiety, tachycardia, thirst, respiratory failure.  Treatment: fluids, antimicrobial therapy, possible surgery to reduce or eliminate the infection. 4-14

43. Neurogenic Shock Loss of sympathetic nerve activity (activates the fight or flight response) from brain’s vasomotor center, which regulates blood pressure, due to an emotional trauma, disease, drug, or traumatic injury to brain or spinal cord Loss of sympathetic nerve activity causes peripheral dilation (expansion of blood vessels) leading to reduction in venous return, thus causing decreased cardiac output with hypotension (low blood pressure) 4-14

44. Neurogenic Shock Signs & symptoms ◦Hypotension (low blood pressure) ◦Bradycardia (low heart rate) ◦Brain and kidneys at risk of failure 4-14

45. Neurogenic Shock Treatment ◦Position supine ◦Contact EMS ◦Monitor vital signs ◦Needs drug therapy to restore cardiac output: like dopamine to promote vasoconstriction, and epinephrine to restore blood pressure and cardiac output. 4-14

46. Obstructive Shock  Results from indirect heart pump failure  Leads to decreased cardiac function and reduced circulation  Etiologies  arterial stenosis: narrowing of an artery  pulmonary embolism: blockage of the main artery of the lung or a branch of the lung by a substance that has traveled through the blood stream.  cardiac tamponade: when fluid fills up the sac around the heart faster than the sac can stretch. 4-14

47. Obstructive Shock Symptoms ◦ Severe Hypotension: low blood pressure ◦Dyspnea: shortness of breath 4-14

48. Obstructive Shock Treatment ◦Position supine ◦Contact EMS ◦Monitor vital signs ◦Needs IV fluids ◦Relieving source of obstruction essential, surgical intervention often required 4-14

49. Hyperventilation  A condition whereby rapid, deep breathing occurs, thus eliminating more carbon dioxide than is produced  Normal respiration rate for an adult: 12 – 20 RPM  Rarely exceeds 22 RPM  A person hyperventilating might have a RR: 22-40  Affects 6–15% of population  More common in females age 30 – 40 4-14

50. Hyperventilation Optimal pH 7.4 – slightly alkaline Hyperventilation – pH 7.5 or higher This minor change can have significant physiological effects 4-14

51. Hyperventilation  Common when individuals are exposed to high altitudes, are pregnant, take CNS stimulants, experience aspirin toxicity, or are extremely anxious  CNS drugs- Central nervous system stimulatory drugs, such as: antidepressants, hallucinogens, marijuana, lidocaine, benzocaine, codeine, hydrocodone, morphine, diazepam.  Lack of carbon dioxide in the arterial blood system (hypocapnia) leads to respiratory alkalosis (increase in the pH of blood) and cerebral vasoconstriction. 4-14

52. Signs and Symptoms Table 7.1 pg 67 Hypocalcemia – reduction in calcium levels in blood Symptoms mimic pulmonary embolism – blockage of pulmonary artery – can be fatal – patients often die within 2 hours of onset

53. Signs and Symptoms  Most common symptoms: Abnormally prolonged rapid and deep respirations  Decrease in carbon dioxide causes vasoconstriction of blood vessels leading to decreased cardiac output – can cause palpitations and chest pain  Impairment of problem solving abilities, motor coordination, balance, and perceptual tasks due to lack of oxygen to the brain. 4-14

54. Figure 7.1 Lorazepam

55. Treatment  Operator remain calm  Place patient in position of their choice – usually upright  Loosen tight clothing in neck region  Work with patient to control rate of respirations  Have patient count to 10 in one breath  Breathe through pursed lips or nose  NO MORE PAPER BAGS: can cause suffocation and cardiac arrest. 4-14

56. Treatment Monitor vital signs DO NOT administer oxygen-it can make the condition worse. If symptoms do not improve administer benzodiazepine (Lorazepam 1-2 mg IM or Diazepam 2-5 mg IM) If symptoms do not improve contact EMS 4-14

57. Seizure Temporary episode of behavior alteration due to massive abnormal electrical discharges in one or more areas of the brain. Changes in consciousness-involuntary contractions of the muscles.** Epilepsy or seizure disorder: condition where a person has recurrent seizures and convulsions.** 4-14

58. Seizure Can be recorded on EEG May be accompanied by convulsions or other neurological, sensory, or emotional changes Can be caused by systemic distress – isolated non-recurrent attacks ◦Hypoxia ◦Hypoglycemia ◦Seizures

59. Seizures Trauma Perinatal injuries Tumors Toxins Infectious agents Electrolyte imbalance Uremia: kidney failure Drug withdrawal Sedative hypnotics Vascular disorders 4-14  Can be caused by damage or disease of the brain from:

60. Preventing Seizure Activity Medical History: identifying patients with a past history of seizures or convulsions.** Evaluate medications the patient is taking to control seizures and if the patient has taken their seizure medications.** Schedule shorter appointments early in the day.** DO NOT use Nitrous Oxide on seizure patients** 4-14

61. Epilepsy Common disorder 2 million in the United States Seizures most common are neurological disorders in pediatrics

62. Epilepsy Initial seizures in adults usually due to trauma, disease, or stroke. A Seizure is not a disease, but a symptom of CNS dysfunction Seizures not usually life-threatening Rare cases if seizure continues without stopping or without a recovery period (status epilepticus) it becomes a true medical emergency and appropriate therapy is needed to prevent death. 4-14

63. Etiology of Seizures Cellular level – several theories ◦Alterations in cell membrane permeability ◦Decreased inhibition of cortical or thalamic neuronal activity ◦Changes in cell structure that alter cellular excitability ◦Imbalances in neurotransmitters

64. Classification of Seizures  Two broad categories  Primary/unprovoked or idiopathic  Usually part of epileptic syndrome  65% of seizures are of this kind  Genetic tendency  Usually require daily anti-seizure medication  Secondary/provoked or acute symptomatic  35% of seizures are of this kind 4-14

65. Secondary/Provoked Classification of Seizures  Preventable if underlying cause is treated  Metabolic disorders: electrolyte imbalance, low blood sugar, hypoxia, low calcium  Injury to CNS: trauma, hypoxia during delivery  Medications (epileptogenic): seizure provoking: penicillin, local anesthetics, hypoglycemic agents.  Rapid drug withdrawal  CNS tumors: most common in 35-50 year olds  Vascular disorders – after age 60 – atherosclerotic cerebrovascular insufficiency, cerebral infarction.  Infections of CNS: bacterial meningitis, malaria, rabies, HIV, brain abscesses.  Photosensitive epilepsy – children exposed to flickering lights – video games 4-14

66. Seizures in Dental Setting  Several potential etiologies  Hypoglycemia  Hypoxia – secondary to syncope  Local anesthetic toxicity  Epilepsy  Hypoglycemia, hypoxia and local anesthetic toxicity can be prevented by appropriate patient management and taking a thorough medical history.  Reducing stress will help prevent seizures caused by epilepsy. 4-14

67. Types of Seizures Partial seizures ◦Simple partial with no loss of consciousness ◦Jacksonian ◦Sensory ◦Complex partial

68. Partial (Focal/Local) Seizures Most common type of seizure among newly diagnosed adults. Come from a localized area in the brain, but can spread to the entire brain causing a generalized seizure. Signs and symptoms depend on the area affected in the brain. Two major types of partial seizures: simple and complex. 4-14

69. Simple Partial Seizures Symptoms ◦Foul smells ◦Aura ◦Visual – occipital lobe ◦Auditory – temporal lobe ◦Amnesia often follows ◦Auras now considered to be a simple partial seizure with impending complex or generalized seizure

70. Simple Partial Seizures Consist of motor, sensory, or psychomotor changes with NO loss of consciousness. Symptoms: illusions, déjà vu, flashing lights, hallucinations, tingling and creeping sensations, vertigo, sounds, and foul smells or auras. Symptoms may reflect the area of the brain activity: visual- occipital lobe; auditory-temporal lobe; olfactory. 4-14

71. Simple Partial Seizures: Auras Symptoms:  Aura – sensory symptom occurring at onset of seizure.  Signals the beginning of abnormal changes in a focal area of the brain.  Typical auras include strong smells, nausea, mood changes, unusual tastes, visual disturbances lasting only a few seconds.  Amnesia often follows  Auras now considered to be a simple partial seizure which serve as a warning sign of impending complex or generalized seizure. 4-14

72. Complex Partial Seizures  Signs and symptoms  Lose contact with surroundings – a few seconds to 20 minutes  Automatisms – repetitive, non-purposeful activity (lip smacking, grimacing, patting, wandering in circle unintelligible speech)  At the end of motor activity – mental confusion or fear

73. Generalized Seizures: Tonic-Clonic (GTCS) or Grand Mal Seizures Most common type of seizure disorder. Occurs equally in males and females, and at any age. Most GTCS occur by puberty. Specific sequence of events from the warning phase to recovery, not all patients experience all events. 4-14

74. Phases of GTCS Generalized Tonic-Clonic Seizures (GTCS) ◦Specific sequence ◦Aura ◦Preictal Phase ◦Ictal ◦Tonic phase ◦Hypertonic phase ◦Clonic phase ◦Postseizure or postictal phase

75. Four stages of GTCS: first stage is aura Aura or prodromal phase. (also discussed under simple partial seizures)  Considered to be a simple partial seizure, an aura is a sensation that precedes seizure activity.  Some people experience changes in emotional state, such as extreme anxiety or depression.  Most have the same aura experience prior to a seizure.  The amnesic effect of seizures causes the person to not remember experiencing an aura. 4-14

76. Preictal Phase: second stage Occurs soon after aura Patient loses consciousness May fall if standing – the most common cause of seizure related injuries. 4-14

77. Ictal Phase Tonic phase ◦Muscles have sustained contraction – patient appears rigid ◦Produces loud cry – epileptic cry or crowing ◦Dyspnea and cyanosis due to contraction of respiratory muscles Hypertonic Phase ◦Extreme muscle rigidity

78. Ictal Phase continue Clonic phase ◦Muscular contractions and relaxation ◦Clenched jaw ◦Saliva + air = froth at mouth ◦Blood from biting tongue or soft tissues ◦2-5 minutes – gradually slow with final flexor jerk

79. Post-Ictal Phase Movement stopped Patient remains unconscious CNS, CVS, and respiratory system depression CNS and respiratory may lead to airway obstruction – time when death is most likely

80. Post-Ictal Phase  Muscle relaxation – urinary or fecal incontinence  Patient awakens – confused, fatigued, wanting to sleep, amnesia  Lasts for minutes to several hours

81. Fourth Ictal Phase  Postseizure or postictal phase:  Movement stopped, pt remains unconscious.  When seizure stops, depression occurs in the central nervous system, cardiovascular, and respiratory systems, related to how severe the seizure was.  Depression of the CNS and respiratory systems may lead to airway obstruction the time when death is most likely to occur.  Muscle relaxation after the first minutes after the seizure causing urinary and/or fecal incontinence,  Patient awakens – confused, fatigued, wanting to sleep, amnesia,  Lasts for minutes to several hours, close observation essential to protect the airway. 4-14

82. Treatment of Seizures  Primary task in the dental office is to try and prevent injury to the patient having the seizure.  Specific steps should be followed depending on the type of seizure. 4-14

83. Treatment of GTCS Seizures Primary task Cease dental treatment Remove instruments from mouth Move equipment out of the way Loosen tight clothing Place in supine position

84. Treatment of GTCS Seizures Leave patient in dental chair Contact EMS ABC’s of CPR Monitor vital signs Gently restrain to prevent injury

85. Treatment of GTCS in the dental office If the patient is in the chair, do not move patient, but lower the chair and help prevent patient from falling by positioning one person at the head and one person at the foot of the chair. Call EMS if the seizure last longer than 3 minutes or the patient becomes cyanotic. Give oxygen 6-8 L/min through a non-rebreather mask. CABs of life support provided if needed, vitals should be monitored. Pt should be gently restrained to prevent injury. Do NOT place anything into the patient’s mouth. 4-14

86. Status Epilepticus  Status epilepticus or continuous GTCS or repetitive recurrence of any type of seizure without recovery between episodes.  Life-threatening situation  May persist for hours or days and is the major cause of mortality related to seizure disorders.  Temperature may rise to 106° F, tachycardia and dysrhythmias may occur, and BP elevated to 200/150.  Uninterrupted grand mal status may continue until death occurs as a result of cardiac arrest, irreversible brain damage due to lack of oxygen, or a significant decrease in blood glucose levels. 4-14

87. Status Epilepticus Incidence of grand mal status has decreased due to effective antiseizure medications. If a tonic-clonic seizure does not stop after 5 minutes, the use of anticonvulsant drugs may be necessary-call EMS. 4-14

88. Absence or Petit Mal Seizures (nonconvulsive) Neither generally pose a problem during dental treatment. If one of these seizures occurs, stop dental treatment, protect the pts airway. Remove all instruments from the pts mouth. Monitor vital signs. Treatment can continue at the end of the seizure if the pt has no ill effects. 4-14

89. Prevention for Known Seizure Patients  Discuss with patients who respond positively to seizures on their med hx:  Recent illnesses, stress, hormone fluctuations, fatigue  Recent hx of head trauma  Recent hx of fever, headache, stiff neck  Alcohol or substance abuse 4-14  General physical condition, including depression  Taking prescribed meds on schedule  Info about seizure history  Alteration or loss of consciousness  Postictal systems such as confusion or amnesia

90. Prevention strategies in the dental office  Clinician may wish to postpone dental tx if there are risk factors indicated in the patient’s medical hx.  Blood glucose levels, fatigue, and anxiety are common triggers for seizures in poorly controlled cases.  Patient’s doctor may need to be consulted. 4-14 Best time to tx seizure pts: early morning appts, after pts have eaten and within a few hours of taking antiseizure meds.** Irritability is often a symptom that a seizure is coming.

91. Cerebrovascular Accident (CVA) AKA stroke Abnormal condition of the brain Leads to cell death Second leading cause of death world wide US ◦third leading cause of death and disability

92. Risk Factors for CVA Age African Americans Atrial fibrillation ◦2 million Americans ◦Two atria quiver ◦Heart pumps blood inefficiently resulting in pooling of blood – leads to thrombi ◦Increases risk of CVA five fold

93. Risk Factors for CVA Oral contraceptives Menopause due to estrogen changes Diabetics Familial history of CVA Carotid Bruit – abnormal sound in carotid artery

94. Transient Ischemic Attacks Brief episodes of neurological dysfunction Last less than one hour 200,000 – 500,000 suffer from TIAs annually 10% of all strokes preceded by TIA CVA often occur within first 4 days of TIA

95. Ischemic CVA Blockage Thrombus or embolus 85% CVAs – 60% thrombotic; 40% embolic Core - central zone of ischemic tissue Penumbra – surrounding tissue receiving diminished blood supply ◦Potentially salvageable if blood supply restored quickly

96. Hemorrhagic CVA Rupture 15% Factors

97. Types of Hemorrhagic CVA  Intracerebral  Subarachnoid Mortality Pressure that is causing damage gradually diminishes and brain regains some of its former function

98. Intracerebral CVA Twice as common Occurs when defective artery within the brain bursts Surrounding tissue fills with blood Blood places pressure on adjacent tissues Due to ruptured artery other areas of brain ischemic leading to additional damage

100. Subarachnoid CVA Occurs when blood vessel on surface of brain ruptures and bleeds into subarachnoid space Blood places pressure on cerebellum causing pressure and damage to brain cells

101. Signs and Symptoms of Ischemic CVA May stop and start again as stroke progresses Severity and location Altered level of consciousness Pupils unequal and dilated Confusion Dizziness Change in balance or coordination (ataxia) Vision changes – loss of half the visual field

102. Signs and Symptoms of Ischemic CVA Deviation of tongue Difficulty swallowing (dysphagia) Speech changes ◦Poorly articulated speech (dysarthria) ◦Impairment of speech (dysphasia) ◦Inability to understand spoken word ◦Inability to speak at all (aphasia)

103. Signs and Symptoms of Ischemic CVA Drooling Weakness, numbness, or tingling in one side of face Facial droop Numbness or tingling in arm or leg or both on one side of body (hemiparesis) Nausea or vomiting

104. Signs and Symptoms of Hemorrhagic CVA Onset abrupt and rapid Severe headache Increased BP Subarachnoid CVA – neck pain or stiffness Inability to stand or walk Papillary malalignment Nausea or vomiting Altered level of consciousness

105. Stroke Scales Cincinnati Pre-Hospital Stroke Scale (CPSS) Looking for facial palsy, arm motor weakness, dysarthria ◦Ask patient to smile – observe for weakness on one side of face ◦Ask patient to hold out both arms palm up and eyes closed for 10 seconds – observe for weakness in one arm

106. Stroke Scales ◦Ask patient to repeat simple sentence – “The sky is blue in Cincinnati.” – observe for difficulty in speech ◦If any of the 3 components found to be abnormal then assume CVA

107. Treatment Contact EMS immediately Position semi-supine BLS – check airway, breathing, and circulation Administer O 2 4-6L/min Test glucose levels to rule out hypoglycemia

108. Treatment Monitor vital signs Transport to ED as soon as possible Aspirin for ischemic CVA reduces death and recurrence rates Aspirin for intracranial hemorrhage CVA patients also improved outcomes – however not recommended

109. Treatment In hospital ◦CT scan to determine etiology ◦Hemorrhagic – probably surgery ◦Ischemic – < 3 hours onset of symptoms then IV thrombolytic therapy with altaplase (r-tPa) – removes thrombus or embolus to restore blood flow ◦Ineffective after 3 hours ◦Contraindicated for hemorrhagic CVA

110. Click to add title An epileptic cry caused by air rushing from the lungs may occur during which stage of a grand mal seizure? a.Preictal b.Convulsive c.Postictal d.Characteristic of hysterical seizure

111. B

112. 4-14