Neurological Emergencies Coma Seizures Syncope Stroke Coma H

Neurological Emergencies Coma, Seizures, Syncope, Stroke

Coma H State of unconsciousness from which patient cannot be aroused

Coma H Unconsciousness = Immediate Life Threat H Loss of airway H Aspiration

Coma H Management of ABC’s must come before investigation of cause

Airway H H Open, clear, maintain If trauma present or no history available, immediately control C -spine

Breathing H H H Assess presence, adequacy High concentration O 2 immediately on all patients with decreased LOC Assist if respiratory rate, tidal volume inadequate

Circulation Pulses? Perfusion?

After ABC’s stabilized. . . H H Quickly investigate cause DERM

D = Depth of coma H H What does patient respond to? How does he respond?

E = Eyes H H H Pupils equal, dilated, constricted, Responsive to light? How?

R = Respiratory pattern H H H Rate? Unusually deep or shallow? Altered pattern?

M = Motor Function H H H Evidence of paralysis? Movement on stimulation? How?

Vital Signs H H H Shock? Increased ICP? Arrhythmias?

Head to Toe Survey H H H Injuries causing coma? Injuries caused by fall? What do the scene, bystanders tell you?

Possible Causes H H Not enough oxygen Not enough sugar Not enough blood flow to deliver O 2, sugar Direct brain injury H Structural (trauma) H Metabolic (toxins, infections, temperature)

Possible Causes Alcohol J Epilepsy J Insulin J Overdose J Uremia (and other metabolic causes) J Trauma J Infection J Psychiatric J Stroke, syncope J

Management H H Secure airway Protective reflexes may be lost Immobilize spine unless absolutely certain injury not present Spinal injury not suspected - patient on left side

Management H High concentration O 2 Assist ventilation as needed Monitor neurological/vital signs every 5 minutes

Management H H H Protect patient’s eyes on long transports (tape shut, moist pads) Patient may hear, understand even though unable to respond Treat, reassure accordingly

Seizures H H Episodes of uncoordinated electrical activity in brain Signs/symptoms depend on area involved

Epilepsy H Tendency to have repeated episodes of seizure activity

Seizure Types H H Grand mal (major motor) Petit mal (absence) Focal motor (simple partial) Psychomotor (complex partial)

Grand Mal Seizure H Aura H Sensation coming before convulsion H Patient may recognize as sign of impending seizure H May help locate origin of seizure in brain

Grand Mal Seizure H Convulsion H Loss of consciousness H Tonic phase - rigidity H Clonic phase - rhythmic jerking, incontinence, ineffective breathing

Grand Mal Seizure H Post-ictal Phase H H Exhaustion Drowsiness Headache Possible hemiparesis (Todd’s paralysis)

Petit Mal Seizure H H H Loss of consciousness No loss of postural tone More common in children

Focal Motor Seizure H H Rhythmic jerking of limb, one side of body No loss of consciousness

Psychomotor Seizure H H Loss of consciousness Sterotyped movements (automatisms) H May look purposeful, but aren’t H Lip smacking, movements of hands H May be called in as “drunk”, “O. D. ”, “psych patient”

Generalized Seizure Management H During seizure H Remove from potential harm H Do not forcibly restrain H Roll on side H Avoid putting anything in mouth

Generalized Seizure Management H After seizure ends H Assess ABC’s H Clear airway Most common cause of seizure deaths is post-ictal airway loss

Generalized Seizure Management H High concentration O 2 - immediately!! H Assist breathing if ventilation inadequate

Generalized Seizure Management H Obtain history/physical H Trauma that could have caused, been caused by seizure H Anti-seizure medications H Neuro/vital signs every 5 minutes H If patient ventilating adequately, transport on left side

Seizures H H Anything that injures brain cause seizures (AEIOU/TIPS) Do not assume seizures are due to idiopathic epilepsy until proven otherwise

Status Epilepticus H H H > 2 seizures without intervening conscious period Immediate Life Threat Management H Secure airway H Assist breathing with O 2 H Transport H Request ALS intercept

Syncope Fainting J Sudden, temporary loss of consciousness J Caused by lack of blood flow to brain J

Causes J Stress, fright, pain (vasovagal syncope) J Orthostatic hypotension (BP fall on standing) Decreased blood volume J Increased size of vascular space J J Decreased cardiac output J Prolonged forceful coughing

Management J ABCs J Keep patient supine, elevate lower extremities J Oxygen J Assess underlying cause

CVA J Cerebrovascular J Stroke accident

CVA H H Damage of portion of brain due to interruption of blood supply Mechanisms H Thrombosis H Hemorrhage H Embolism

Thrombosis H H Blockage of vessel by thrombus Usually forms at area narrowed by atherosclerosis Typically in older persons Frequently occurs during sleep

Hemorrhage H H H Vessel ruptures Associated with hypertension, aneurysms of cerebral blood vessels Usually characterized by H H Sudden onset Severe signs, symptoms

Embolism H H Blood clots, plaque fragments travel through vessel; lodge, block flow Often associated with: H Atherosclerosis of carotids H Chronic atrial fibrillation

Signs/Symptoms H Alterations in consciousness H Altered affect H Confusion H Dizziness H Coma

Signs/Symptoms H Localizing signs H Paralysis H Loss of sensation H Loss of speech H Unilateral blindness H Loss of vision in half of visual field of both eyes H Unequal pupils

Signs/Symptoms H H H Seizures Headache Stiff neck

Transient Ischemic Attacks H H TIAs “Little strokes” Produce deficits that resolve completely in <24 hours Frequently precede CVA

Management H H H Assess ABC’s Protect airway High concentration O 2 Vital signs every 5 -10 minutes Note increased BP, irregular pulse

Management H H H Nothing by mouth Avoid rough handling Transport paralyzed side down Guard your conversation Patients who cannot speak may still understand!

Management H H CVAs caused by thrombus, embolus may be reversible with thrombolytics (clot busters) Early recognition, rapid transport to appropriate facility is critical