hello and welcome to chapter 18 neurologic emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the significance and characteristics of the following anatomy and physiology of the nervous system common disease processes relating to strokes seizures headaches and altered mental status assessment and basic care management involving patients with a neurologic emergency including performing tests for speech facial movement and arm movement and assistance of the aels provider and managing these neurologic emergencies drogue is the fifth leading cause of death and the leading cause of adult disability in the united states it is common in geriatric patients contributing factors for stroke include family history and race and new treatments are available for stroke seizures and alter mental status may also occur when there is a disorder in the brain now seizures may occur as a result of a recent head injury brain tumors some type of metabolic problem fever or a genetic disposition possible causes of altered mental status include intoxication head injury hypoxia stroke or metabolic disturbances and treatments vary widely so let's talk about the anatomy and physiology of a neurologic emergency the brain is the body's computer it controls breathing speech and all other body functions there are three major parts this includes the brain stem the cerebellum and the cerebrum now the cerebrum is the largest part the brain stem controls the basic functions such as blood pressure breathing and swallowing also pupil constriction and the cerebellum controls muscle and body coordination the figure on this slide illustrates the three major parts of the brain and you could see the cerebrum the cerebellum and the brainstem okay let's talk a little bit about more about these parts so the cerebrum is located above the cerebellum it's divided into the right and left hemispheres each controls activities on opposite sides of the body the front of the cerebrum controls emotion and thought the middle part controls sensation and movement and the back processes sight in most people speech is controlled on the left side of the brain near the middle of the cerebrum messages sent to and from the brain travel through nerves you have 12 cranial nerves and they run directly from the brain to parts of the head the rest of the nerves join in the spinal cord and exit the brain through a large opening in the base of the skull called the forum magnum each vertebrae in the neck back and neck has two nerves which branch out from the spinal cord and carry signals to and from the spinal cord the figure on this slide illustrates the skull and the spinal cord and the intersection of that the spinal cord exits you could see the skull at the four magnum and two nerves branch out of the spinal cord at each vertebra in the neck and back so let's talk about some of the pathophysiology many different disorders may cause brain dysfunction and may affect the patient's level of consciousness speech and voluntary muscle control the brain is the most sensitive to changes in oxygen glucose and temperature levels a significant change in any of these levels will result in a neurologic damage or change so let's talk about headache first one of the most common complaints you will hear from your patients in terms of pain is a headache headaches can be a symptom of another condition or it can be a neurologic condition on its own only a small percentage of headaches are caused by a serious medical condition tension headaches migraines and sinus headaches are the most common types of headaches let's talk about tension headaches first it's caused by muscle contractions in the head and neck and are contributed to stress the pain is usually described as squeezing dull or an ache usually do not require medical attention next we have migraine headaches and they are thought to be caused by changes in blood pressure uh vessel size in the base of the brain the pain is usually described as pounding throbbing or pulsating and they're often associated with nausea and vomiting and may be preceded by visual warning signs such as flashing lights or partial vision loss migraine headaches can last for several hours two days then you have sinus headaches and they are caused by pressure that is a result of fluid accumulation in the sinus cavities patients may also have cold like signs and symptoms of nasal congestion cough and fever pre-hospital emergency care is usually not required and then there's serious conditions that include headaches such as a hemorrhagic stroke or brain tumor or meningitis so let's start talking about a stroke a stroke which is also known as a cerebral vascular accident or cva is an interruption of blood flow to an area within the brain that results in loss of brain function you have two different types of stroke first we're going to talk about the ischemic stroke and this is the most common it accounts for 87 of all the strokes it results from a thrombus or an emboli and symptoms may range from nothing at all to complete paralysis atherosclerosis in the blood vessels is often the cause so this illustration shows an ischemic stroke and then you have a hemorrhagic stroke and this accounts for 13 of all strokes it results from bleeding inside the brain in cerebral hemo hemorrhages are often fatal people at a high risk include those experiencing stress or exertion and people at highest risk are those who have very high blood pressure or long-term elevated pressure that is not treated in this very aneurysm there are also common causes of hemorrhagic strokes in healthy young people and it presents as the worst headache of their life and causes a sub or arachnoid hemorrhage then you have a tia and this is a transient ischemic attack and it's stroke-like symptoms that go away on their own within less than 24 hours it may be a warning sign of a larger stroke to come and it's considered an emergency about one-third of patients who have a tia will experience a stroke soon after and all patients with a tia should be evaluated by a physician so let's talk about the signs and symptoms of a stroke general signs and symptoms include facial drooping sudden weakness or numbness in the face arm leg or one side of the body you could have decrease or absent movement and sensation on one side of the body lack of muscle coordination or loss of balance sudden loss of vision in one eye or blurred or double vision you could have difficulty swallowing decreased level of responsiveness perhaps some speech disorders aphasia which is difficulty expressing thoughts or inability to use the right words or difficulty understanding spoken words okay slurred speech sudden and severe headache confusion or dizziness you could have weakness combativeness restfulness tongue deviation or coma so if the stroke happens in the left hemisphere it may cause aphasia aphasia is the inability to produce or understand speech and speech problems can vary widely strokes that affect the left side of the brain can also cause paralysis of the right side of the body then on the right side if you have a stroke on the right side it may affect the brain and it could cause paralysis of the whole left side of the body okay so usually patients will understand language and be able to speak but their words may be slurred and hard to understand and patients may be oblivious to this their problem and also it may affect certain parts of their vision neglect and lack of pain cause many patients to delay seeking help bleeding in the brain so let's talk about this so patients may have who have very high blood pressure and may cause bleeding and so um when it causes bleeding uh basically this is a compensatory response and so a trend of increasing blood pressures is an important sign as the body may increase the blood pressure to get blood to the brain tissues significant drops in blood pressure may result as the patient's condition worsens so conditions that may mimic a stroke are hypoglycemia or low blood sugar postdictal state and that's that state right after you have a seizure or a subdural or epidural bleeding okay so the figure on the slide illustrates intracranial bleeding trauma to the head may result in intracranial bleeding so bleeding outside the dura and under the skull is called epidural bleeding and bleeding beneath the dura but outside of the brain is called subdural bleeding let's talk about seizures so a seizure is a neurologic episode caused by a surge of electrical activity in the brain and in the united states it's estimated that 3.5 million people have epilepsy seizures are caused by two basic groups you have a generalized seizure or a partial seizure now partial seizures are also called focal seizures so let's talk about generalized seizures first you'll hear them referred to as tonic clonic seizures and this is a result from abnormal electrical discharges in large areas of the brain involving both hemispheres typically characterized by unconsciousness and a generalized severe twitching of all the muscles and it lasts usually several minutes or longer then you have absence seizures and this does not involve any changes in the motor activity they're characterized by brief lapse of consciousness in which the patient seems to stare or not respond then you have focal this is the partial seizure in a focal onset of awareness of a seizure so you might not have a change in the patient's level of consciousness patients may be numb weak dizzy they might have visual problems or an unusual smell and it may cause some twitching or br brief paralysis focal onset so you're going to have an impaired awareness of a seizure the patient has an altered mental status and does not interact normally with his or her environment results from abnormal discharges from the temporal lobe of the brain other characteristics may be lip smacking eye blinking or jerking patients also may experience unpleasant smells and visual hallucinations exhibit uncontrollable fear or perform repetitive physical behavior so patients may experience a warning sign prior to a seizure and this is an aura okay and it could include visual changes or hallucinations people with a history of seizures recognize their auras and they usually take steps to minimize injury such as sitting or laying down auras do not occur prior to every seizure but not all and not all patients with a seizure disorder experience auras so a generalized seizure and this is characterized by sudden loss of consciousness followed by chaotic muscle movement and tone and apnea and it may exhibit bilateral muscle movement characterized by a cycle of muscle rigidity and relaxation typically it lasts about five minutes it's followed by a post-ictal state and then you have the absence formerly called a petite maul and this is a seizure that may last for seconds after which the patient fully recovers with only brief lapse of memory of the event status epileptis that's a seizure that lasts for more than five minutes and are and they progress um to assass epilepsis so seizures that continue every few minutes without a person regaining consciousness or lasting longer than 30 minutes okay reoccurring or prolonged seizures should be considered immediately life-threatening situations all right so on the slide you can see some causes of seizures so these are common causes of seizures you have congenital metabolic or febrile seizure epileptic seizures usually can be controlled with medicines medicines used often to treat seizures include kepra dylan phenobarbital tegritol adepa code topomax and klonopin it's important to recognize seizures so recognize a seizure is occurring and whether the episode differs from the previous one recognize the post-ictal state and complications of seizures and identify other problems associated with seizures the post-ictal state is when the seizure has stopped the patient's muscles relax becoming almost flaccid or floppy and the breathing becomes labored okay it may be characterized by hemiparesis or weakness on one side of the body and that might resemble a stroke the postal state is the most commonly characterized by lethargy and confusion and if the patient's condition does not improve you should consider other possible underlying conditions a syncope so seizures are often mistaken for syncope or fainting and fainting typically occurs while the patient's standing and seizures may occur in any position so fainting is not associated with a post-actual state then let's talk about altered mental status so aside from a stroke and seizure the most common type of neurologic emergency that you will encounter in a patient is an altered mental status this includes hypoglycemia so low sugar hypoxia intoxication delirium drug overdose or perhaps an unrecognized head injury a brain infection perhaps body temperature abnormalities a brain tumor an overdose or a poisoning so let's talk about the patient assessment of this these neurologic emergencies okay so first of course you're going to have that scene size up and you need to make an early determination whether it's a medical or trauma situation look for threats to safety and follow standard precautions consider the need for spinal immobilization and call for additional resources early next is that primary assessment so look for life-threatening conditions perform a rapid exam and establish priorities based on assessment of the patient's level of consciousness and ex-abcs history taking so if the patient is unresponsive gather any history from the family members or bystanders if no one's around look for explanations for an altered mental status you could look for signs and symptoms that may indicate a patient who has an alter mental status and tried to determine the events which led up to that incident try and obtain a sample history patients with a significant intracranial bleeding may have a great deal of pressure in the skull and so when we're taking the vital signs this could cause slow pulse and also respirations can be erratic blood pressure is usually high to compensate for poor perfusion in the brain and unequal pupil size and reactivity indicate significant bleeding and pressure in the brain also when you're doing vital signs make sure you check blood glucose levels okay so let's talk about a stroke assessment so stroke assessments scale um you're going to evaluate the face arms and speech there's an acronym called be fast and that's a mnemonic also the cincinnati pre-hospital stroke scale and the los angeles pre-hospital stroke scales are commonly used so there's a three item stroke severity scale and that's the lag and then the los angeles motor scale that's the lams then you have the glasgow coma scale and that's a score for neurologic assessments so this table on the slide displays the b fast mnemonic so you have balance eyes facial droop arm drift speech and time then this table on the slide displays the cincinnati pre-hospital stroke scale you're going to see facial droop so you want to ask the patient to show their teeth arm drift ask the patient to close their eyes hold both arms out with the palms up and then ask the patient to say you can't teach an old dog new tricks the table on this slide displays the los angeles pre-hospital stroke screen so if they have any of those criteria in one through six um it's a probability of a stroke is 97 and then the table on this slide displays the three item stroke severity scale all patients with an altered mental status should also have a glass galcoma score calculated in the table on this slide displays the glass calcoma score and it consists of eye opening best verbal response and best motor response the best score you could have is a 15 and the the lowest score you could have is a three okay then we're going to do the reassessment so we're going to focus on reassessing the abcs vital signs and interventions we're going to compare baseline findings with updated information we're going to watch carefully for changes in the pulse blood pressure respirations and glass galcoma scores and we're going to notify the receiving facility of the patient's chief complaint and assessment findings how we're going to treat these patients okay so in general most patients with a suspected stroke physicians in the emergency department need to determine whether there is bleeding in the brain if there's no bleeding the patient may be a candidate for blood clot dissolving medicine if bleeding is present the medicine will increase the bleeding with disastrous consequences so we need to notify the hospital regarding the last time the patient was known to be without their current signs and symptoms of a stroke patients who have had a seizure require definitive evaluation and treatment at the hospital in patients who are having a seizure protect them from harm maintain a clear airway by suctioning provide oxygen as quickly as possible and if a head or neck trauma suspected we need to provide spinal immobilization for patients who continue to have a seizure and this is known as that status epileptis we need to suction the airway we're going to have to provide positive pressure ventilations transport quickly to the hospital and rendezvous with advanced life support if possible patients with a headache we're going to be concerned if the patient complains of a sudden onset of a severe headache now sudden onset of a headache with a fever seizures or altered mental status following trauma we have to be worried about okay so when it comes to emergency medical care for migraine we want to always assess the patient for other signs and symptoms that might indicate a more serious condition we're going to give them high flow too if they can tolerate it we want to darken and quiet the environment and we're not going to use sirens or lights during transport emergency medical care for a stroke so we're going to support the abcs and provide rapid transport to the stroke center we're going to maintain a spo2 level of at least 94 percent routine use of oxygen therapy is not recommended unless the patient is experiencing respiratory distress or showing signs of hypoxia fibrolytic therapy and methods of mechanically removing the blood clot may reverse stroke symptoms and even stop the stroke if given within three hours or six hours if possible transport to his designated stroke center okay so when it comes to emergency medical care for seizures the patient may be in a post-dictal state on arrival or the patient may still be actively having the seizure so we want to continue to assess and treat the abcs we want to protect the patient from harm if they're still seizing and if the patient refuses transport after the seizure contact online medical direction and ask them to speak directly with the patient and follow local protocols when it comes to emergency care for altered mental status we need to determine the cause and so we also might need to provide spinal mobilization airway and vent support if indicated okay so transport to the appropriate facility all right so that concludes the lecture section for chapter 18 neurologic emergencies next we're just going to go through the review questions to see what we've learned so a 41 year old man presents with slow irregular hypotension and dilated pupils these signs most likely indicate a dysfunction of the all right so respiratory i already i immediately think it's going to be brain stem all right and it is so brain stem is the controls that function for breathing blood pressure and pupil constriction an acute ischemic stroke is caused by now we know rupture is the bleed hemorrhagic increase intracranial pressure usually bleed and let's say a blocked cerebral artery yep a thrombus or an emboli causes a block cerebral artery and that is um that's d 56 year old man experience a sudden severe headache and then became unresponsive he has a history of high blood pressure the most likely cause of this condition is i'm going to say a hemorrhagic stroke because remember that high blood pressure and then that sudden severe headache so he's bleeding somewhere yeah a rupture of the cerebral artery unlike an ischemic stroke a transient ischemic attack is characterized by all of the following except so we know that the symptoms usually resolve within 24 hours and so that means that b the symptoms may persist for longer is incorrect a patient with a suspected stroke presents with slurred speech that has difficult for you to understand this is referred to as okay so what do we think we have three that are very similar so let's take a look at this okay so dis is difficulty okay so difficulty and then we know um that phase that ph is going to be difficulty swallowing um so we know that dysarthria is going to be the answer okay and that's um difficult to understand for us to understand okay so a type of a seizure that's characterized by severe twitching of all the body's muscles and lasts for several minutes or longer is called and this is going to be a generalized seizure yeah so it often lasts for several minutes or longer the most important reason for promptly transporting a stroke patient is to the hospital is and we know that we they could have fibrolytic and you heard it earlier called a clot buster medication and it could reverse that clot which of the following are components of that cincinnati pre-hospital stroke scale we know that it's arm drift facial symmetry arm drift and uh we're going to ask him to smile we're going to ask him to talk and then we're going to ask him to hold the both arms out so so your patient opens his eyes when you say his name is making incomprehensible sounds and withdraws when you pinch his earlobe so we're gonna calculate this okay so let's see opens his eyes when you say his name that's a three incomprehensible sounds that's a two and withdraws when you pinch his earlobe that's a four so i'm thinking we have a glass cow of nine and yes yeah we have a glass cow of nine and this is often difficult to understand and sometimes occasionally you might have to have the chart out in front of you or write the chart down really fast if a patient complains of a severe migraine you should be how should the patient be transported and we know that we don't want it to be in a brightly lit ambulance or with sirens so i think there they want you to do without lights and sirens yeah without lights and sirens you can give them some oxygen if they if it they tolerate it okay so this concludes chapter 18 neurologic emergencies thank you for joining me today and uh i hope you have a great day