Neurological Emergencies Coma, Seizures, Syncope, Stroke Temple College EMS Professions

Coma H State of unconsciousness from which patient cannot be aroused

Coma H Unconsciousness = Immediate Life Threat HLoss of airway HAspiration

Coma H Management of ABCs must come before investigation of cause

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

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

Circulation Pulses? Perfusion?

After ABCs stabilized... H Quickly investigate cause H DERM

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

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

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

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

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

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

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

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

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

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

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

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

Epilepsy H Tendency to have repeated episodes of seizure activity

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

Grand Mal Seizure H Aura HSensation coming before convulsion HPatient may recognize as sign of impending seizure HMay help locate origin of seizure in brain

Grand Mal Seizure H Convulsion HLoss of consciousness HTonic phase - rigidity HClonic phase - rhythmic jerking, incontinence, ineffective breathing

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

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

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

Psychomotor Seizure H Loss of consciousness H Sterotyped movements (automatisms) HMay look purposeful, but arent HLip smacking, movements of hands H May be called in as drunk, O.D., psych patient

Generalized Seizure Management H During seizure HRemove from potential harm HDo not forcibly restrain HRoll on side HAvoid putting anything in mouth

Generalized Seizure Management H After seizure ends HAssess ABCs HClear airway Most common cause of seizure deaths is post-ictal airway loss

Generalized Seizure Management HHigh concentration O 2 - immediately!! HAssist breathing if ventilation inadequate

Generalized Seizure Management HObtain history/physical HTrauma that could have caused, been caused by seizure HAnti-seizure medications HNeuro/vital signs every 5 minutes HIf patient ventilating adequately, transport on left side

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

Status Epilepticus H > 2 seizures without intervening conscious period H Immediate Life Threat H Management HSecure airway HAssist breathing with O 2 HTransport HRequest ALS intercept

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

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

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

CVA J Cerebrovascular accident J Stroke

CVA H Damage of portion of brain due to interruption of blood supply H Mechanisms HThrombosis HHemorrhage HEmbolism

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

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

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

Signs/Symptoms H Alterations in consciousness HAltered affect HConfusion HDizziness HComa

Signs/Symptoms H Localizing signs HParalysis HLoss of sensation HLoss of speech HUnilateral blindness HLoss of vision in half of visual field of both eyes HUnequal pupils

Signs/Symptoms H Seizures H Headache H Stiff neck

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

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

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

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