Neurologic Emergencies

As with any other section, the best place to start would be with a review of the structure of the brain, the 'source' of any of the Neurologic Emergencies. The Neurologic Emergencies dealt with in this section can be grouped into three categories:

Stroke, Seizure, and Altered Mental Status.

Stroke

Cerebrovascular Accident

Cerebrovascular Accident (CVA) is a condition created when the normal blood flow to the brain is interrupted and a loss of function results. The lost function will be dependant on the area of the brain that has become ischemic. Left uncorrected, this condition can lead to a group of brain cells becoming necrotic (infarcted cells) and the lost function MAY become permanent. Timely medical treatment of this patient may avert the necrosis and help the patient regain the lost function. Without specialized diagnostic equipment there is not way to determine either, the cause of the stroke or, the totality of the interrupted circulation. Therefore it is prudent to immediately treat this patient with high flow oxygen at the BLS level. If a small amount of blood is 'getting through' to the affected area, hyper-oxygenating that blood may prevent the necrosis from occurring. At the ALS level, after properly diagnosising the cause of the stroke, the patient may be treated with 'clot busting' medication (a therapy used in ischemic type strokes, but inappropriate if the cause of the stroke is found to be hemorrhagic.) When assessing a patient for stroke, concern yourself with the ABC's, first. Assuming that the patient's breathing and circulation are adequate, keep in mind that any altered mental state may compromise the patient's ability to maintain an adequate airway, and consider the use of an appropriate airway adjunct. As mentioned above, the 'lost function' will be the result of the area of the brain affected by the interrupted circulation. Outwardly, the patient may present with some degree of paralysis. Left or right hemiparesis, left or right sided facial droop, left or right arm drift are all indications of the degree of paralysis. Communicating with this patient may be a challenge, if the 'communications center' in the brain has become ischemic. The patient may be experiencing receptive aphasia where the patient is incapable of understanding language, or, more common from our experience, expressive aphasia where the patient understands but is unable to verbally respond to your questions. Usually this inability is only verbal, the patient understands your questions and knows what the appropriate answer should be, but cannot speak it. Patients may also be affected by dysarthria (they understand language and are capable of speaking, but their words may be slurred and difficult to understand.) Find another way to communicate with this patient. For example, ask question that can be answered by "yes" or "no," and have the patient use head-nodding to answer. Of critical importance during your focused history is to try and determine the time when the symptoms began. The advanced therapy mentioned above must be started within 2 to 3 hours of the onset of symptoms for it to be effective. In addition to ischemic and hemorrhagic stroke, there is a third type. Sometimes referred to as a 'mini-stroke,' a TIA (Transient Ischemic Attack) is a stroke that resolves within 24 hours without intervention, although some may resolve as quickly as an hour or so. TIA's are to be considered as serious as any stroke because they may cause small areas of ischemia (or even necrosis) within the brain, and are considered a 'warning' of a more serious stroke to follow. Your text suggests additional ways to accomplish an appropriate patient assessment for patients of suspected stroke, as well as suggestions regarding the proper position for transportation to the hospital. Our purpose is not, nor has it ever been, to replace (or re-state) the textbook. Read and understand your text, and apply those suggestions that are within the guidelines of local protocol.

Seizure

Brain abnormalities

Seizure can be the result of some medical conditions, brain abnormalities, blood chemistry imbalance, head injury, poisoning, overdose, or as a withdrawal symptom from drugs and alcohol . It can also be brought on, especially in children, by the sudden onset of high fever (febrile seizure.) Seizure can be as dramatic as generalized (Grand Mal) seizure where the patient is unable to control muscle tone. The limbs tremor, the body shakes, the eyes close, some utterances (moaning) may occur and the patient is unable to communicate. This may last for a 3 to 5 minutes. Or seizure can be as quiet as a focal (Petit Mal) seizure where the patient may experience a tremor in one arm or a blank stare for a few seconds. It has been suggested that "day dreaming" may actually be the quietest form of petit mal seizure. Patients experiencing focal seizure usually 'recover' after a few minutes with, maybe, a brief lapse of memory of the event. A single grand mal seizure is not considered a life threat, and the BLS intervention should be to "protect" the patient, administer high-flow oxygen, and transport the patient to the nearest appropriate facility as soon as possible. When the seizure stops, protect the patient's airway, by positioning the head, and monitor the patient's breathing. If the patient stops breathing, or doesn't start breathing after the seizure stops, make certain that the head is hyperextended and administer full-flow oxygen via a bag-valve-mask. Following any generalized seizure, the patient will experience a 'postictal state, where the patient will remain unresponsive for an extended period of time (up to 30 minutes,) after which the patient will begin to recover and awaken. If the patient experiences a second, or subsequent seizure, before awakening from the postictal state, this is a condition known as status epilepticus (status seizures) and is to be considered a serious life threat. This patient need advanced support, IMMEDIATELY.Altered Mental Status A patient who experiences petit mal seizure may not want to be transported to the hospital. It's considered a good practice to try and convince this patient to be evaluated by a medical professional as soon as possible. The sooner the better. "Why not NOW." (In most areas, it's a free ride to the hospital.)

Altered Mental Status

Altered Mental Status includes all those events, other than Stroke and Seizure, that may render a patient 'not thinking clearly,' or 'unable to be aroused'. Of all the possible causes, including (but not limited to) hypoglycemia, hypoxemia, intoxication, drug overdose, abnormal body temperature, head injury, metabolic brain disorder, poisoning, and overdose, a proper patient history SHOULD lead you to the appropriate diagnosis in a relatively short period of time. In the absence of a 'source' for the patient history, one of our instructors once said, "When you hear 'hoof beats,' look for horses, not unicorns." Start with the most common cause of Altered Mental Status as dictated by YOUR UNITS patient care history. (If you don't know what that means...try looking for SIGNS of each of the causes in the order that they are mentioned above...it represents the order of occurrence that we have found is most likely to occur.) Whatever the cause, Altered Mental Status should be considered an immediate medical emergency, even when it's the patient that you encounter every Saturday morning at about 2:00am, that just left the corner bar. ALL PATIENTS with Altered Mental Status should be transported to nearest appropriate medical facility, without regard to the cause of this event.