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Neurological EmergenciesComa, Seizures, Syncope, Stroke
Coma
State of unconsciousness from which patient cannot be aroused
Coma
Unconsciousness = Immediate Life ThreatLoss of airwayAspiration
Coma
Management of ABC’s must come before investigation of cause
Airway
Open, clear, maintain If trauma present or no history
available, immediately control C-spine
Breathing
Assess presence, adequacy High concentration O2 immediately
on all patients with decreased LOC Assist if respiratory rate, tidal
volume inadequate
Circulation
Pulses?Perfusion?
After ABC’s stabilized. . .
Quickly investigate causeDERM
D = Depth of coma
What does patient respond to?How does he respond?
E = Eyes
Pupils equal, dilated, constricted,
Responsive to light?How?
R = Respiratory pattern
Rate?Unusually deep or shallow?Altered pattern?
M = Motor Function
Evidence of paralysis?Movement on stimulation? How?
Vital Signs
Shock? Increased ICP?Arrhythmias?
Head to Toe Survey
Injuries causing coma? Injuries caused by fall? What do the scene, bystanders tell
you?
Possible Causes
Not enough oxygen Not enough sugar Not enough blood flow to deliver O2,
sugar Direct brain injury
Structural (trauma)Metabolic (toxins, infections, temperature)
Possible Causes
Alcohol Epilepsy Insulin Overdose Uremia (and
other metabolic causes)
Trauma Infection Psychiatric Stroke,
syncope
Management
Secure airway Protective reflexes may be lost Immobilize spine unless absolutely
certain injury not present Spinal injury not suspected -
patient on left side
Management
High concentration O2
Assist ventilation as neededMonitor neurological/vital signs
every 5 minutes
Management
Protect patient’s eyes on long transports (tape shut, moist pads)
Patient may hear, understand even though unable to respond
Treat, reassure accordingly
Seizures
Episodes of uncoordinated electrical activity in brain
Signs/symptoms depend on area involved
Epilepsy
Tendency to have repeated episodes of seizure activity
Seizure Types
Grand mal (major motor)Petit mal (absence)Focal motor (simple partial)Psychomotor (complex partial)
Grand Mal Seizure
AuraSensation coming before convulsionPatient may recognize as sign of
impending seizureMay help locate origin of seizure in
brain
Grand Mal Seizure
ConvulsionLoss of consciousnessTonic phase - rigidityClonic phase - rhythmic jerking,
incontinence, ineffective breathing
Grand Mal Seizure
Post-ictal PhaseExhaustionDrowsinessHeadachePossible hemiparesis (Todd’s
paralysis)
Petit Mal Seizure
Loss of consciousnessNo loss of postural toneMore common in children
Focal Motor Seizure
Rhythmic jerking of limb, one side of body
No loss of consciousness
Psychomotor Seizure
Loss of consciousness Sterotyped movements
(automatisms)May look purposeful, but aren’tLip smacking, movements of hands
May be called in as “drunk”, “O.D.”, “psych patient”
Generalized Seizure Management
During seizureRemove from potential harmDo not forcibly restrainRoll on sideAvoid putting anything in mouth
Generalized Seizure Management
After seizure endsAssess ABC’sClear airway
Most common cause of seizure deaths is post-ictal
airway loss
Generalized Seizure Management
High concentration O2 - immediately!!
Assist breathing if ventilation inadequate
Generalized Seizure Management
Obtain history/physicalTrauma that could have caused, been
caused by seizureAnti-seizure medications
Neuro/vital signs every 5 minutesIf patient ventilating adequately,
transport on left side
Seizures
Anything that injures brain can cause seizures (AEIOU/TIPS)
Do not assume seizures are due to idiopathic epilepsy until proven otherwise
Status Epilepticus
> 2 seizures without intervening conscious period
Immediate Life Threat Management
Secure airwayAssist breathing with O2
TransportRequest ALS intercept
Syncope
Fainting Sudden, temporary loss of
consciousness Caused by lack of blood flow to
brain
Causes
Stress, fright, pain (vasovagal syncope) Orthostatic hypotension (BP fall on
standing) Decreased blood volume Increased size of vascular space
Decreased cardiac output Prolonged forceful coughing
Management
ABCs Keep patient supine, elevate
lower extremities Oxygen Assess underlying cause
CVA
Cerebrovascular accident Stroke
CVA
Damage of portion of brain due to interruption of blood supply
MechanismsThrombosisHemorrhageEmbolism
Thrombosis
Blockage of vessel by thrombus Usually forms at area narrowed by
atherosclerosis Typically in older persons Frequently occurs during sleep
Hemorrhage
Vessel ruptures Associated with hypertension,
aneurysms of cerebral blood vessels Usually characterized by
Sudden onset Severe signs, symptoms
Embolism
Blood clots, plaque fragments travel through vessel; lodge, block flow
Often associated with:Atherosclerosis of carotidsChronic atrial fibrillation
Signs/Symptoms
Alterations in consciousnessAltered affectConfusionDizzinessComa
Signs/Symptoms
Localizing signsParalysisLoss of sensationLoss of speechUnilateral blindnessLoss of vision in half of visual field of
both eyesUnequal pupils
Signs/Symptoms
SeizuresHeadacheStiff neck
Transient Ischemic Attacks
TIAs “Little strokes” Produce deficits that resolve
completely in <24 hours Frequently precede CVA
Management
Assess ABC’s Protect airway High concentration O2
Vital signs every 5-10 minutes Note increased BP, irregular pulse
Management
Nothing by mouth Avoid rough handling Transport paralyzed side down Guard your conversation Patients who cannot speak may
still understand!
Management
CVAs caused by thrombus, embolus may be reversible with thrombolytics (clot busters)
Early recognition, rapid transport to appropriate facility is critical