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Wendell A. Grogan, MD, FAASM
Medical Director: Stroke Program, Inpatient Rehabilitation, and Sleep Disorders Center
Kingwood Medical CenterKingwood, TX
Lt Col, Houston MRG Medical Reserve Brigade, Texas State Guard
The American Stroke Association wants you to learn the warning signs of stroke:
* Sudden numbness or weakness of the face, arm or leg, especially on one side of the body * Sudden confusion, trouble speaking or understanding * Sudden trouble seeing in one or both eyes * Sudden trouble walking, dizziness, loss of balance or coordination * Sudden, severe headache with no known cause
Stroke
Introduction to Neurological Emergencies
What are we likely to encounter How do we recognize the signs and symptoms of
common neurological conditions What can be done on site When do we need to transfer What can be done if transfer is not an option
General Principles
Neurological Conditions come in three types Chronic, persistent Chronic intermittent New Onset
They also come in three severities Bothersome perhaps painful, but not life threatening Life threatening, but manageable Life threatening, untreatable
General Principles
The most painful or distressing may not be the most dangerous
With certain exceptions, severe neurological conditions typically are painless
The victim is often unaware of problem even when the condition is devastating
General Principles
Most serious neurological conditions are not treatable in the first aid setting
In limited resource situations, evacuating victims of devastating neurological illness may not be wise utilization
Stroke
Knowing the signs of stroke is useful in every day life
“Time is Brain”
Stroke
Warning signs of stroke:
Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
Sudden confusion, trouble speaking or understanding
Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of
balance or coordination Sudden, severe headache with no known cause
Stroke
Strokes come in two major varieties: Bleeding- these are generally the painful ones Ischemic- ie. A blood clot cuts of blood supply to part
of the brain. AKA “bland infarct”
Stroke
If the person can be evaluated in within three hours of onset of symptoms, blood clot dissolving agent may help to return blood flow to the damaged part of the brain
This is highly problematic in an evacuation/disaster shelter situation
Stroke
First Aid: Watch for trouble swallowing
Since the victim may not be aware of the problem, they may try to eat or drink when they are no longer capable of safely doing so
Watch for falling, self injury Again, lack of awareness may lead to attempts to walk, get
out of bed when able to support their own weight Spills of hot liquids or dropping objects on themselves may
also occur
Stroke
Even if not able to be transferred within the 3 hour time frame, victim will need acute care, hospital setting treatment to minimize complications
Simultaneous stroke and heart attack is relatively common and the stroke victim may not be able to tell you about heart attack symptoms
Stroke
Relationship between stress and stroke is not well established by itself.
Disruptions of food and water supplies, loss of medication or inability to time dosing of medication, loss of sleep/rest will all tend to increase chances of stroke occurring in susceptible individuals
Seizures
Three major categories Generalized shaking with loss of consciousness-
“grand mal” Localized shaking- “partial” seizures Loss of consciousness or lapse of awareness with blank
stare or abnormal behavior- “petit mal”
Seizures
May or may not come after a warning period “aura”
Often stress- physical or emotional- will trigger off seizures
Everyone has a “seizure threshold”, thus it is possible in a disaster/evacuation scenario that people may have seizures who never had one before
Seizures
Symptoms: Often there will be a sudden change in behavior-
typically the person will sudden stop whatever they were doing
A brief or prolonged stare followed by stiffening of muscles, sometimes severe even to the point of breaking bones or dislocating joints
Seizures
Symptoms Hard banging movements of the major joints/head with
tongue biting, incontinence, spasm of chest muscles causing cessation of breathing
Sudden relaxation, often without regaining consciousness right away, or with confusion to the point of combativeness
Seizures
Each stage may last several seconds to minutes or may transition to the next phase so rapidly as to not be noticed.
The “post ictal” stage of confusion or extreme lethargy will usually last much longer than the “ictus” (seizure) typically several minutes up to hours
Seizures
First aid principles Protect the victim from further harm
Move away from potentially dangerous objects or placements
Turn to side to prevent aspiration of stomach contents if they vomit
Keep people from trying to place spoons or other objects in the victims mouth
Restrain gently if needed during post-ictal confusion phase
Seizures
Like stroke, patient may not be aware of the event
Seizures
After the event, determine if person has a history of seizures. If this is a typical event, transfer to hospital may not be
needed If on medication, make sure they get their medication
If this is the first time, look for stroke signs as a stroke or other brain injury may have triggered the seizure
Consider transfer to hospital setting for patient's safety in case of additional events
Seizures
Most seizures last a minute or two Although frightening, the seizure itself is rarely
life threatening if self limited Seizures lasting more than 5 minutes are true life
threatening emergencies
Neuromuscular failure
Numerous causes, including GBS (Guillain-Barre syndrome), botulism, neurotoxins (nerve gas, insecticide)
Sudden or gradual onset of weakness, often first manifested by inability to stand or lift arms
May end up compromising ability to swallow or even breath
Neuromuscular failure
Always potentially fatal Needs transportation to hospital setting as soon as
possible Victim is often aware, often before it is obvious to
observers that something is wrong First symptoms may be respiratory
compromise- “air hunger” or shortness of breath
Neuromuscular failure
Little to be done in the first aid setting other than recognizing the seriousness- not just “tired” or intoxicated- and transporting as soon as possible
Metabolic disorders
Most common is hypoglycemia, “low blood sugar” in a diabetic
In older persons, infections such as bladder infection or pneumonia may cause similar symptoms
Metabolic disorders
Person may seem to be “drunk” or “stoned” Confusion, slurred speech, irritability or
combativeness may occur Victim often not aware of situation
Metabolic disorders
Sometimes difficult to distinguish from stroke or post ictal confusion
If left untreated, may be fatal
Metabolic disorders
Unless the person is identified as a diabetic and administering sugar corrects the problem, transportation to medical facility will be necessary
Trauma
Open skull wounds and fractures of spine are typically pretty obvious
Look for sudden paralysis after blow to neck or back
Trauma
Scalp wounds bleed profusely but can usually be stopped by direct pressure.
Although they will need to be seen in ER for closure, not a “drop everything and transport” situation if resources are limited
Trauma
Be aware of a penetrating wound Whatever cut through the scalp may have
continued on through the skull and into the brain
The pure scalp injury victim will be in pain, but should not have any stroke like symptoms
Summary
Often the person with the neurological emergency is unaware of the problem or at least the severity of it
The most serious are often painless Most are not treatable in the first aid setting, but
awareness of the consequences of not treating emergently will help allocate resources if they are limited
Summary
Because of the stress and disruptions inherent to an evacuation setting, pre-existing disorders, like epilepsy and vascular disease will tend to worsen abruptly and may precipitate a devastating event
Summary
Seizures and scalp wounds tend to look more severe and dangerous than they are
Strokes and neuromuscular problems tend to be quieter and “appear” less severe and dangerous than they really are