Ch.18 Neurologicemergencies Flashcards
The__ is the body’s computer. It controls breathing, speech, and all other body functions. All thoughts, memories, needs, and desires reside in the_. Different parts of the__ perform different functions. For example, some parts of the__ receive input from the senses, including sight, hearing, taste, smell, and touch; some control the muscles and movement; and some control the formation of speech.
brain
The brain is divided into three major parts: the_, __,__, which is the largest part. The brainstem controls the most basic functions of the body, such as breathing, blood pressure, swallowing, and pupil constriction. Located just behind the brainstem is the cerebellum, which controls muscle and body coordination.
The cerebellum is responsible for coordinating complex tasks that involve many muscles, such as standing on one foot without falling, walking, writing, picking up a coin, and playing the piano.
brainstem, the cerebellum, and the cerebrum
The area of the brain between the spinal cord and cerebrun, surrounded by the cerebellum; controls functions that are necessary for life, such as respiration
Brainstem
One of the three major subdivisions of the brain, sometimes called the little brains; coordinates the various activities of the brain particularly fine body movements
Cerebellum
The largest part of the three subdivisions of the brain, sometimes called the gray matter; made up of several loves that control movement, hearing, balance, speech, visual perception, emotions, and personality
Cerebrum
The cerebrum, located above the cerebellum, is divided down the middle into the right and left ____
Cerebral hemispheres
The ___ part of cerebrum controls emotion and thought
Front part
The __ part controls sensation and movement
Middle part
The __ part of the cerebrum processes sight
Back part
In most people, speech is controlled on the __ side of the brain, near the middle of the cerebrum
Left side
Messages sent to and from the brain travel through __
Nerves
Twelve pairs of cranial nerves run directly from the brain to various parts of the body, especially in the head, such as the eyes, ears, nose, and face. The remaining nerves join in the spinal cord and exit the brain through a larger opening in the base of the skull called the _
Foramen magnum
At each vertebra in the neck and back, two nerves, called _, branch out from the spinal cord, one on each side, and carry signals to and from the body
Spinal nerves
The ___ is the continuation of the brainstem. It exits the skull at the foramen magnum and extends down to the level of the second lumbar vertebra
Spinal cord
Many different disorders may cause brain dysfunction or other neurologic symptoms and may affect the patient’s level of consciousness, speech, and voluntary muscle control. The brain is most sensitive to changes in oxygen, glucose, and temperature levels. A significant change in any one of these three levels will result in a neurologic change. In general, if the problem is caused primarily by disorders in the heart and lungs, the entire brain will be affected. For example, when blood flow is stopped (cardiac arrest), the patient will go into a____, a state of profound unconsciousness, and permanent brain damage can result within minutes. However, if the primary problem is in the brain, such as a poor blood supply to one side of the brain, the patient may have signs and symptoms affecting only one side of the body. A low oxygen level in the bloodstream will affect the entire brain, often causing anxiety, restlessness, and confusion. Low blood glucose levels (hypoglycemia) can cause a wide spectrum of symptoms ranging from mild confusion to symptoms that mimic stroke.
coma
The brain and skull do not actually sense pain because neither contains pain receptors. The pain associated with a____ is felt from the surrounding areas of the face; scalp; meninges (membranes that cover the brain and spinal cord); larger blood vessels; and muscles of the head, neck, and face.
headache
Three distinct layers of tissue that surround and protect the brain and the spinal cord within the skull and the spinal cord
Meninges
The thick skin covering the cranium, which usually bears hair
Scalp
___headaches are caused by muscle contractions in the head and neck and are attributed to stress. Patients usually describe the pain as squeezing, dull, or an ache. This type of headache typically does not have any associated symptoms and usually does not require medical attention.
Tension headaches
____headaches are thought to be caused by changes in blood vessel size in the base of the brain. Both adults and children can experience___. Women are three times as likely as men to experience___. Frequently, the patient will have a history of migraines and will tell you that this episode is similar to one in the past. Pain from a_____ headache is usually described as pounding, throbbing, or pulsating._____ are often associated with nausea and vomiting and may be preceded by visual warning signs such as flashing lights or partial vision loss. These headaches can last for several hours to days.
Migraine headaches
____headaches are caused by pressure that is the result of fluid accumulation in the sinus cavities. Patients may also have coldlike signs and symptoms of nasal congestion, cough, and fever if they have a sinus infection. Patients may report increased pain when they bend over or when their heads are moved forward. This type of headache is usually self-limiting, and prehospital emergency care is not required.
Sinus headaches
______(bleeding in the brain), brain tumor, and meningitis are serious neurologic conditions that may include headache as a symptom. Be concerned if the patient reports a sudden-onset, severe headache or a sudden-onset headache that has associated symptoms. Headaches accompanied by fever, stiff neck, seizures, or altered mental status or following a head trauma are potentially life threatening and require a complete assessment and transport to the hospital (TABLE 18-1). A ___will often present with a complaint of headache that is described as “the worst headache of my life.” If a patient describes a headache this way, you should have a very high index of suspicion and transport expeditiously to the hospital. An incident with multiple patients reporting a headache may indicate carbon monoxide poisoning.
Hemorrhagic stroke
A sudden, severe headache, often described as the worst pain the patient has ever had, could be a sign of a hemorrhagic stroke. The blood from a ruptured blood vessel irritates the tissues of the brain and can cause increased___, resulting in severe headache pain. This type of pain may initially be localized and then become more diffuse as the irritation in the meninges spreads. You should suspect a hemorrhagic stroke in patients with a severe headache, seizures, and altered mental status. Early signs of increased__ include headache, vomiting, altered mental status, and seizures. Increasing___ may also be caused by a hemorrhagic stroke (a blood vessel swells and ruptures), a tumor, or head trauma that may have occurred hours or days before this event. During your patient assessment, ask if the patient has experienced any recent head trauma.
intracranial pressure (ICP)
____, an inflammation of the meninges caused by a bacterial infection, is a central nervous system infection in which the patient may complain of a headache, stiff neck, fever, and sensitivity to light. This is a serious condition requiring prompt medical attention and is highly contagious. Use standard precautions and provide supportive care of the XABCs. Provide a quiet, darkened environment when possible and avoid using lights and siren.
Bacterial meningitis
A type of stroke that occurs as a result of bleeding inside the brain
Hemorrhagic stroke
A__, is an interruption of blood flow to an area within the brain that results in the loss of brain function.
cerebrovascular accident (CVA), or stroke
Medical 728
science currently has little to offer in the way of treatment once brain cells are dead. However, when oxygen levels are decreased, but not absent, because an insufficient amount of blood is getting through, brain cells may be damaged more slowly. It may take several hours or more for brain cells to die in this situation. When brain cells die or are injured, severe disability may result. For example, if cells that are responsible for controlling the left arm are starved for oxygen, the patient will not be able to move that arm. The brain cells will develop__, a reduction in blood supply that results in inadequate oxygen being supplied to the brain cells. This causes those cells to stop functioning properly. If normal blood flow is restored to that area of the brain in time, the cells will not die and the patient may regain full use and control of the arm.
Unfortunately, many patients experiencing a stroke deny or ignore their symptoms and delay seeking medical attention.
The delay in seeking care can result in devastating consequences, because “time is brain.”
ischemia
A lack of oxygen that deprives tissues of necessary nutrients, resulting from partial or complete blockage of blood flow; potentially reversible because permanent injury has not yet occurred
Ischemia
The two main types of stroke are ischemic and hemorrhagic. An ____occurs when blood flow through the cerebral arteries is blocked. In__, a blood vessel ruptures and the accumulated blood causes increased pressure in the brain.
ischemic stroke
hemorrhagic stroke
According to the American Stroke Association, ___is the most common type of stroke, accounting for 87% of all strokes. When blood flow to a specific part of the brain is stopped by a blockage (blood clot) inside a blood vessel, the result is an_. Patients who experience an___ may have dramatic symptoms, including loss of movement on the side of the body opposite the side where the occlusion has occurred.
ischemic stroke
Patients who experience an ischemic stroke may have dramatic symptoms, including loss of movement on the side of the body opposite the side where the occlusion has occurred
This blockage may be due to___, where a clot forms at the site of blockage, or an embolus, where the blood clot forms in a remote area (such as a diseased heart) and then travels to the site of the blockage. Patients with atrial fibrillation (a heart rhythm where the atria shake rather than squeeze) are prone to ischemic strokes caused by an___ and often take blood thinners to reduce the risk of these events.
thrombosis
embolus
As with coronary artery disease,___ in the blood vessels is often the cause of ischemic stroke.
____is a disorder in which calcium and cholesterol build up, forming plaque inside the walls of the blood vessels This plaque may obstruct blood flow and interfere with the vessels’ ability to dilate. Eventually,___ may cause complete occlusion of an artery (FIGURE 18-3). In other cases, an atherosclerotic plaque in the carotid artery in the neck ruptures. A blood clot forms over the crack in the plaque. Sometimes, it grows large enough to completely block all blood flow through that artery. The parts of the brain supplied by the artery are deprived of oxygen and stop functioning.
atherosclerosis
A blood clot, either in the arterial or venous system. When the clot occurs in a cerebral artery, it may result in the interruption of cerebral blood flow and subsequent stroke
Thrombosis
A blood clot or other substance in the circulatory system that travels to a blood vessel where it causes a blockage of blood flow
Embolus
A disorder in which cholesterol and calcium build up inside the walls of the blood vessels, forming plaque, which eventually leads to a partial or complete blockage of blood flow
Atherosclerosis
Even if the blockage in the carotid artery is not complete, smaller pieces of the blood clot may embolize (break off and be carried by the normal flow of blood) deep into the brain, where they may become lodged in a smaller branch of a blood vessel. This__ then blocks blood flow (FIGURE 18-4). Depending on the location of the lodged blood clot, the patient’s symptoms can vary widely, from nothing at all to complete paralysis or loss of function to the areas or functions of the body controlled by that portion of the brain.
cerebral embolism
____occurs as a result of bleeding inside the brain. According to the American Stroke Association,___ account for 13% of all strokes. In____, a blood vessel ruptures and the accumulated blood then forms a blood clot, which compresses the brain tissue next to it. The compression prevents oxygenated blood from getting into the area, and the brain cells begin to die. Cerebral hemorrhages are often massive and rapidly fatal.
___\commonly occurs in people experiencing stress or exertion. The people at highest risk for____ are those with extremely high blood pressure or long-term untreated elevated blood pressure. Many years of high blood pressure weaken the blood vessels in the brain. If a vessel ruptures, the bleeding in the brain will increase the pressure inside the cranium. Proper treatment of high blood pressure can help prevent this long-term damage to the blood vessels, decreasing the risk of this devastating complication.
Hemorrhagic stroke
Some people are born with a weakness in the walls of an artery. An__, a swelling or enlargement of the wall of an artery resulting from a defect or weakening of the arterial wall, may then develop. FIGURE 18-5 is an angiogram showing a cerebral aneurysm. The most notable symptom of a ruptured aneurysm is often a sudden-onset, severe headache, typically described by the patient as the worst headache he or she has ever had. The headache is caused by the irritation of blood on the brain tissue after the artery swells and ruptures. A hemorrhagic stroke in an otherwise healthy young person is often caused by a weakness in a blood vessel called a berry___. This type of____ resembles a tiny balloon (or berry) that juts out from the artery. When the____ is overstretched and ruptures, blood spurts into an area between two of the coverings of the brain called the subarachnoid space. These types of strokes are called subarachnoid hemorrhages. If the patient gets to the hospital quickly, surgical repair of the aneurysm may be possible. However, like other brain bleeding and cerebral hemorrhage, this condition is often fatal.
aneurysm
A swelling or enlargement of the wall of a blood vessel that results from weakening of vessell wall
Aneurysm
In a patient with coronary artery disease, blood flow to the heart muscle may be obstructed, causing chest pain (angina), which is considered a warning sign of a potential myocardial infarction. Similarly, when blood flow to the brain is obstructed due to atherosclerosis or a small blood clot, the patient may exhibit signs of a stroke. When these strokelike symptoms resolve on their own in less than 24 hours, the event is called a___. Some people call these mini strokes. As with angina, no actual death of tissue (infarction) occurs with a___. However, because symptoms of a___ can last up to 24 hours, you may not be able to differentiate between a stroke and a__
Although most patients with___ do well, every__ is an emergency. It may be a warning sign that a more significant stroke may occur in the future. Approximately one-third of patients who have a__ will experience a stroke soon after the__. For this reason, all patients with a___ should be evaluated by a physician to determine whether preventive action should be taken.
transient ischemic attack (TIA)
The inability to understand and/or produce speech
Aphasia
Difficulty understanding spoken words
Receptive aphasia
Slurred speech
Dysarthria
If the___ cerebral hemisphere has been affected by a stroke, the patient may exhibit a speech disorder called aphasia, the inability to produce or understand speech. Speech problems can vary widely. Some patients will have trouble understanding speech but will be able to speak clearly. You can detect this problem by asking the patient a question such as “What day is today?” The patient may respond with an inappropriate answer such as “Green.” The speech is clear, but it does not make sense. Other patients will be able to understand the question but cannot produce the right sounds to provide an answer.
left cerebral hemisphere
If the__ cerebral hemisphere of the brain is not getting enough blood, the patient will have trouble moving the muscles on the left side of the body. Usually, the patient will understand language and be able to speak, but the words may be slurred and hard to understand
Interestingly, patients with right-hemisphere strokes may be completely oblivious to their problems. If you ask these patients to lift their left arms and they cannot, they will lift their right arms instead. Patients will seem to have forgotten that their left arms even exist. This symptom is called neglect. Patients with conditions affecting the back part of the cerebrum may neglect certain parts of their vision. Generally, this is hard to detect in the field because patients compensate without conscious effort. Nevertheless, be aware of the possibility. Sit or stand on the patient’s “good” side because he or she may be unable to see things on the “bad” side.
Neglect and lack of pain cause many patients who have had strokes to delay seeking help. A patient may be unaware that he or she has a problem until someone points out that some part of the patient’s body is not functioning properly.
right cerebral hemisphere
Patients with bleeding in the brain (________) may have very high blood pressure. High blood pressure can either cause the bleeding or be a compensatory response to the bleeding. Blood pressure increases as the body attempts to force more oxygen to the area of the brain where the damage is occurring. Remember, the brain is located inside a box (skull) with only a few openings. When bleeding occurs inside the brain, the pressure inside the skull increases. The body must increase the blood pressure to get blood to the brain’s tissues, increasing the pressure even further. A trend of increasing blood pressure is an important sign. Blood pressure may then taper off and return to normal. Significant drops in blood pressure may also occur as the patient’s condition worsens. Therefore, it is important to monitor the blood pressure for changes in these patients.
cerebral hemorrhage
The following conditions may appear to be a stroke!
• Hypoglycemia
• A______(period following a seizure that lasts between 5 and 30 minutes, characterized by labored respirations and some degree of altered mental status )
• Subdural or epidural bleeding (a collection of blood near the skull that presses on the brain)
postictal state
Because oxygen and glucose are needed for brain metabolism, a patient with___ may present in a manner similar to a patient who is experiencing a stroke. Good patient assessment includes finding out whether the patient’s medical history includes diabetes. Always check the blood glucose level in patients with altered mental status if allowed by your local protocol.
hypoglycemia
Subdural and epidural bleeding usually occur as a result of trauma. The___ is the leathery covering of the brain that lies next to the skull. A fracture near the temples may cause an artery to bleed on top of the___, resulting in pressure on the brain (FIGURE 18-6A). The onset of epidural bleeding is usually very rapid after injury. When the veins just below the__ bleed, this is referred to as subdural bleeding (FIGURE 18-6B). Subdural bleeding is slower than epidural bleeding, sometimes occurring over a period of several days.
The dura
Bleeding outside the dura and under the skull is called
Epidural hematoma (or bleeding)
Bleeding beneath the dura but outside the brain is called
Subdural hematoma (or bleeding)
With epidural hemorrhage after a head injury, the patient may have normal mental status for a period of time (usually minutes to hours), only to deteriorate markedly. This period between injury and deterioration is called a___.
lucid interval
A___ is a neurologic episode caused by a surge of electrical activity in the brain. It can take the form of a convulsion, characterized by generalized, uncoordinated muscle activity, and/or possibly a temporary alteration in consciousness. Nearly 3.5 million people in the United States have epilepsy, which is a common cause of__.___ are classified as either generalized or focal, and their underlying cause can be either known (ie, secondary to a brain tumor or a metabolic disorder) or unknown (idiopathic).
seizure
A disorder in which abnormal electrical discharges occur in the brain, causing seizures and possible loss of consciousness;
Epilepsy
A____ results from abnormal electrical discharges from large areas of the brain, involving both hemispheres. It is typically characterized by unconsciousness and a___ twitching of the body’s muscles that lasts several minutes or longer (identified as “motor”). In___ seizures (sometimes classified as tonic-clonic), almost all of the muscles in the body are contracting at the same time, causing twitching or jerking motions. In other cases, the seizure may simply be characterized by a brief lapse of consciousness in which the patient seems to stare and not to respond to anyone. This type of seizure does not involve any changes in motor activity and is called a generalized-onset absence seizure.
generalized seizure
A seizure characterized by severe twitching of all of the body’s muscles that may last several minutes or more; formerly known as a grand mal seizure
Generalized seizure
A___ begins in one part of the brain. ___seizures are classified as either aware or impaired-awareness,
and either type can be motor or nonmotor (absence).
focal seizure
In a__, no change occurs in the patient’s level of consciousness. Patients may report numbness, weakness, or dizziness. The senses may also be involved; the patient may report visual changes and unusual smells or tastes. A focal-onset aware (motor) seizure may also cause twitching of the muscles and the extremities that may spread slowly from one part of the body to another, but it is not characterized by the dramatic severe twitching and muscle movements seen in a generalized seizure. The patient may also experience brief paralysis.
focal-onset aware seizure
In a__, the patient has an altered mental status and does not interact normally with his or her environment. This type of seizure results from abnormal discharges from the temporal lobe of the brain. Other signs may include lip smacking, eye blinking, and isolated convulsions or jerking of the body or one part of the body such as an arm. The patient may experience unpleasant smells and visual hallucinations, exhibit uncontrollable fear, or exhibit repetitive physical behavior such as constant sitting and standing. In impaired-awareness seizures, the patient usually does not remember events occurring during the seizure.
focal-onset, impaired-awareness seizure
Some____ remain on only one side of the body. Others begin on one side and gradually progress to the entire body. In focal-onset aware seizures, the patient may have no loss of consciousness but still experience body shaking or muscle tremors. Most people with lifelong or chronic seizures tolerate these events reasonably well without complications, but in some patients, seizures may signal life-threatening conditions.
focal-onset seizures
Often, a patient may experience a warning sign prior to the event. This is referred to as an_. An__ can include visual changes (flashing lights or blind spots in the field of vision) or hallucinations (seeing, hearing, or smelling things that are not actually present). People with a history of seizures recognize their auras and usually take steps to minimize injury, such as sitting or lying down, knowing what is about to happen. However, be aware that auras do not occur prior to every seizure, and not all patients with a seizure disorder experience an__
aura
A___ may be characterized by sudden loss of consciousness followed by chaotic muscle movement and tone. The patient may experience a tonic phase, usually lasting only seconds, in which there is a period of extreme muscular rigidity. This period is usually followed immediately by a clonic phase, lasting much longer, of constant muscle contraction and trembling, tongue biting, bladder incontinence, or bowel incontinence. During a generalized seizure, the patient typically may exhibit bilateral movement characterized by a cycle of muscle rigidity and relaxation. Throughout a generalized seizure, the patient exhibits tachycardia, hyperventilation, sweating, and intense salivation; however, other responses are also possible.
____typically last less than 5 minutes and are followed by a lengthy period (5 to 30 minutes or more) called a postictal state, in which a patient is unresponsive at first and gradually regains consciousness. The postictal state is over when the patient regains a complete return of his or her normal level of consciousness. In most cases, the patient will gradually begin to recover and awaken but appear dazed, confused, and fatigued. In contrast, a generalized nonmotor or absence seizure may last for just seconds, after which the patient fully recovers with only a brief lapse of memory of the event.
generalized motor seizure
Seizures lasting more than 5 minutes are at risk for progressing to____, which describes seizures that
continue every few minutes without the person regaining consciousness or that last longer than 30 minutes.
Recurring or prolonged seizures should be considered immediately life-threatening situations in which patients need emergency medical care. If the patient does not regain consciousness or the seizure continues, protect the patient from self-harm, and call for advanced life support (ALS) backup. These patients need advanced airway management and medication to stop the seizure.
status epilepticus
Patients with epilepsy will often have seizures if they stop taking their medications or if they do not take the prescribed dose on a regular basis.
Seizures may also be caused by abnormalities in the brain, such as a benign or cancerous tumor, an infection (brain abscess, meningitis), or scar tissue from some type of injury within the skull. These seizures are said to have a structural cause. Seizures from a metabolic cause may result from abnormal levels of certain blood chemicals (eg, extremely low sodium level), hypoglycemia (low blood glucose level), hyperglycemia (high blood glucose level), poisons, drug overdoses, or sudden withdrawal from routine heavy alcohol or sedative drug use or even from prescribed medications. Phenytoin, a drug that is used to control seizures, may itself cause seizures if the person takes too much.
Seizures may also result from sudden high fevers, primarily in children. These____ are frightening for parents but are generally well tolerated by the child. Always transport a child who has had a ___to the hospital, as the seizure may be a sign of a serious medical condition.
febrile seizure
Because most seizures involve a vigorous twitching of the muscles, the muscles use a lot of__. This excessive demand consumes___ that is needed for the vital functions of the body. As a result, there is a buildup of acids in the bloodstream, and the patient may turn cyanotic (blue lips, tongue, and skin) from the lack of__. Often, the seizures themselves prevent the patient from breathing normally, making the problem worse. In a patient with diabetes, the blood glucose level may decrease because of the excessive muscular contraction of a seizure. If possible, closely monitor the blood glucose level after a patient with diabetes has a seizure.
oxygen
Recognizing seizure activity also means looking at other problems associated with the seizure. For example, the patient may have fallen during the seizure episode and been injured; head injury is the most serious possibility. Some patients may experience___ during a generalized seizure, meaning that they may have a loss of bowel or bladder control.
Therefore, one clue that unresponsive or confused patients may have had a seizure is to find that they were__.
Although___ can occur with other medical conditions, sudden__ is likely a sign of a seizure. When the patient regains consciousness, he or she is likely to be embarrassed by this temporary loss of control. Minimize the patient’s discomfort by covering the patient and assuring him or her that__ is part of the loss of control that accompanies a seizure
incontinence
Once a seizure has stopped, the patient’s muscles relax, becoming almost flaccid, or floppy, and the breathing becomes labored (fast and deep) to compensate for the buildup of acids in the bloodstream. By breathing faster and more deeply, the body can balance the acidity in the bloodstream. With normal circulation and liver function, the acids clear away within minutes, and the patient will begin to breathe more normally. The longer and more intense the seizures, the longer it will take for this imbalance to correct itself. Likewise, longer and more severe seizures will result in longer postictal unresponsiveness and confusion. Once the patient regains a normal level of consciousness, the___ is over.
postictal state
In some situations, the postictal state may be characterized by__, or weakness on one side of the body, resembling a stroke. However, unlike a stroke, hypoxic___ soon resolves. Most commonly, the postictal state is characterized by lethargy and confusion to the point that the patient may be combative. Be prepared for these circumstances in your approach to scene control and in your treatment of the patient’s symptoms. If the patient’s condition does not improve, consider other possible underlying conditions such as hypoglycemia or infection.
hemiparesis
Weakness on one side of the body
Hemiparesis
Status epilepticus is harmful at any age, but because of physical changes caused by the normal aging process,___ are at greater risk of hypoxia, hypotension, and/or cardiac dysrhythmias.
geriatric patients
Seizures are often mistaken for___ fainting); however, fainting typically occurs while the patient is standing, whereas seizures may occur in any position. Fainting is not associated with a postictal state.
syncope
Aside from stroke and seizures, the most common type of neurologic emergency you will encounter is a patient with__. Simply put,___ means the patient is not thinking clearly or is incapable of being awakened.
In some cases, the patient will be unconscious; other times, the patient may be alert but confused (FIGURE 18-7). The range of problems is wide and the causes are many, including hypoglycemia, hypoxemia, intoxication, delirium, drug overdose, unrecognized head injury, brain infection, body temperature abnormalities, brain tumors, and overdoses and/or poisonings.
altered mental status
The clinical picture of patients with altered mental status caused by___ is complex. Because oxygen and glucose are needed for brain function,___ can mimic conditions in the brain associated with stroke. In these cases, the patient may have hemiparesis similar to that seen with a stroke. The principal difference is that a patient who has experienced a stroke may be alert and attempting to communicate normally, whereas a patient with___ almost always has an altered or decreased level of consciousness
hypoglycemia
___is a symptom, not a disease. It presents as a new complaint, rather than a long-standing alteration in behavior. It is a temporary state that often has a physical or mental cause (eg, infection, changes in medications, hypoxia) and may be reversed with proper treatment.
Signs and symptoms include confusion and disorientation, disorganized thoughts, inattention, memory loss, striking changes in personality and affect, hallucinations, delusions, or a decreased level of consciousness. The patient may experience a rapid alteration between mental states such as lethargy and agitation. Symptoms of delirium may mimic intoxication, drug abuse, or severe psychological disorders such as schizophrenia.
Delirium
BE - FAST stands for
Balance
Eyes
Facial droop
Arm drift
Speech
Time
The Cincinnati stroke scale tests what
Facial droop
Arm drift
Speech
In addition, a newer scoring system called the___, looks specifically at three items— level of consciousness, arm drift (motor function), and gaze. This system may be used to assess the likelihood your patient is experiencing a stroke. Each item is scored from 0 to 2, with zero (0) being normal and two (2) being a severe abnormality (TABLE 18-6). Data show that a score of 5 or 6 indicates a high probability the patient is experiencing a stroke. Become familiar with what is used in your local protocol.
3-Item Stroke Severity Scale, sometimes called the LAG scale
Recently it has been determined that large vessel occlusion (LVO) strokes, which are a subtype of ischemic stroke, can be fairly reliably identified by EMS. These strokes, caused by an occlusion of a large blood vessel in the brain, respond well to fibrinolytics or mechanical thrombectomy but require rapid identification to provide the best results.
___, which is based on the Los Angeles Prehospital Stroke Screen, was developed to identify LVO strokes faster and more accurately to guide EMS to the best transport destination for the patient. The
LAMS gives points for facial droop (absent = 0, present = 1), arm drift (absent = 0, slow drift = 1, rapid fall = 2), and grip
strength (normal = 0, weak grip = 1, no grip = 2). A score of 4 or more is a strong indication of an LVO stroke and
indicates consideration of transport to a comprehensive stroke center, if available.
The Los Angeles Motor Scale (LAMS)
The following is key information to document for a patient who may have had a stroke:
• Time of onset of the signs and symptoms
• Score on the GCS
• Results of a stroke assessment tool (Cincinnati, Los Angeles, LAG, or BE-FAST)
• Changes noted on reassessment
The brain gradually deteriorates and shrinks as a part of the normal aging process. These processes increase the risk of brain injury from minor forces because the brain can more readily impact the inside of the skull as a result of the increased space and because the veins that connect the brain to the dura are stretched. A reduced brain mass may also reduce the patient’s mental status and capacity. A smaller brain can impair memory function. A ____with lapses in short-term memory may often ask the same or similar questions repeatedly.
geriatric patient
Fibrinolytic therapy (blood clot-dissolving drugs) and methods to mechanically remove the blood clot may reverse stroke symptoms and even stop the stroke if implemented within 3 hours (drugs) or 6 hours (mechanical methods) of the onset of symptoms. In some very specific situations at centers with advanced capabilities, the window during which mechanical removal of the clot may offer benefit may extend as long as 24 hours after the time at which the patient was last seen to be normal. These therapies may not work for all patients, and they cannot be given to patients with bleeding-type (hemorrhagic) strokes. Comprehensive stroke centers are able to offer advanced stroke care, and in some cases, may be able to provide thrombolytic therapy even well after the____- to 6-hour window and in some specific cases up to 24 hours after onset of symptoms. Because hospital personnel will ultimately make these treatment decisions, you should proceed under the assumption that the affected area of the brain may be saved. The sooner the treatment is begun, the better the prognosis for the patient.
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