Chapter 15: Neurologic Emergencies Flashcards
Discuss
How many cranial nerves are there?
12
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What environmental factors is the brain sensitive to?
O2, glucose, temperature
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Possible causes of headache
- Not life threatening: Tension (stress), migraines (changes in blood vessel size in brain), sinus headaches
- Serious causes:
- hemorrhagic stroke
- brain tumors
- meningitis
- Beware sudden onset
Discuss
…the two types of CVA?
Ischemic and hemorrhagic.
- Ischemic: blockage of blood flow due to thrombosis or embolus. This is 80% of strokes, often associated with atherosclerosis.
- Hemorrhagic results from ruptured blood vessel causing intracranial pressure and brain damage. Compressed tissue loses blood supply. Commonly with stress or exertion, with chronic high BP.
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Subarachnoid hemorrhage
Results in sudden severe headache, “worst ever”
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TIA
Transient ischemic attack: when stroke symptoms go away in <24 hrs. All should be evaluated by physician since a TIA indicates stroke risk.
Discuss
CVA/TIA S/S
Ataxia, dysphasia (speech disorder), expressive aphasia (difficulty expressing thoughts), dysarthria (slurred speech), receptive aphasia (difficulty understanding others)
Discuss
What are indicators of the location of the CVA?
Left hemisphere: aphasia (inability to produce/understand speech), paralysis of right side. Right hemisphere: Left side paralysis, may be oblivious to their problem “Neglect”
Discuss
What would suggest hemorrhagic stroke over ischemic?
Increasing BP as the body compensates for perceived lack of pressure to perfuse brain
Discuss
Conditions mimicking stroke
Hypoglycemia, postictal state, subdural (slow onset of AMS because usually a vein) or epidural bleeding (fast onset of AMS because usually an artery)
Discuss
Components of the Cincinnati Stroke Scale
- Facial droop (“smile!”);
- Arm drift (“close your eyes and hold both arms out with palms up”);
- Speech (“Say, ‘the sky is blue in Cincinnatti’”). DOCUMENT TIME OF ONSET AND GET GCS score
Discuss
Generalized seizure
Unconciousness and twitching of body. From abnormal discharges from large areas of the brain (grand mal) OR a brief lapse of consciousness (petite mal)
Discuss
Partial seizure
Begins in one part of the brain and can be simple or complex.
- Simple: no change in LOC, just weakness or dizziness or numbness. May involve senses. May involve extremity twitching.
- Complex: AMS, isolated convulsions, repetitive physical behavior like lip smacking and eye blinking (automatisms), smells and hallucinations,
Discuss
Aura
A feeling a patient may get that warns them a seizure is coming
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Tonic-clonic seizure
Bilateral muscle rigidity and relaxation 1-3 minutes, rhythmic back and forth motion of extremity, with tachycardia, hyperventilation, sweating, salivation
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Typical time progress of seizure
Seizures last 3-5 minutes followed by 5-30 minute postictal state
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Postictal state
- Floppy muscles
- slowly regaining LOC
- labored breathing, fast and deep to combat acidosis
- Occasional hemiparesis.
- Sometimes combative.
Discuss
Hemiparesis
Weakness on one side of body. Can occur in postictal state and mimick stroke.
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Status epilepticus
Seizures that continue every few minutes without regaining consciousness OR seizures lasting longer than 30 minutes. POTENTIALLY LIFE THREATENING. Pt needs ALS for medication and advanced airway management.
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Causes of seizures
- Epileptic: congenital.
- Structural: tumor, infection, scar tissue, head trauma, stroke.
- Metabolic: hypoxia, hypoglycemia (monitor blood glucose closely after seizure since the seizure can dramatically lower levels), poisoning, drugs, withdrawal, chemical imbalance (eg electrolytes).
- Febrile: sudden high fever. Usually well tolerated by child, but needs evaluation.
Discuss
Seizure meds
Dilantin, phenobarbital
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Seizure treatment
Encourage pt to see physician, package softly, do not restrain, give O2 and consider NPA in pt having a seizure
Discuss
What are possible causes of AMS?
- T: Trauma
- I: Infection
- P: Psychogenic
- S: Seizure/syncope
- A: Alcohol
- E: Electrolytes
- I: Insulin
- O: Opiates
- U: Uremia
Discuss
How to distinguish hypoglycemia from stroke and seizure
Hypoglycemia almost always has altered LOC. Pt’s will have meds that lower blood glucose level. If pt has hypoglycemic seizure, their mental status may not improve during the postictal state
Discuss
Glasgow Coma Scale
- Eye opening
- 4: Spontaneous
- 3: In response to speech
- 2: In response to pain
- 1: None
- Best Verbal Response
- 5: Oriented conversation
- 4: Confused conversation
- 3: Inappropriate words
- 2: Incomprehensible sounds
- 1: None
- Best Motor Response
- 6: Obeys commands
- 5: Localizes pain
- 4: Withdraws to pain
- 3: Abnormal flexion
- 2: Abnormal extension
- 1: None
Discuss
Significance of GCS scores
13-15: Mild dysfunction to none. 9-12: Moderate dysfunction. <8: Severe dysfunction
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Questions to ask when postictal pt refuses transport
Awake and completely oriented (GCS of 15?). No indication of trauma or complications? Has patient had seizure before? Was this seizure the “usual” seizure in every way? Pt currently being treated with meds and receiving regular evaluations? If yes to all, consider agreeing to refusal to transport
Discuss
Aneurysm
Swelling or enlargement of part of blood vessel –> weakening of vessel wall
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Aphasia
Inability to understand/produce speech
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Coma
State of profound unconsciousness from which one cannot be roused
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Thrombosis
Clotting of cerebral arteries that may result in the interruption of cerebral blood flow
