Chapter 18 Flashcards
Seizures may occur as a result of
- Recent or prior head injury
- A brain tumor
- Metabolic problems
- Fever
- A genetic disposition
Possible causes of altered mental status include
- Intoxication
- Head injury
- Hypoxia
- Stroke
- Metabolic disturbances
The brain is the body’s computer - it controls
- breathing,
- speech,
- and all body functions
Three major parts of the brain
- brainstem
- cerebellum
- cerebrum
The cerebrum is the largest part
The brainstem controls
Most basic functions.
- Breathing
- blood pressure
- swallowing
- pupil constriction
The cerebellum controls
muscle and body coordination
The cerebrum
The cerebrum is divided into right and left hemispheres.
- Each controls activities on the opposite side of the body.
- The front of the cerebrum controls emotion and thought.
- The middle controls sensation and movement.
- The back processes sight.
speech is controlled
In most people, speech is controlled on the left side of the brain near the middle of the cerebrum.
Messages sent to and from the brain travel through
nerves
Twelve cranial nerves run directly from the brain to parts of the head.
foramen magnum
the opening in the skull where the spine enters
- The rest of the nerves join in the spinal cord and exit the brain through a large opening in the base of the skull called the foramen magnum.
- At each vertebra in the neck and back, two nerves branch out (spinal nerves).
- These carry signals to and from the body.
The spinal cord
The spinal cord 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.
Many different disorders may cause brain dysfunction, may affect the patient’s level of consciousness
- speech
- and voluntary muscle control
The brain is sensitive to changes in
oxygen,
- glucose,
- and temperature.
Headaches
- One of the most common complaints
- Can be a symptom of another condition or a neurologic condition on its own
- Only a small percentage of headaches are caused by a serious medical condition.
- Tension headaches, migraines, and sinus headaches are the most common.
Tension headaches
- Caused by muscle contractions in the head and neck
- Attributed to stress
- Pain is usually described as squeezing, dull, or as an ache.
- Usually do not require medical attention
Migraine headaches
- Thought to be caused by changes in blood vessel size in the base of the brain.
- Pain is usually described as pounding, throbbing, and pulsating.
- Often associated with nausea and vomiting, and may be preceded by visual changes
- Can last for several hours or days
Sinus headaches
- Caused by pressure that is the result of fluid accumulation in the sinus cavities
- Patients may also have cold-like symptoms of nasal congestion, cough, and fever.
- Prehospital emergency care is not required.
Serious conditions that include headache as a symptom are
- hemorrhagic stroke (bleeding into the brain by the rupture of a blood vessel)
- brain tumor (an abnormal mass of tissue in which cells grow and multiply uncontrollably, seemingly unchecked by the mechanisms that control normal cells)
- meningitis (inflammation of the tissues surrounding the brain and spinal cord)
Stroke
- Also called a cerebrovascular accident (CVA)
- Interruption of blood flow to an area within the brain
- Results in the loss of brain function
- There are two main types of stroke: ischemic and hemorrhagic.
Ischemic Stroke
- Most common, accounting for 87% of strokes
- Results from thrombosis or an embolus
- Symptoms may range from nothing at all to complete paralysis.
- Atherosclerosis in the blood vessels is often the cause
Atherosclerosis
Atherosclerosis can damage the wall of a
cerebral artery, producing narrowing and/or a blood clot.
When a vessel is narrowed or completely blocked, blood
flow to part of the brain may be blocked, causing brain
cells to die because of the lack of adequate oxygenation
Hemorrhagic Stroke
- Accounts for 13% of strokes
- Results from bleeding inside the brain
- Cerebral hemorrhages are often fatal.
- People at high risk include those experiencing stress or exertion.
- People at highest risk are those who have very high blood pressure.
Aneurysm
Swelling or enlargement of the wall of an artery resulting from a defect or weakening of the arterial wall
Transient Ischemic Attack (TIA)
- Stroke-like symptoms go away on their own in less than 24 hours.
- May be a warning sign of a larger stroke to come
- About one-third of patients who have a TIA will experience a stroke.
Signs and Symptoms of Stroke
- Facial drooping
- Sudden weakness or numbness in the face, arm, leg, or one side of body
- Decreased or absent movement and sensation on one side of the body
- Lack of muscle coordination (ataxia) or loss of balance
- Sudden vision loss in one eye
- Blurred and double vision
- Difficulty swallowing
- Decreased level of responsiveness
- Speech disorders
- Aphasia
- Slurred speech (dysarthria)
- Sudden and severe headache
- Confusion
- Dizziness
- Weakness
- Combativeness
- Restlessness
- Tongue deviation
- Coma
Left Hemisphere
A stroke in the left cerebral hemisphere may cause aphasia.
- Inability to produce or understand speech
- Speech problems can vary widely.
- May also cause paralysis of the right side of the body
Right Hemisphere
- Stroke may cause paralysis of the left side of the body.
- Usually, patients can understand language and are able to speak.
- Patients may be oblivious to their problem (neglect).
- Neglect and lack of pain cause many patients to delay seeking help.
Bleeding in the Brain
- Patients may have high blood pressure.
– May be the cause of the bleeding
– May be caused by the bleeding, as a compensatory response - Increasing blood pressure is an important sign.
- Significant drops in blood pressure may occur as the patient’s condition worsens.
Conditions That May Mimic Stroke
- Hypoglycemia (a condition in which your blood sugar (glucose) level is lower than the standard range)
- Postictal state (a period that begins when a seizure subsides and ends when the patient returns to baseline)
- Subdural or epidural bleeding
Bleeding outside the dura and under the skull is called
epidural bleeding
Bleeding beneath the dura but outside the brain is called
subdural bleeding
Seizures
- A neurologic episode caused by a surge of electrical activity in the brain
- Can take the form of a convulsion and/or can be associated with a temporary alteration in consciousness.
- Two basic groups: generalized and partial (focal)
Generalized Seizure
- Results from abnormal electrical discharges from large areas of the brain
- Typically characterized by unconsciousness and a generalized severe twitching of all muscles lasting several minutes or longer
Absence Seizure
- Does not involve any changes in motor activity
- Characterized by a brief lapse of consciousness in which the patient seems to stare and not respond
Partial (Focal) Seizure
Focal-onset aware seizure
- No change in the patient’s level of consciousness
- May have numbness, weakness, dizziness, visual changes, or unusual smells/tastes
- May have some twitching or brief paralysis
Focal-onset, impaired awareness seizure
- Altered mental status
- Results from abnormal discharges from the temporal lobe of the brain
- Lip smacking, eye blinking, isolated jerking
- Unpleasant smells, visual hallucinations, uncontrollable fear, repetitive physical behavior
Aura
- Patients may experience an aura prior to a seizure.
- Can include visual changes or hallucinations
- People with a history of seizures recognize their auras and usually take steps to minimize injury.
- Auras do not occur prior to every seizure, and not all patients with a seizure disorder experience an aura.
Generalized Seizure
- Characterized by sudden loss of consciousness, chaotic muscle movement and tone, and apnea.
- May exhibit bilateral muscle movement characterized by a cycle of muscle rigidity and relaxation
- Typically lasts less than 5 minutes
- Followed by a postictal state
Absence Seizure
- Formerly called petit mal
- May last for seconds
- Patient fully recovers with a brief lapse of memory
Status Epilepticus
- Seizures lasting more than 5 minutes are likely to progress to status epilepticus.
- Seizures that continue every few minutes without the person regaining consciousness or last longer than 30 minutes
Epileptic seizures usually can be controlled by medications
- Levetiracetam (Keppra)
- Phenytoin (Dilantin)
- Phenobarbital
- Carbamazepine (Tegretol)
- Valproate (Depakote)
- Topiramate (Topamax)
- Clonazepam (Klonopin)
The Postictal State
The postictal state is a period that begins when a seizure subsides and ends when the patient returns to baseline
- After a seizure, the muscles relax and breathing becomes labored.
- May be characterized by hemiparesis (one-sided of the body muscle weakness)
- Most commonly characterized by lethargy and confusion
If the patient does not improve, consider other possible underlying conditions.
Syncope
a loss of consciousness for a short period of time.
- Seizures are often mistaken for syncope, or fainting.
- Fainting typically occurs while the patient is standing.
- Seizures may occur in any position.
Fainting is not associated with a postictal state.
Causes of AMS (altered mental state)
- Hypoglycemia
- Hypoxemia
- Intoxication
- Delirium
- Drug overdose
- Unrecognized head injury
- Brain infection
- Body temperature abnormality
- Brain tumor
- Overdose and/or poisoning
XABC
XABC exsanguinating hemorrhage ( It occurs when someone loses enough blood to cause death), ABC
Vital signs
Significant intracranial bleeding leads to a great deal of pressure in the skull, compressing the brain.
- Slow pulse and erratic respirations
- High blood pressure
- Changes in pupil size
If the patient has an AMS (altered mental state), check the blood glucose level.
Stroke assessment
Stroke scales evaluate the face, arms, and speech.
- BE-FAST mnemonic
- Cincinnati Prehospital Stroke Scale
- Los Angeles Prehospital Stroke Screen
- 3-Item Stroke Severity Scale (LAG)
- Glasgow Coma Scale (GCS) score
BE-FAST mnemonic
B - Balance - Watch for sudden loss of balance
E - Eyes - Check for vision loss
F - Face - Look for uneven smile
A - Arms - Check if one arm is weak
S - Speech - Listen for slurred speech
T - Time - Call 911 Right away
Cincinnati Prehospital Stroke Scale
- facial droop
- dysarthria (where you have difficulty speaking because the muscles you use for speech are weak)
- upper extremity weakness
Los Angeles Prehospital Stroke Screen
- unilateral deficit facial paresis
- hand grip weakness
- arm drift
3-Item Stroke Severity Scale (LAG)
- level of consciousness
- gaze
- motor function
Glasgow Coma Scale (GCS) score
The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of three parameters: best eye response (E), best verbal response (V), and best motor response (M). The components of the GCS should be recorded individually; for example, E2V3M4 results in a GCS score of 9. A score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate injury, and a score of 8 or less represents severe brain injury.
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ED physicians determine if there is bleeding in the brain for patients with a suspected stroke with a CT scan of the head
If no bleeding is present, the patient may be a candidate for blood clot dissolving medication.
Notify the hospital regarding the last time the patient was known to be without their current signs and symptoms of stroke.
Patients who have had a seizure require definitive evaluation and treatment
Supplemental oxygen is strongly advised.
For patients who are having a seizure:
Protect them from harm.
Maintain a clear airway by suctioning.
Provide oxygen as quickly as possible.
If head or neck trauma is suspected, provide spinal immobilization.
For patients who continue to have a seizure, as in status epilepticus:
Suction the airway.
Provide positive pressure ventilations.
Transport quickly to the hospital.
Rendezvous with ALS, if possible.
You should be concerned if the patient complains of
You should be concerned if the patient complains of:
Migraine
Always assess the patient for other signs and symptoms that might indicate a more serious condition.
Apply high-flow oxygen, if tolerated.
Provide a darkened, quiet environment.
Do not use lights and siren during transport.
Stroke
Support XABCs and provide rapid transport to a stroke center.
Maintain a SpO2 level of at least 94%.
Oxygen therapy not recommended unless the patient is in respiratory distress or is hypoxic.
If possible, transport to a designated stroke center.
Seizure
The patient may be in a postictal state upon your arrival.
The patient may still be having a seizure:
Continue to assess and treat XABCs.
Protect the patient from harm.
If the patient refuses transport after a seizure:
Contact medical control.
Follow local protocols.
Altered Mental Status
Determine the cause.
Provide spinal motion restriction.
Provide airway and ventilation support.
Transport to the appropriate facility.
