Chapter 18: Altered Mental Status, Stroke, and Headache Flashcards
reticular activating system (RAS)
one of two components necessary for a patient to be awake/conscious, the network of nerve cells in the brain stem that constantly transmit environmental and sensory information to and from the cerebrum
altered mental status
significant indication of injury or illness in a patient, can range from simple disorientation to complete unconsciousness in which the patient is not responsive, even to painful stimuli
coma
an unconscious state in which the patient does not respond to painful stimuli
structural causes of altered mental status
- brain tumor
- hemorrhage in the cranium but outside of the brain
- hemorrhage in the brain tissue
- direct brain tissue damage from trauma to the brain
- degenerative disease of the brain
- brain abscess or infection
toxic-metabolic causes of altered mental status
- severe hypoxia or anoxia
- abnormal blood glucose conditions
- liver failure
- kidney failure
- poisoning
other causes of altered mental status
- shock
- drugs that depress the central NS
- post seizure
- infection
- cardiac rhythm disturbance
- stroke
physical exam for altered mental status
- head
- pupils
- mouth and oral mucosa
- chest
- breath sounds
- abdomen
- lower and upper extremities
- lower extremities (peripheral edema)
- posterior body
signs and symptoms of altered mental status commonly associated with trauma
- obvious signs of trauma
- abnormal respiratory pattern
- increased or decreased HR
- unequal pupils
- high or low BP
- Battle’s Sign
- Raccoon eyes
- pale, cool, moist skin
- flexion or extension
Battle’s Sign
discoloration around eyes, late sign of altered mental status associated with trauma, suggests basilar skull fracture
signs and symptoms of altered mental status commonly associated with a non-traumatic or medical condition
- abnormal respiratory pattern
- dry or moist skin
- cool or hot skin
- pinpoint, midsize, dilated, or unequal pupils
- stiff neck
- lacerations to the tongue indicating seizure activity
- high systolic BP and low HR
- loss of bowel or bladder control
- abnormally high or abnormally low blood glucose reading
AEIOU-TIPPSS
mnemonic for common causes of altered metnal status
A: Alcohol intoxication
E: Epilepsy (seizure)
I: Insulin (diabetic emergency)
O: Oxygen (hypoxia)
U: Uremia (toxic from kidney failure
T: Trauma
I: Infection
P: Psychiatric
P: Poisoning (including drug overdose)
S: Shock
S: Stroke
emergency medical care for altered mental status
along with care for the other injuries/conditions
1) consider spine motion restriction precautions
2) maintain a patent airway
3) suction any secretions, vomitus, or blood
4) maintain adequate oxygenation
5) be prepared to assist ventilation
6) position the patient: lateral recumbent position or supine (if ventilation needed)
7) transport
neurologic defecit
any deficiency in the functioning of the brain or nervous system
stroke/non-traumatic brain injury
a medical injury to the brain that is not related to trauma
AHA/ASA stroke chain of survival
1) rapid recognition of stroke signs and symptoms by the public and immediate access to EMS through 911
2) 911 call taker recognition of the signs and symptoms leading to rapid EMS dispatch
3) rapid EMS response, assessment, recognition of stroke, and transport while providing pre-arrival notification of a stroke patient to include the results of a verified stroke scale to the receiving medical facility
4) rapid diagnosis and treatment by the medical facility
F.A.S.T mnemonic for public stroke recognition
F: Facial droop
A: Arm weakness
S: Speech difficulty
T: Time to call 911 (if any sign or symptom found)
more subtle signs/symptoms of stroke
- sudden onset of numbness or weakness to the face, arm, or leg, especially on one side of the body
- sudden onset of confusion
- sudden slurring of speech or trouble speaking or the ability to understand
- sudden onset of blurred vision, double vision, or other vision disturbance in one or both eyes
- sudden onset of dizziness, lack of balance or coordination, or trouble walking
- sudden onset of a severe headache with no other known cause
collateral circulation
blood supply from the smaller arteries surrounding an occluded artery, to make up for the occluded artery
“electrically silent” cells
cells that do not get enough ATP to run their normal functions so they cannot produce or send out electrical impulses
ischemic penumbra
the area of ischemia during the stroke where the brain cells are electrically silent from lack of ATP but are still alive, aka ischemic shadow, it is possible to salvage these cells
infarct zone
the area of dead tissue due to a complete absence of blood flow
ischemic stroke
stroke caused by a blockage
hemorrhagic stroke
stroke causes by rupture and bleeding
thrombus
a clot that developed at the site of occlusion
thrombosis
the process of clot formation
thrombotic stroke
a stroke resulting from thrombus formation, severe headache not usually seen, typically has slower onset of symptoms
embolus
a clot or other matter that has traveled from another area of the body
cerebral embolism
when the emolys occludes the cerebral artery
embolic stroke
stroke resulting from cerebral embolism, sudden onset of symptoms, usually when patient is awake and active
types of ischemic strokes
thrombosis, embolism, atrial fibrillation and stroke
aneurysm
a ballooning of a weakened area within an artery wall
arteriovenous malformation (AVM)
a tangle of abnormally formed blood vessels in the brain or on its surface, divert blood directly from the artery to the vein and bypass capillaries
hemorrhagic stroke symptoms
sudden onset, headache is common and often severe, rapid deterioration, seizures, stiff neck
intracerebral hemorrhage stroke symptoms
- headache
- nausea and vomiting
- weakness to one side of body
- decreased consciousness
subarachnoid hemorrhage stroke symptoms
- worst headache
- intolerance to light
- vomiting
- decreased consciousness
anterior circulation stroke
occurs from the blockage of a cerebral artery that perfuses the cerebrum and cerebral cortex
signs and symptoms of an anterior circulation stroke
- paralysis and motor deficits
- numbness, tingling, loss of sensation
- language disturbance
- vision disturbance
- eye gaze
aphasia
communication disorder from damage to language areas in the brain
expressive aphasia
non-fluent, the patient knows what they want to say but cannot form the words
receptive aphasia
fluent, the patient has difficulty understanding what you are asking or telling, but can form fluent words
global aphasia
most severe, patient cannot understand or speak
posterior circulation
perfuses the brainstem and cerebellum (only 1/5 of brain)
signs and symptoms of a posterior circulation stroke
- paralysis and motor deficits
- numbness, tingling, loss of sensation
- language disturbance (not usually aphasia, usually dysarthria)
- vision disturbance
- ataxia and vertigo
dysarthria
slurred or difficult-to-understand speech caused by weakness or paralysis of the muscles used to form words
transient ischemic attack (TIA)
“mini strokes,” cerebral artery blockage is temporary or transient, signs and symptoms disappear without any obvious permanent neurologic deficits
cryptogenic stroke
a stroke that cannot be conclusively attributed to an embolism from the heart, thrombosis in the artery, or small artery disease
Cincinnati prehospital stroke scale (CPSS)
tests for facial droop, arm drift, abnormal speech
Los Angeles prehospital stroke screen (LAPSS
gathers info of: age greater than 45 years, history of seizures/epilepsy, duration of symptoms, wheelchair or bedridden status, blood glucose level, test asymmetry of strength
Miami emergency neurologic deficit (MEND) scale
takes about 3 minutes to complete, more comprehensive, has CPSS elements as well as elements from NIHSS
large vessel occlusion (LVO)
aka emergent large vessel occlusion (ELVO), a stroke caused by blockage of a large cerebral artery, has the highest mortality rate and worst patient outcomes
rapid arterial occlusion evaluation (RACE) scale
enables prehospital providers to perform a quick assessment that can both predict the stroke and identify an LVO
- facial palsy
- arm motor function
- leg motor function
- head and gaze deviation
- aphasia (right side deficit)
- agnosia (left side deficit)
questions to ask a stroke patient for a history
- when did the symptoms begin
- is there any recent history of trauma to the head
- does the patient have a history of a previous stroke
- was there any seizure activity noted prior to arrival
- what was the patient doing at the time of onset of the signs and symptoms
- does the patient have a history of diabetes
- has the patient complained of a headache or a stiff neck
- has the patient complained of dizziness, nausea, vomiting, or weakness
- has the patient experienced any slurred speech
other helpful questions to get info for hospital staff
- does the patient take any oral anticoagulant drugs
- does the patient have a history of hypertension
- has the patient taken amphetamines, cocaine, or some other stimulant drug
- was the onset of signs and symptoms gradual or sudden
- did the signs and symptoms get progressively worse or better
- did the paralysis or weakness affect one part of the body first and then progress to other areas
- does the patient have a history of atrial fibrillation or irregular heartbeat
emergency medical care for strokes
1) maintain a patent airway
2) suction secretions and vomitus
3) be prepared to assist ventilation
4) maintain adequate oxygenation
5) position the patient: left lateral recumbent (unresponsive), semi-fowlers less than 30°, supine position if spinal injury suspected
6) check blood glucose level if protocol permits
7) protect any paralyzed extremities
8) rapid transport
vascular headache
due to dilation or distention of vessels or inflammation within the cranium
migraine headaches
caused by spasm of vessels followed by vasodilation and a change in the chemicals that transmit nervous impulses in the brain. throbbing, generalized or localized, photosensitivity, nausea, vomiting, sweating
cluster headaches
occur repetitively in clusters, similar to migraines, pain usually found only on one side of head or face in the temporal region or around the eye, typically excruciating
tension headaches
caused by contractions of the muscles of the neck and scalp, tight or viselike pain, throbbing, aching, squeezing pain in frontal, temporal, occipital regions with radiation to neck and shoulders
organic headaches
aka traction or inflammatory headaches, symptoms of another condition
if called to a headache, these symptoms suggest a serious underlying condition
- altered mental status
- motor or sensory deficit
- behavior change
- seizure
- first experience of this type of headache with an abrupt onset
- worsening of pain with coughing, sneezing, or bending over
- fever of stiff neck
- change in the quality of a chronic headache
emergency medical care for a headache
1) establish and maintain an adequate airway
2) be prepared to suction
3) assess and maintain adequate ventilation
4) maintain adequate oxygenation
5) place the patient in a position of comfort
6) always be prepared to treat for seizures and transport to a medical facility
serious causes of a headache
- tumor
- bleeding within brain
- bleeding around brain
- meningitis
- hypertension
- hypoglycemia
- carbon monoxide poisoning, other toxic inhalation
- fever
- hypoxia
- stroke
- depression
- cyanide poisoning
stroke
a sudden disruption in blood flow to the brain that results in brain cell damage
