Neurological EmergenciesComa, Seizures, Syncope, Stroke

Coma

State of unconsciousness from which patient cannot be aroused

Coma

Unconsciousness = Immediate Life ThreatLoss of airwayAspiration

Coma

Management of ABC’s must come before investigation of cause

Airway

Open, clear, maintain If trauma present or no history

available, immediately control C-spine

Breathing

Assess presence, adequacy High concentration O2 immediately

on all patients with decreased LOC Assist if respiratory rate, tidal

volume inadequate

Circulation

Pulses?Perfusion?

After ABC’s stabilized. . .

Quickly investigate causeDERM

D = Depth of coma

What does patient respond to?How does he respond?

E = Eyes

Pupils equal, dilated, constricted,

Responsive to light?How?

R = Respiratory pattern

Rate?Unusually deep or shallow?Altered pattern?

M = Motor Function

Evidence of paralysis?Movement on stimulation? How?

Vital Signs

Shock? Increased ICP?Arrhythmias?

Head to Toe Survey

Injuries causing coma? Injuries caused by fall? What do the scene, bystanders tell

you?

Possible Causes

Not enough oxygen Not enough sugar Not enough blood flow to deliver O2,

sugar Direct brain injury

Structural (trauma)Metabolic (toxins, infections, temperature)

Possible Causes

Alcohol Epilepsy Insulin Overdose Uremia (and

other metabolic causes)

Trauma Infection Psychiatric Stroke,

syncope

Management

Secure airway Protective reflexes may be lost Immobilize spine unless absolutely

certain injury not present Spinal injury not suspected -

patient on left side

Management

High concentration O2

Assist ventilation as neededMonitor neurological/vital signs

every 5 minutes

Management

Protect patient’s eyes on long transports (tape shut, moist pads)

Patient may hear, understand even though unable to respond

Treat, reassure accordingly

Seizures

Episodes of uncoordinated electrical activity in brain

Signs/symptoms depend on area involved

Epilepsy

Tendency to have repeated episodes of seizure activity

Seizure Types

Grand mal (major motor)Petit mal (absence)Focal motor (simple partial)Psychomotor (complex partial)

Grand Mal Seizure

AuraSensation coming before convulsionPatient may recognize as sign of

impending seizureMay help locate origin of seizure in

brain

Grand Mal Seizure

ConvulsionLoss of consciousnessTonic phase - rigidityClonic phase - rhythmic jerking,

incontinence, ineffective breathing

Grand Mal Seizure

Post-ictal PhaseExhaustionDrowsinessHeadachePossible hemiparesis (Todd’s

paralysis)

Petit Mal Seizure

Loss of consciousnessNo loss of postural toneMore common in children

Focal Motor Seizure

Rhythmic jerking of limb, one side of body

No loss of consciousness

Psychomotor Seizure

Loss of consciousness Sterotyped movements

(automatisms)May look purposeful, but aren’tLip smacking, movements of hands

May be called in as “drunk”, “O.D.”, “psych patient”

Generalized Seizure Management

During seizureRemove from potential harmDo not forcibly restrainRoll on sideAvoid putting anything in mouth

Generalized Seizure Management

After seizure endsAssess ABC’sClear airway

Most common cause of seizure deaths is post-ictal

airway loss

Generalized Seizure Management

High concentration O2 - immediately!!

Assist breathing if ventilation inadequate

Generalized Seizure Management

Obtain history/physicalTrauma that could have caused, been

caused by seizureAnti-seizure medications

Neuro/vital signs every 5 minutesIf patient ventilating adequately,

transport on left side

Seizures

Anything that injures brain can cause seizures (AEIOU/TIPS)

Do not assume seizures are due to idiopathic epilepsy until proven otherwise

Status Epilepticus

> 2 seizures without intervening conscious period

Immediate Life Threat Management

Secure airwayAssist breathing with O2

TransportRequest ALS intercept

Syncope

Fainting Sudden, temporary loss of

consciousness Caused by lack of blood flow to

brain

Causes

Stress, fright, pain (vasovagal syncope) Orthostatic hypotension (BP fall on

standing) Decreased blood volume Increased size of vascular space

Decreased cardiac output Prolonged forceful coughing

Management

ABCs Keep patient supine, elevate

lower extremities Oxygen Assess underlying cause

CVA

Cerebrovascular accident Stroke

CVA

Damage of portion of brain due to interruption of blood supply

MechanismsThrombosisHemorrhageEmbolism

Thrombosis

Blockage of vessel by thrombus Usually forms at area narrowed by

atherosclerosis Typically in older persons Frequently occurs during sleep

Hemorrhage

Vessel ruptures Associated with hypertension,

aneurysms of cerebral blood vessels Usually characterized by

Sudden onset Severe signs, symptoms

Embolism

Blood clots, plaque fragments travel through vessel; lodge, block flow

Often associated with:Atherosclerosis of carotidsChronic atrial fibrillation

Signs/Symptoms

Alterations in consciousnessAltered affectConfusionDizzinessComa

Signs/Symptoms

Localizing signsParalysisLoss of sensationLoss of speechUnilateral blindnessLoss of vision in half of visual field of

both eyesUnequal pupils

Signs/Symptoms

SeizuresHeadacheStiff neck

Transient Ischemic Attacks

TIAs “Little strokes” Produce deficits that resolve

completely in <24 hours Frequently precede CVA

Management

Assess ABC’s Protect airway High concentration O2

Vital signs every 5-10 minutes Note increased BP, irregular pulse

Management

Nothing by mouth Avoid rough handling Transport paralyzed side down Guard your conversation Patients who cannot speak may

still understand!

Management

CVAs caused by thrombus, embolus may be reversible with thrombolytics (clot busters)

Early recognition, rapid transport to appropriate facility is critical