Transcript Coma, Seizure, Stroke - Hatzalah of Miami-Dade

Neurological Emergencies
Coma, Seizures, Syncope, Stroke
Coma

State of unconsciousness from
which patient cannot be aroused
Coma
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Unconsciousness =
Immediate Life Threat
 Loss of airway
 Aspiration
Coma

Management of ABC’s must come
before investigation of cause
Airway
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Open, clear, maintain
If trauma present or no history
available, immediately control
C-spine
Breathing
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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. . .
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Quickly investigate cause
DERM
D = Depth of coma
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What does patient respond to?
How does he respond?
E = Eyes
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Pupils equal, dilated, constricted,
Responsive to light?
How?
R = Respiratory pattern
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Rate?
Unusually deep or shallow?
Altered pattern?
M = Motor Function
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Evidence of paralysis?
Movement on stimulation?
How?
Vital Signs
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Shock?
Increased ICP?
Arrhythmias?
Head to Toe Survey
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Injuries causing coma?
Injuries caused by fall?
What do the scene, bystanders tell you?
Possible Causes
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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
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Management
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Secure airway
Protective reflexes may be lost
Immobilize spine unless absolutely
certain injury not present
Spinal injury not suspected - patient
on left side
Management
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High concentration O2
Assist ventilation as needed
Monitor neurological/vital signs
every 5 minutes
Management
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Protect patient’s eyes on long
transports (tape shut, moist pads)
Patient may hear, understand even
though unable to respond
Treat, reassure accordingly
Seizures
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Episodes of uncoordinated
electrical activity in brain
Signs/symptoms depend on area
involved
Epilepsy
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Tendency to have repeated
episodes of seizure activity
Seizure Types
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Grand mal (major motor)
Petit mal (absence)
Focal motor (simple partial)
Psychomotor (complex partial)
Grand Mal Seizure
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Aura
 Sensation coming before convulsion
 Patient may recognize as sign of
impending seizure
 May help locate origin of seizure in brain
Grand Mal Seizure
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Convulsion
 Loss of consciousness
 Tonic phase - rigidity
 Clonic phase - rhythmic jerking,
incontinence, ineffective breathing
Grand Mal Seizure
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Post-ictal Phase
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Exhaustion
Drowsiness
Headache
Possible hemiparesis (Todd’s paralysis)
Petit Mal Seizure
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Loss of consciousness
No loss of postural tone
More common in children
Focal Motor Seizure
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Rhythmic jerking of limb, one
side of body
No loss of consciousness
Psychomotor Seizure
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Loss of consciousness
Sterotyped movements (automatisms)
 May look purposeful, but aren’t
 Lip smacking, movements of hands
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May be called in as “drunk”, “O.D.”,
“psych patient”
Generalized Seizure Management
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During seizure
 Remove from potential harm
 Do not forcibly restrain
 Roll on side
 Avoid putting anything in mouth
Generalized Seizure Management
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After seizure ends
 Assess ABC’s
 Clear 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/physical
Trauma that could have caused, been
caused by seizure
Anti-seizure medications
 Neuro/vital signs every 5 minutes
 If patient ventilating adequately,
transport on left side
Seizures
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Anything that injures brain can
cause seizures (AEIOU/TIPS)
Do not assume seizures are due
to idiopathic epilepsy until proven
otherwise
Status Epilepticus
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> 2 seizures without intervening
conscious period
Immediate Life Threat
Management
 Secure airway
 Assist breathing with O2
 Transport
 Request 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)
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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
 Stroke
accident
CVA
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Damage of portion of brain due to
interruption of blood supply
Mechanisms
 Thrombosis
 Hemorrhage
 Embolism
Thrombosis
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Blockage of vessel by thrombus
Usually forms at area narrowed by
atherosclerosis
Typically in older persons
Frequently occurs during sleep
Hemorrhage
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Vessel ruptures
Associated with hypertension,
aneurysms of cerebral blood vessels
Usually characterized by
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Sudden onset
Severe signs, symptoms
Embolism
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Blood clots, plaque fragments travel
through vessel; lodge, block flow
Often associated with:
 Atherosclerosis of carotids
 Chronic atrial fibrillation
Signs/Symptoms

Alterations in consciousness
 Altered affect
 Confusion
 Dizziness
 Coma
Signs/Symptoms
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Localizing signs
 Paralysis
 Loss of sensation
 Loss of speech
 Unilateral blindness
 Loss of vision in half of visual field of
both eyes
 Unequal pupils
Signs/Symptoms
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Seizures
Headache
Stiff neck
Transient Ischemic Attacks
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TIAs
“Little strokes”
Produce deficits that resolve
completely in <24 hours
Frequently precede CVA
Management
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Assess ABC’s
Protect airway
High concentration O2
Vital signs every 5-10 minutes
Note increased BP, irregular pulse
Management
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Nothing by mouth
Avoid rough handling
Transport paralyzed side down
Guard your conversation
Patients who cannot speak may still
understand!
Management
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CVAs caused by thrombus, embolus
may be reversible with thrombolytics
(clot busters)
Early recognition, rapid transport to
appropriate facility is critical