Neurological EmergenciesHeadaches, Seizures and Syncope

Presence Regional EMSNovember 2015 CE

Objectives•Review normal anatomy and physiology of

the central nervous system•Compare and contrast the conditions of

migraine headaches, tension headaches, cluster headaches and hemorrhagic stroke

•Differentiate between seizures and syncope•Using a variety of scenarios outline the

assessment and management of patients with neurological emergencies

Anatomy and Physiology

•The brain is the body’s computer.▫Controls breathing, speech, and all body

functions

•Three major parts: brain stem, cerebellum, and cerebrum▫The cerebrum is the largest part.

Anatomy and Physiology

Anatomy and Physiology

•The brain stem controls the most basic functions.▫Breathing, blood pressure, swallowing,

pupil constriction

•The cerebellum controls muscle and body coordination.▫Walking, writing, playing piano

Anatomy and Physiology

•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 touch and movement.

▫The back processes sight.

Anatomy and Physiology

•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: eyes, ears, nose, and face.

Anatomy and Physiology

•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).

▫They carry signals to and from the body.

Anatomy and Physiology

Pathophysiology

•Many different disorders can cause brain dysfunction.▫Can affect the patient’s level of

consciousness, speech, and voluntary muscle control

•The brain is sensitive to changes in oxygen, glucose, and temperature.

Pathophysiology

•General rule:▫If a problem is caused by the heart and

lungs, the entire brain is affected.

▫If the problem is in the brain, only part of the brain is affected.

Headache•One of the most common complaints

•Can be a symptom of another condition or a neurologic condition on its own

•Most headaches are harmless and do not require emergency medical care.

Headache•Sudden, severe headache requires

assessment and transport.▫If more than one patient reports headache,

consider carbon monoxide poisoning.

•Serious conditions that include headache as a symptom are hemorrhagic stroke, brain tumors, and meningitis.▫You should be concerned if the patient

complains of a sudden-onset, severe headache or a sudden headache that has associated symptoms.

Headache

•Types – Vascular Migraines

Thought to be caused by changes in the blood vessel size in the base of the brain

Throbbing pain, photosensitivity, nausea, vomiting, and sweats; more frequent in women

Can last for several days

Cluster One-sided with nasal congestion, drooping

eyelid, and irritated or watery eye; more frequent in men

Typically lasts 1–4 hours.

Headache

•Types▫Tension

Caused by muscle contractions in the head and neck

Attributed to stress Pain is usually described as squeezing, dull,

or as an ache.▫Organic

Occurs due to tumors, infection, or other diseases of the brain, eye, or other body system.

Headaches associated with fever, confusion, nausea, vomiting, or rash can be indicative of an infectious disease.

Headache

•Assessment▫What was the patient doing at the onset

of pain?▫Does anything provoke or relieve the

pain?▫What is the quality of the pain?▫Does the pain radiate to the neck, arm,

back, or jaw?▫What is the severity of the pain?▫How long has the headache been

present?

Headache Assessment

▫Is there a history of trauma in the last few weeks?

▫Is this typical for your headaches?

Headache

•Management▫ Scene safety and BSI▫ Maintain the airway.▫ Position the patient.▫ Establish IV access.▫ Determine blood glucose level.▫ Monitor the cardiac rhythm.▫ Consider medication.

Antiemetics or analgesics▫ Reassure the patient and transport.

Seizures

•A seizure, or convulsion, is a temporary alteration in consciousness.

•Account for up to 30% of EMS calls

•In the United States, it is estimated that 4 million people have epilepsy.

Seizures

•Generalized Seizures▫Tonic-Clonic

Aura Loss of Consciousness Tonic Phase Hypertonic Phase Clonic Phase Postseizure Postictal

▫Absence▫Pseudoseizures

Seizures

•Partial Seizures▫Simple Partial Seizures

Involve one body area. Can progress to generalized seizure.

▫Complex Partial Seizures “Psychomotor” Characterized by auras. Typically 1–2 minutes in length. Loss of contact with surroundings.

Causes of Seizures

•Some seizure disorders are congenital.

•Others may be caused by high fever, structural problems in the brain, or metabolic or chemical problems.

Causes of Seizures (2 of 3)

•Epileptic seizures usually can be controlled by medications.

•Seizures may be caused by an abnormal area in the brain, such as:▫A benign or cancerous tumor

▫An infection (brain abscess)

▫Scar tissue from some type of injury

Causes of Seizures (3 of 3)

•Seizures from a metabolic cause can result from:▫Abnormal levels of certain blood chemicals

▫Hypoglycemia

▫Poisons

▫Drug overdoses

▫Sudden withdrawal from routine heavy alcohol or sedative drug use

The Importance of Recognizing Seizures (1 of 2)

•Recognize when a seizure is occurring and whether this episode differs from previous ones.▫Patient may turn cyanotic.

▫Seizures may prevent the patient from breathing.

▫In a patient with diabetes, the blood glucose value may drop.

The Importance of Recognizing Seizures (2 of 2)

•You must look at other problems associated with the seizure.▫Patients who have fallen during a seizure

may have a head injury.

▫Patients having a generalized seizure may also experience incontinence.

The Postictal State (1 of 2)

•After a seizure, the muscles relax, becoming almost flaccid, and breathing becomes labored.▫With normal circulation and liver function,

the patient will begin to breathe more normally within minutes

The Postictal State (2 of 2)

•Most commonly characterized by lethargy and confusion▫The patient may be combative.

▫Be prepared for these circumstances.

•If the patient’s condition does not improve, consider hypoglycemia or infection.

Seizures

•Patient History (AEIOU TIPS)▫History of Seizures▫History of Head Trauma▫Any Alcohol or Drug Abuse▫Recent History of Fever, Headache, or Stiff

Neck▫History of Heart Disease, Diabetes, or

Stroke▫Current Medications

Phenytoin (Dilantin), phenobarbitol, valproic acid (Depakote), or carbamazepine (Tegretol)

▫Physical Exam Signs of head trauma or injury to tongue,

alcohol or drug abuse

Patient History (AEIOU TIPS)

Allergies, alcoholEnvironment, epilepsyInsulin (too much or too little)OpiatesUremia – kidney failureTrauma, toxins, InfectionPsychosisShock, stroke, sepsis

Seizures•BLS Management

▫Scene safety & BSI.▫Position the patient.▫Maintain the airway.

Suction if required.▫Administer high-

flow oxygen.▫Do not restrain the

patient. Protect the patient

from the environment.

▫Maintain body temperature.

Seizures

•ALS Management▫Establish IV access.▫Treat hypoglycemia if present.▫Monitor cardiac rhythm.▫If seizure persists longer than three

minutes, administer VERSED: IV: 0.05 mg/kg IV over 2 minutes (maximum

dose 5 mg); may repeat x 1 after 5 minutes if seizure persists.

IM: 0.1 mg/kg IM (maximum dose 10 mg) IN: 10 mg IN (5 mg/nostril)

Seizures

•Status Epilepticus▫Two or More Generalized Seizures

Seizures occur without a return of consciousness.

Syncope

•A Sudden, Temporary Loss of Consciousness

•Assessment▫Cardiovascular.

Dysrhythmias or mechanical problems.▫Noncardiovascular.

Metabolic, neurological, or psychiatric condition.

▫Idiopathic. The cause remains unknown even after

careful assessment.▫Extended unconsciousness is NOT syncope.

Syncope

•Management▫Scene safety & BSI.▫Maintain the airway.▫Support breathing.▫Check circulatory status.▫Monitor mental status.▫Establish IV access.▫Determine blood glucose level.▫Monitor the cardiac rhythm.▫Reassure the patient and transport.

Seizures or Syncope?

•Differentiating Between Syncope & Seizure Bystanders frequently confuse syncope and

seizure.

“Weak and Dizzy”

•Assessment▫Symptomatic of Many Illnesses▫Focused Assessment

Include a detailed neurological exam.

Specific signs and symptoms: Nystagmus Nausea and vomiting Dizziness

“Weak and Dizzy”

•Management▫Scene safety & BSI.▫Maintain airway & administer high-

flow oxygen.▫Position of comfort.▫Establish IV access & monitor cardiac

rhythm.▫Determine blood glucose level.▫Consider medication for

nausea/vomiting. Antiemetic -- Zofran

▫Transport and reassure patient.

Review•If doing this CE individually, please e-mail

your answers to:• Shelley.Peelman@presencehealth.org

•Use “November 2015 CE” in subject box.•You will receive an e-mail confirmation.

Print this confirmation for your records, and document the CE in your PREMSS CE record book.

•IDPH site code: 067100E1215

Review

1. True or False: All headaches are considered harmless and do not require emergency medical care.

2. Name 2 metabolic causes of seizures.3. Describe the postictal state.4. List the steps in management of a

patient with seizures.5. Differentiate between seizures and

syncope.

Scenario•You get called to a local church on Sunday at

1030 for a woman who has passed out. •Mrs. Nelson is 65 years old and is laying in a

pew with her feet elevated.•She tells you that she got weak and shaky and

the next thing she knew she was on the floor. •Now she feels very sweaty and clammy and

has a mild headache. •What else do you want to know about Mrs.

Nelson?

•Alert and oriented•Airway open and clear•Breathing unlabored at a rate of 16 •Oxygen saturation on room air 92%•Circulation: Radial pulse irregular at

about 70 skin warm and moist. BP 150/92•Blood glucose: 72

Cardiac Rhythm

SAMPLE History

•Allergies: codeine•Medications: Synthroid, catapress,

potassium •Past history: low thyroid, hypertension•Last meal: Coffee and donut at about

1000 between Sunday School and Church•Events: she got weak and shaky and the

next thing she knew she was on the floor

6. What is the problem Mrs. Nelson has called?

7. What might have caused Mrs. Nelson to do this?

8. How can you find out if this was a seizure or not?

9. How do you want to manage Mrs. Nelson?

10.Mrs. Nelson wants to refuse treatment, is that a good idea?