Seattle/King County EMT-B Class

1. Seattle/King County EMT-B Class

2. 1 2 3 Topics Neurological Emergencies: Chapter 13 Geriatric Emergencies: Chapter 33 Geriatric Assessment: Chapter 34

3. 3 Neurological Emergencies

4. 1 Brain Structure and Function

5. 1 The Spinal Cord

6. 1 Common Causes of Brain Disorder • Many different disorders can cause brain dysfunction and can affect LOC, speech, and muscle control. • If problem is caused by heart and lungs, entire brain will be affected. • If problem is in the brain, only that portion of brain will be affected.

7. 1 Common Causes of Brain Disorder • Stroke is a common cause of brain disorder and is treatable. • Seizures and altered mental status are other causes of brain disorder.

8. 1 Stroke • Interruption of blood flow to the brain that results in the loss of brain function.

9. 1 Potential Results of a CVA • Thrombosis — Clot that forms at the site • Arterial rupture —Rupture of a cerebral artery • Cerebral embolism —Obstruction of a cerebral artery caused by a clot that was formed elsewhere and traveled to the brain

10. 1 Hemorrhagic Stroke • Results from bleeding in the brain • High blood pressure is a risk factor. • Some people are born with aneurysms.

11. 1 Ischemic Stroke • Results when blood flow to a particular part of the brain is cut off by a blockage inside a blood vessel.

12. 1 Atherosclerosis

13. 1 Transient Ischemic Attack (TIA) • A TIA is a “mini-stroke.” • Stroke symptoms go away within 24 hours. • Every TIA is an emergency. • TIA may be a warning sign of a larger stroke. • Patients with possible TIA should be evaluated by a physician.

14. 1 Signs and Symptoms of Stroke • Left hemisphere • Aphasia: Inability to speak or understand speech • Receptive aphasia: Ability to speak, but unable to understand speech • Expressive aphasia: Inability to speak correctly, but able to understand speech

15. 1 Signs and Symptoms of Stroke • Right hemisphere • Dysarthria: Able to understand, but hard to be understood

16. 1 Stroke Mimics • Hypoglycemia • Postictal state • Subdural or epidural bleeding

17. 1 Scene Size-up • Scene safety remains a priority. • Ensure that needed resources are requested. • Consider spinal immobilization. • Be aware that many serious medical conditions can mimic stroke; consider all possibilities. 1. Scene Size-up

18. 1 Initial Assessment • Chief complaint may include confusion, slurred speech, or unresponsiveness. • Patient may have difficulty swallowing or choke on own saliva. 1. Scene Size-up • Initial Assessment

19. 1 Initial Assessment, continued • Decide SICK/NOT SICK. • Ensure adequate airway. • If unresponsive (and no c-spine precaution is necessary), place in recovery position. • Administer oxygen. 1. Scene Size-up • Initial Assessment

20. 1 Focused History/Physical Exam • Quickly determine when patient last appeared normal. • Medications may give you a clue to the patient’s past medical history. • Patient may still be able to hear and understand; be careful what you say. 1. Scene Size-up • Initial Assessment • Focused History/ Physical Exam

21. 1 Detailed Physical Exam • Perform when time and conditions permit. • Generally performed en route to the hospital. • Do not delay transport, especially due to the time sensitivity of stroke treatment. 1. Scene Size-up • Initial Assessment • Focused History/ Physical Exam • Detailed Physical Exam

22. 1 Ongoing Assessment • Reassess ABCs, interventions, vital signs. • Stroke patients can lose airway without warning. • Relay information to the hospital as soon as possible. • Report any pertinent physical findings, Cincinnati Stroke Scale, GCS score, any other changes. 1. Scene Size-up • Initial Assessment • Focused History/ Physical Exam • Detailed Physical Exam • Ongoing Assessment

23. 1 Transport Decision • Place patient in a position to maintain airway. • Elevate head approximately 6". • Spend as little time on scene as possible. Thrombolytics may reverse stroke symptoms or stop a stroke if given within 3 hours of onset.

24. 1 Cincinnati Stroke Scale • accurate in identifying patients with stroke • an abnormal finding in ANY of the 3 tests strongly suggests a stroke

25. 1 Cincinnati Stroke Scale How does this patient appear to you? • facial droop

26. 1 Cincinnati Stroke Scale How does this patient appear to you? • facial droop • arm drift

27. 1 Cincinnati Stroke Scale How does this patient appear to you? • facial droop • arm drift • speech

28. 1 Cincinnati Stroke Scale How does this patient appear to you? • facial droop • arm drift • speech

29. 1 Cincinnati Stroke Scale How about now? • facial droop

30. 1 Cincinnati Stroke Scale How about now? • facial droop • arm drift

31. 1 Cincinnati Stroke Scale How about now? • facial droop • arm drift • speech

32. 1 Cincinnati Stroke Scale How about now? • facial droop • arm drift • speech

33. 1 Baseline Vital Signs • Excessive bleeding in the brain may slow pulse and cause erratic respirations. • Blood pressure is usually high. • Excessive bleeding in the brain may cause changes in pupil size and reactivity.

34. 1 Interventions • Based on assessment findings • If the patient is unresponsive, you may consider the recovery position to protect the airway.

35. 1 Emergency Care for Stroke • Patient needs to be evaluated by computed tomography (CT). • Recognizing the signs and symptoms of stroke can shorten the delay to CT. • Treatment needs to start as soon as possible, within 3 hours of onset.

36. 1 Seizures • Generalized (grand mal) seizure • Unconsciousness and generalized severe twitching of the body’s muscles that lasts several minutes • Absence (petit mal) seizure • Seizure characterized by a brief lapse of attention

37. 1 Signs and Symptoms of Seizures • Seizures may occur on one side or gradually progress to a generalized seizure. • Usually last 3 to 5 minutes and are followed by postictal state • Patient may experience an aura. • Seizures recurring every few minutes are known as status epilepticus.

38. 1 Causes of Seizures • Congenital (epilepsy) • High fevers • Structural problems in the brain • Metabolic disorders • Chemical disorders (poison, drugs) • Sudden high fever

39. 1 Recognizing Seizures • Cyanosis • Abnormal breathing • Possible head injury • Loss of bowel and bladder control • Severe muscle twitching • Postictal state with deep and labored respirations

40. 1 Postictal State • Patient may have labored breathing. • Hemiparesis: weakness on one side of the body. • Patient may be lethargic, confused, or combative. • Consider underlying conditions: • Hypoglycemia • Infection

41. 1 Scene Size-up • Spinal immobilization may be needed with a seizure. • Ensure that scene is safe and wear BSI. • Request ALS assistance earlier rather than later. 1. Scene Size-up

42. 1 Initial Assessment • Decide SICK/NOT SICK. • Focus on ABCs. • Assess LOC using AVPU scale. • Expect pulse to be rapid and deep. • Pulse should slow to normal rates after several minutes. 1. Scene Size-up • Initial Assessment

43. 1 Focused History/Physical Exam • Obtain information from family or bystanders. • Observe patient for recurrent seizures. • If patient is responsive, begin with SAMPLE history. • If the patient has an altered mental status, utilize the Glasgow Coma Scale. 1. Scene Size-up • Initial Assessment • Focused History/ Physical Exam

44. 1 Detailed Physical Exam • If life threats are treated, consider performing detailed physical exam. • Check patient for injuries, including tongue. • Assess for weakness or loss of sensation on one side of body. 1. Scene Size-up • Initial Assessment • Focused History/ Physical Exam • Detailed Physical Exam

45. 1 Ongoing Assessment • Note additional seizure activity. • Reassess ABCs, interventions, vital signs. • Include descriptions of seizure from witnesses if available. • Document whether this is first seizure or whether patient has history of seizures. 1. Scene Size-up • Initial Assessment • Focused History/ Physical Exam • Detailed Physical Exam • Ongoing Assessment

46. 1 Transport Decision • It is difficult to package a seizing patient for transport. • Monitor ABCs while waiting for seizure to finish. • Protect the seizing patient from his or her surroundings. • Never restrain an actively seizing patient. • Not every patient who has a seizure wishes to be transported. • Encourage every patient to be seen and evaluated in the emergency department.

47. 1 Interventions • Most seizures will be over by the time you arrive. • Treat trauma as you would for any other patient. • For patients who continue to seize, suction the airway according to local protocol, provide positive pressure ventilation, transport quickly to hospital. • Consider rendezvous with ALS, who have medications to stop prolonged seizures.

48. 1 Emergency Medical Care for Seizure • Most patients should be evaluated by a physician after a seizure. • With severe injury, suspect spinal injury. • Attempt to lower body temperature if febrile seizure. • Patient and family may be frightened.

49. Hypoglycemia Hypoxemia Intoxication Drug overdose Unrecognized head injury 1 Altered Mental Status • Brain infection • Body temperature abnormalities • Brain tumors • Glandular abnormalities • Poisoning

50. 1 Assessing Altered Mental Status • Same assessment process. • Patient cannot tell you reliably what is wrong. • Be vigilant in ongoing assessment. • Monitor for changes or deterioration. • Provide prompt transport to hospital while monitoring the patient.