Download Headaches, Seizures and Syncope

Neurological Emergencies
Headaches, Seizures and Syncope
Presence Regional EMS
November 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
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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)
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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, alcohol
Environment, epilepsy
Insulin (too much or too little)
Opiates
Uremia – kidney failure
Trauma, toxins,
Infection
Psychosis
Shock, 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
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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
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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:
• [email protected]
• 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?
•
•
•
•
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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?