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Seattle/King County EMT-B Class Topics 1 Neurological Emergencies: Chapter 13 2 Geriatric Emergencies: Chapter 33 3 Geriatric Assessment: Chapter 34 3 Neurological Emergencies 1 Brain Structure and Function 1 The Spinal Cord 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. 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. 1 Stroke • Interruption of blood flow to the brain that results in the loss of brain function. 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 1 Hemorrhagic Stroke • Results from bleeding in the brain • High blood pressure is a risk factor. • Some people are born with aneurysms. 1 Ischemic Stroke • Results when blood flow to a particular part of the brain is cut off by a blockage inside a blood vessel. 1 Atherosclerosis 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. 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 1 Signs and Symptoms of Stroke Right hemisphere • Dysarthria: Able to understand, but hard to be understood 1 Stroke Mimics • Hypoglycemia • Postictal state • Subdural or epidural bleeding 1 Scene Size-up 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 Initial Assessment 1. Scene Size-up 2. Initial Assessment • Chief complaint may include confusion, slurred speech, or unresponsiveness. • Patient may have difficulty swallowing or choke on own saliva. 1 Initial Assessment, continued 1. Scene Size-up 2. Initial Assessment • Decide SICK/NOT SICK. • Ensure adequate airway. • If unresponsive (and no cspine precaution is necessary), place in recovery position. • Administer oxygen. 1 Focused History/Physical Exam 1. Scene Size-up • Quickly determine when patient last appeared 2. Initial normal. Assessment • Medications may give you a clue to the patient’s past 3. Focused History/ medical history. Physical Exam • Patient may still be able to hear and understand; be careful what you say. 1 Detailed Physical Exam 1. Scene Size-up • Perform when time and conditions permit. 2. Initial • Generally performed en Assessment route to the hospital. 3. Focused History/ • Do not delay transport, especially due to the time Physical Exam sensitivity of stroke 4. Detailed Physical treatment. Exam 1 Ongoing Assessment 1. Scene Size-up • Reassess ABCs, interventions, vital signs. 2. Initial • Stroke patients can lose Assessment airway without warning. 3. Focused History/ • Relay information to the hospital as soon as Physical Exam possible. 4. Detailed Physical • Report any pertinent Exam physical findings, Cincinnati Stroke Scale, GCS score, 5. Ongoing any other changes. Assessment 1 Transport Decision Thrombolytics may reverse stroke symptoms or stop a stroke if given within 3 hours of onset. • Place patient in a position to maintain airway. • Elevate head approximately 6". • Spend as little time on scene as possible. Cincinnati Stroke Scale 1 • accurate in identifying patients with stroke • an abnormal finding in ANY of the 3 tests strongly suggests a stroke Test Normal Abnormal facial droop both sides of the face move equally one side of the face does not move as well as the other arm drift both arms move the same or both arms do not move at all (palms up, eyes closed) one arm drifts down compared to the other or one arm does not move speech patient says correct words with no slurring of words patient slurs words, says the wrong words, or is unable to speak 1 Cincinnati Stroke Scale How does this patient appear to you? facial droop 1 Cincinnati Stroke Scale How does this patient appear to you? facial droop arm drift 1 Cincinnati Stroke Scale How does this patient appear to you? facial droop arm drift speech 1 Cincinnati Stroke Scale How does this patient appear to you? facial droop arm drift speech 1 Cincinnati Stroke Scale How about now? facial droop 1 Cincinnati Stroke Scale How about now? facial droop arm drift 1 Cincinnati Stroke Scale How about now? facial droop arm drift speech 1 Cincinnati Stroke Scale How about now? facial droop arm drift speech 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. 1 Interventions • Based on assessment findings • If the patient is unresponsive, you may consider the recovery position to protect the airway. 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. 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 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. 1 Causes of Seizures • Congenital (epilepsy) • High fevers • Structural problems in the brain • Metabolic disorders • Chemical disorders (poison, drugs) • Sudden high fever 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 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 1 Scene Size-up 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 Initial Assessment 1. Scene Size-up 2. 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 Focused History/Physical Exam 1. Scene Size-up • Obtain information from family or bystanders. 2. Initial • Observe patient for Assessment recurrent seizures. 3. Focused History/ • If patient is responsive, begin with SAMPLE history. Physical Exam • If the patient has an altered mental status, utilize the Glasgow Coma Scale. 1 Detailed Physical Exam 1. Scene Size-up • If life threats are treated, consider performing 2. Initial detailed physical exam. Assessment • Check patient for injuries, including tongue. 3. Focused History/ • Assess for weakness or Physical Exam loss of sensation on one 4. Detailed Physical side of body. Exam 1 Ongoing Assessment 1. Scene Size-up • Note additional seizure activity. 2. Initial • Reassess ABCs, Assessment interventions, vital signs. 3. Focused History/ • Include descriptions of seizure from witnesses if Physical Exam available. 4. Detailed Physical • Document whether this is Exam first seizure or whether patient has history of 5. Ongoing seizures. Assessment 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. 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. 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. 1 Altered Mental Status • Hypoglycemia • Brain infection • Hypoxemia • Body temperature abnormalities • Intoxication • Drug overdose • Unrecognized head injury • Brain tumors • Glandular abnormalities • Poisoning 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. Questions • What questions do you have? To review this presentation, go to: http://www.emsonline.net/emtb 2 Geriatric Emergencies 2 Geriatrics • Geriatric patients are individuals older than 65 years of age. • Older people are major users of EMS and health care in general. • Geriatric assessment has unique challenges. • Preexisting conditions may affect findings. Effective treatment will require an increased understanding of geriatric care. 2 Polypharmacy Refers to the use of multiple prescriptions by a single patient. • The average geriatric patient takes four or more medications. • Many medications can have interactions or counter actions when taken together. 2 Common Stereotypes • mental confusion • illness • sedentary lifestyle • immobility Older people can stay fit; most older people lead very active lives. 2 Medical Emergencies • Determining chief complaint is challenging. • Multiple conditions and complaints. • Sensation of pain may be diminished. • Fear of hospitalization • Conditions may present differently. Ask what bothers them most today. 2 Common Complaints • Shortness of Breath (dyspnea) • Chest pain • Altered mental status • Dizziness or weakness • Fever • Falls • Nausea, vomiting, and diarrhea 2 Leading Cause of Death • • • • Heart disease Cancer Stroke COPD and other respiratory illnesses • Diabetes • Trauma 2 Trauma • An older patient may have decreased ability to localize even simple injuries. • Assessment must include all past medical conditions. 2 Trauma, continued Common mechanisms of injury: • Falls • Motor vehicle trauma • Pedestrian accidents • Burns 2 Head Injuries • Assume significant injury in patients who have signs and symptoms of head injury. • Suspect brain injury in patients who take blood thinners. • Maintain oxygen delivery to brain. 2 Injuries to the Spine • Osteoporosis is a contributing factor to spinal injuries. • Prompt spinal immobilization can reduce further damage and pain. • Pad void spaces. 2 Injuries to Pelvis and Hip • Often present as hip or buttock pain. • Pelvic injury can lead to hemorrhage or internal organ injury. • Maintain leg in position found to prevent further injury. 2 Cardiovascular Emergencies Syncope: Interruption of blood flow to the brain Can occur for many reasons: • Standing up too fast • Straining to have bowel movement • Myocardial infarction • Diabetic shock 2 Cardiovascular Emergencies Heart Attack • Classic symptoms are often not present. • Many have “silent” heart attacks. Common signs and symptoms: • Sudden onset of weakness • Shortness of breath • Toothache • Arm pain • Back pain 2 Shortness of Breath (Dyspnea) Related to many causes: • Asthma • COPD • Congestive heart failure • Pneumonia Provide oxygen immediately for all patients experiencing shortness of breath. 2 Acute Abdomen • Older patients with abdominal pain have higher chances of hospitalization, surgery, and death than younger patients. 2 Acute Abdomen, continued Abdominal aortic aneurysm (AAA) • Walls of the aorta weaken. • Treat for shock and provide prompt transport. Gastrointestinal bleeding • Blood in emesis • May cause shock 2 Acute Abdomen, continued Bowel obstructions • Vagus nerve is stimulated and produces vasovagal syndrome. • Vasovagal syndrome can cause dizziness and fainting. Patient requires transport to rule out other conditions. 2 Altered Mental States Delirium • Recent onset. • Usually associated with underlying cause. Dementia • Develops slowly over a period of years. 2 Psychiatric Emergencies • Depression is common among older adults. • Physical pain, psychological distress, and loss of loved ones can lead to depression. • Women are more likely to suffer depression. 2 Psychiatric Emergencies, cont'd • Older men have the highest suicide rate. • Older patients use much more lethal means. • EMT-Bs should consider all suicidal thoughts or actions to be serious. 3 Geriatric Assessment, cont. 3 Elder Abuse • This problem is largely hidden from society. • Definitions of abuse and neglect among older people vary. • Victims are often hesitant to report an incident. • Signs of abuse are often overlooked. 3 Signs of Physical Abuse • Signs of abuse may be obvious or subtle. • Obvious signs include bruises, bites, and burns. • Look for injuries to the ears. • Consider injuries to the genitals or rectum with no reported trauma as evidence of abuse. 3 Assessment of Physical Abuse • • • • • • • • Repeated visits to the emergency room A history of being “accident prone” Soft-tissue injuries Vague explanation of injuries Self-destructive behavior Eating and sleeping disorders Depression or a lack of energy Substance and/or sexual abuse 3 Communicating with Patients • Make and keep eye contact. • Use the patient’s proper name. • Tell the patient the truth. • Use language the patient can understand. • Be careful of what you say about the patient to others. 3 Communicating with Patients, cont'd • Be aware of your body language. • Always speak slowly, clearly, and distinctly. • If the patient is hearing impaired, speak clearly and face him or her. • Allow time for the patient to answer questions. • Act and speak in a calm, confident manner. 3 Geriatric Patients • Determine the person’s functional age. • Do not assume that an older patient is senile or confused. • Allow patient ample time to respond. • Watch for confusion, anxiety, or impaired hearing or vision. • Explain what is being done and why. 3 Geriatric Patients Older patients may need a little more time to process your question. 3 Communicating with Children • Allow people or objects that provide comfort to remain close. • Explain procedures truthfully. • Position yourself on their level. 3 Hearing-Impaired Patients • Always assume that the patient has normal intelligence. • Make sure you have a paper and pen. • Face the patient and speak slowly, clearly and distinctly. • Never shout! • Learn simple phrases used in sign language. 3 Vision-Impaired Patients • Ask the patient if he or she can see at all. • Explain all procedures as they are being performed. • If a guide dog is present, transport it also, if possible. 3 Non-English Speakers • Use short, simple questions and answers. • Point to specific parts of the body as you ask questions. • Learn common words and phrases in the non-English languages used in your area. Questions • What questions do you have? To review this presentation, go to: http://www.emsonline.net/emtb