Neurological Emergencies II
Nov 25th, 2009 by
RH-111
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Dr Trowers
Seizures
Sudden uncoordinated electrical activity in the brain
Generalized Seizures
Petit mal , most common in ages 4-12, rarely after 20. typically less than 15 seconds, no postictal phase.
Grad Mal – tonic/conic – often preceded by aura, can occur at any age, typically followed by postictal phase. Can progress to status epilepticus (seizure lasting longer than 5 minutes or back to back seizures with no return to consciousness)
Tonic – body wide rigidity
Clonic – rhythmic contraction of major muscle groups,
Partial Seizures (Focal)
Simple partial seizure – Jacksonian March seizure – tonic/clonic active localized to one part of the body – may spread and progress to a generalized seizure – No aura or LOC
Complex partial seizure – mood changes, abrupt rage , often preceded by aura, 1-2 minutes, no postictal phase.
Seizure Management
Protect from injury
maintain airway
provide oxygen
establish vascular access
emotional support and transport
Meds (NYC REMAC Protocols)
dextrose 25gm IVP (50% Solution)
(Peds: glucagon 1mg IM, dextrose 0.5gm/kg IVP – > one month old use 10% solution, 25% for patients 1 month to 14 years)
lorazepam 2mg IVP, IN or IM if no IV access (repeat once) OR
(Peds: Medical Control option: 0.05mg/kg IV/IN over two minutes)
diazepam 5mg IVP (repeat once) OR
(Peds: Medical Control option: 0.1mg/kg IV/IO over two minutes, if no IV 0.5mg/kg via rectum)
midazolam 10mg IVP, IM or IN if no IV access (repeat once)
(Peds: if no IV 0.1mg/kg IM/IN max dose 5mg)
Neurological Emergencies
Nov 18th, 2009 by
RH-111
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Dr Trowers
Neurological Emergencies
Three of the 15 leading causes of death
Stroke is the third leading cause of death
Risk Factors
Age
Risk more than doubles each decade after age 55
Gender
Race
African Americans, Mexican American, Native Americans have higher predisposition
Genetic predisposition
increased risk if parent, grand parent or sibling had a stroke
Previous medical condition
Prior CVA, TIA, MI, HTN, Atherosclerosis
History of trauma
History & Physical Exam
time of onset of symptoms
focal neurological symptoms
cognitive impairment
weakness or incoordination of limbs
facial weakness
numbness of limbs or face
cranial nerve palsies
dysarthria
Global symptoms
headache
nausea and vomiting
altered alertness
abnormal vital signs
Differential Diagnosis
Neurologic
migraine
seizures/Todd’s paralysis
neuropathies
Metabolic
hyper/hypoglycemia
hyper/hyponatremia
uremic encephalopathy
Infectious
Traumatic
Toxins
Vascular
TIA
Vasculitis
Aortic dissection
Other
syncope
heat stroke
conversion disorder
Stroke Types
Ischemic strokes much more prevalent (80%) than hemorrhagic strokes
Cincinnati Pre-hospital Stroke Scale
Facial Droop (have patient smile) Normal: Both sides of face move equally Abnormal: One side of face does not move as well
Arm Drift (have patient hold arms out for 10 seconds) Normal: Both arms move equally or not at all Abnormal: One arm drifts compared to the other, or does not move at all
Speech (have patient speak a simple sentence) Normal: Patient uses correct words with no slurring Abnormal: Slurred or inappropriate words, or mute
F.A.S.T.
F acial paralysis A rm weakness S peech difficulties T ime to act
Physical Exam
General: posturing, LOC, GCS
Head, pupils, visual findings
Speech and language
Motor function
Sensation
Blood sugar
Chest, abdomen, extremities
Altered LOC
Consider AMS causes – AEIOU-TIPS
Seizures
Sudden, uncoordinated electrical activity
Classification: generalized or partial
Phases: aura, LOC, tonic, clonic, postseizure, postictal
Causes
Status epilepticus
Protect from injury.
Maintain airway patency.
Provide oxygen, ventilation assistance.
Establish vascular access.
Emotional support and transport
Anticonvulsant medications
Syncope
Sudden, temporary LOC
Causes
Vasovagal (young adults)
Cardiac dysrhythmias (older adults)
Headaches
Multiple Sclerosis