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)

• (Peds: Medical Control option: 0.05mg/kg IV/IN over two minutes)

• (Peds: Medical Control option: 0.1mg/kg IV/IO over two minutes, if no IV 0.5mg/kg via rectum)

• (Peds: if no IV 0.1mg/kg IM/IN max dose 5mg)

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
  • Female > Male
• 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
  • meningitis
  • abscess
• Traumatic
  • traumatic hematomas
• Toxins
  • drug overdose
  • botulism
• 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.

Facial paralysis
Arm weakness
Speech difficulties
Time 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

• Tension
• Migraine
• Cluster

Multiple Sclerosis