‫‪Session 2 – Neurologic Emergencies‬‬

‫ﺟﻣﻌﯾﺔ اﻹﺳﻌﺎف اﻟﻠﺑﻧﺎﻧﯾﺔ – أﻛﺎدﯾﻣﯾﺔ اﻟطوارئ و اﻻﻏﺎﺛﺔ‬

Objectives
• Review and Explain the basic anatomy and physiology of the Nervous system
• Discuss the pathophysiology of neurologic emergencies
• Discuss Cerebrovascular Accident, types and signs & symptoms
• Explain the Assessment and basic care management involving patients with
Cerebrovascular Accident
• Discuss Seizures, types and signs & symptoms
• Explain the assessment and basic care management involving patients
suffering from seizures

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

Objectives
• Discuss the Altered Mental Status Emergencies

• Apply the Patient Assessment Sequence in care, treatment and transport of

patients who are experiencing a neurologic emergency

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Objective 1

The Basic Anatomy and

Physiology of The Nervous System
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 The Nervous System
• Most Complex organ • Allows the
system within the performance of
human body higher-level activity

• Many functions such • Divided into Central

as control breathing, Nervous System and
heart rate, blood Peripheral Nervous
pressure System

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫‪Central Nervous System‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 The Brain
CEREBRUM
1. Form 3/4 of the brain
BRAINSTEM
2. Made up of neurons bodies
3. Responsible for higher brain 1. Located in deep within the cranium
functions 2. Act as a relay center connecting the
4. Divided into 2 hemispheres cerebrum and cerebellum to the
5. Each hemisphere has 4 lobes spinal cord
3. Control all involuntary life-sustaining
functions
4. Composed of Midbrain, Pons and
Medulla Obloganta
5. It Contains the network of neurons
called Reticular Activation System

CEREBELLUM

1. Located underneath the cerebrum

2. Controls balance, muscles coordination and
posture

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
Structure of Nervous System and General Functions

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

Structure of Nervous System and General Functions
 The Spinal Cord
• It is the extension of the brainstem

• It travels through the spinal canal and ends

on L2

• It contains nerve cells bodies

• It transmits messages between the brain

and the body in form of electrical impulses

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫‪Peripheral Nervous System‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫‪The Nervous System‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 Objective 2

The Pathophysiology of Neurologic

Emergencies and Altered Mental Status
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 The brain requires

Continuous Oxygen Supply

Glucose

Sensitive to Temperature
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 ‫‪Objective 3‬‬

‫‪The Cerebrovascular Accident‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 Cerebrovascular Accident Definition

• Also known as Stroke, is the interruption of

blood flow to an area within the brain that
results in the loss of brain functions

• Severe disabilities may result when CVA occurs

• The brain cells develop ischemia

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫?‪What are the causes of Strokes‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Cause of Strokes

High Blood Pressure Smoking Diabetes Diet and Life Style

Sickle Cell Anemia Age, Gender, Race and Family History

Obesity Heart and Artery Disease
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 Types of Stroke

Ischemic Stroke Hemorrhagic Stroke

• When blood flow • Blood vessel ruptures and
through the cerebral increase of pressure in the
arteries is blocked brain

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Ischemic Stroke
• It is the most common type of stroke – 87%

• It occurs when blood flow to a specific part of

the brain is stopped by a blood clot inside a
blood vessel

• The blockage can be either

• Due to Thrombosis
• Due to Embolus

• It can be caused by Atherosclerosis

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 ‫‪Ischemic Stroke‬‬
‫‪Thrombosis‬‬ ‫‪Embolus‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Hemorrhagic Stroke
• It occurs as a result of bleeding inside the brain
– almost 13% of all strokes
• A blood vessel ruptures in the brain which will
casue the pressure in the brain to increase
• The accumulated blood then forms a blood clot
which compresses the brain tissue
• This compression prevents oxygenated blood
from getting in the area – Brain cells die
• Cerebral hemorrhages are iften massive and
rapidly fatal
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
Transient Ischemic Attack

• It occurs when the blood flow to the

brain is obstructed and signs of
stroke appears

• Signs and symptoms resolve on

their own in lee than 24 hours

• 1/3 of patients who have TIA will

experience a stroke soon after the
TIA

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫‪What are the general signs and symptoms of‬‬
‫?‪Stroke‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Signs and Symptoms of Strokes
Facial Drooping
Speech Disorders
Sudden Weakness or numbness Aphasia
in the face, arm, leg

Decreased or absent of Slurred Speech

movement and sensation

Lack of muscle coordination Sudden or severe

or loss of balance - Ataxia headache

Confusion &
Sudden vision loss in one
Dizziness
eye; blurred or double
vision or abnormal eye Tongue Deviation
movements

Difficulty swallowing Coma

Decreased level of High Blood Pressure

responsiveness

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Conditions that may Mimic Stroke

Hypoglycemia Postictal State Subdural and

1. A patient in
Epidural Bleeding
1. Take patient’s 1. Due to head
postictal state
medical history Trauma
may look like a
patient who is
2. Check blood experiencing 2. They have onset
glucose level in stroke of stroke-like
patients with signs and
altered mental 2. usually, the symptoms
status patient recover
rapidly
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 ‫‪Objective 4‬‬

‫‪Stroke Assessment Tools‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 Assessments and Tools for Strokes

BE-FAST

Glasgow Coma Scale

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 BE FAST
• It is a mnemonic to evaluate the Balance, Eyes, Face, Arm, Speech and Onset
Time

Balance Eyes and Pupils

Did the patient experience sudden loss B E 1. Is there any change in vision?
of balance or inability to walk? 2. Pupils Assessment - PEARRL

Time
When did the symptoms
T F
Facial Droop
Does one side of the patient’s face
first appear? droop when he or she smiles?

Speech Arm Drift

Is the patient slurring words or S A Does the patient demonstrate
using words that do not make weakness or inability to move one
sense? of the arms?

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Pupils Assessment - PEARRL
• It is a mnemonic useful in assessing the pupils

• The diameter and reactivity to light of the pupils reflect the status of the brain’s
perfusion, oxygenation and condition

Regular React to
Pupils Equal And Round
in size Light

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫‪Pupils Assessment - PEARRL‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫‪Glasgow Coma Scale‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

‫ﺟﻣﻌﯾﺔ اﻹﺳﻌﺎف اﻟﻠﺑﻧﺎﻧﯾﺔ – أﻛﺎدﯾﻣﯾﺔ اﻟطوارئ و اﻻﻏﺎﺛﺔ‬
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
‫‪Let’s Slido‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Application 1
When you arrive to a patient you find him asleep, he opens his eyes when you
call him. When you ask him about his chief complaint, he can’t remember his
name nor recognize you. You ask him to raise his right hand, he does it.

Answer: 13
1. Eye Opening = 3

2. Verbal Response = 4

3. Motor Response = 6

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Application 2
You respond to a 75 years old woman. When you arrive, her eyes are open. You
ask her about her chief complaint, she starts cursing you. You hold her hand and
ask her to lift her arm, she doesn’t respond. When you pinch her on her
shoulder, she removes your hand, she hits you and curses you.
Answer: 13
1. Eye Opening = 4

2. Verbal Response = 4

3. Motor Response = 5

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Application 3
You are responding to a 50 years old man; he is alert when you arrive. You ask
him about his name, he tells you that his son left him. He keeps repeating “my
son left me” all the time you are on the scene. You ask him to lift his arm, he
doesn’t obey, you pinch him on his shoulder, he moves away from the source of
pain while flexing his elbow keeping it below the nipple line.
Answer: 12
1. Eye Opening = 4

2. Verbal Response = 4

3. Motor Response = 4
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 ‫‪Objective 5‬‬

‫‪Seizures‬‬
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 Seizures

• It is a neurologic episode caused by a

surge of electrical activity in the brain

• It can be classified by
• Generalized Motor Seizure
• Generalized non-motor Seizure
• Focal On-set Aware Seizure
• Focal Impaired-awareness seizure

• We will cover only the Generalized Motor

Seizure for now

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Generalized Motor Seizure – Tonic-Clonic
• It results from abnormal electrical discharges from large
areas of the brain

• It is Characterized by unconsciousness and severe

twitching of the body’s muscles

• It can lasts several minutes or longer

• Known as Tonic-Clonic Seizure

• Tonic phase lasts for seconds characterized by extreme
muscular rigidity
• Clonic phase lasts much longer characterized by constant
muscle contraction, trembling and tongue biting

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 Tonic-Clonic Seizure Phases
Sudden Loss of Unresponsiveness

After the seizure

Before the Seizure

During the seizure

Consciousness Fatigue
Muscle stiffening and
Patient may rigidity
Hyperventilation
Tachycardia
experience Tongue biting
Sleepy
Up rolling of the eyes
Aura Intense drooling
Weak
Tired
Apnea
Paralyzed
Hyperventilation
Hypertension
Cyanosis
Tachycardia
BE Aware of the STATUS EPILEPTICUS!!! ‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 Transport

• If Consious – Comfort Position

• If Unconscious with gag reflex – In recovery position

• If Unconscious with an airway adjunct – Supine position

• If agitated patient, do not immobilize - WAIT

• If trauma is suspected, Fully immobilize according to guidelines and your

assessment

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 ‫‪Objective 7‬‬

‫‪Altered Mental Status‬‬

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
 Altered Mental Status

• It is the common type of neurologic

emergencies you will encounter

• It means the patient is not thinking clearly

or incapable of being awakened

• Some patients may be unconscious

• Others may be alerted but confused

‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬

 AMS CAUSE
M – Metabolic (Hypercalcemia) S – Seizure

O – Oxygen (Hypoxia) T – Trauma

V – Vascular (Bleed, CVA) U – Uremia

E – Endocrine (Hypoglycemia) P – Psychiatric

I – Infections
D – Drugs and Alcohol
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬
‫ﺟﻤﻌﯿﺔ اﻹﺳﻌﺎف اﻟﻠﺒﻨﺎﻧﯿﺔ – أﻛﺎدﯾﻤﯿﺔ اﻟﻄﻮارئ و اﻻﻏﺎﺛﺔ‬