Wendell A. Grogan, MD, FAASM

Medical Director: Stroke Program, Inpatient Rehabilitation, and Sleep Disorders Center

Kingwood Medical CenterKingwood, TX

Lt Col, Houston MRG Medical Reserve Brigade, Texas State Guard

The American Stroke Association wants you to learn the warning signs of stroke:

* Sudden numbness or weakness of the face, arm or leg, especially on one side of the body * Sudden confusion, trouble speaking or understanding * Sudden trouble seeing in one or both eyes * Sudden trouble walking, dizziness, loss of balance or coordination * Sudden, severe headache with no known cause

Stroke

Introduction to Neurological Emergencies

What are we likely to encounter How do we recognize the signs and symptoms of

common neurological conditions What can be done on site When do we need to transfer What can be done if transfer is not an option

General Principles

Neurological Conditions come in three types− Chronic, persistent− Chronic intermittent− New Onset

They also come in three severities− Bothersome perhaps painful, but not life threatening− Life threatening, but manageable− Life threatening, untreatable

General Principles

The most painful or distressing may not be the most dangerous

With certain exceptions, severe neurological conditions typically are painless

The victim is often unaware of problem even when the condition is devastating

General Principles

Most serious neurological conditions are not treatable in the first aid setting

In limited resource situations, evacuating victims of devastating neurological illness may not be wise utilization

Stroke

Knowing the signs of stroke is useful in every day life

“Time is Brain”

Stroke

Warning signs of stroke:

Sudden numbness or weakness of the face, arm or leg, especially on one side of the body

Sudden confusion, trouble speaking or understanding

Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of

balance or coordination Sudden, severe headache with no known cause

Stroke

Strokes come in two major varieties:− Bleeding- these are generally the painful ones− Ischemic- ie. A blood clot cuts of blood supply to part

of the brain. AKA “bland infarct”

Stroke

If the person can be evaluated in within three hours of onset of symptoms, blood clot dissolving agent may help to return blood flow to the damaged part of the brain

This is highly problematic in an evacuation/disaster shelter situation

Stroke

First Aid:− Watch for trouble swallowing

Since the victim may not be aware of the problem, they may try to eat or drink when they are no longer capable of safely doing so

− Watch for falling, self injury Again, lack of awareness may lead to attempts to walk, get

out of bed when able to support their own weight Spills of hot liquids or dropping objects on themselves may

also occur

Stroke

Even if not able to be transferred within the 3 hour time frame, victim will need acute care, hospital setting treatment to minimize complications

Simultaneous stroke and heart attack is relatively common and the stroke victim may not be able to tell you about heart attack symptoms

Stroke

Relationship between stress and stroke is not well established by itself.

Disruptions of food and water supplies, loss of medication or inability to time dosing of medication, loss of sleep/rest will all tend to increase chances of stroke occurring in susceptible individuals

Seizures

Three major categories− Generalized shaking with loss of consciousness-

“grand mal”− Localized shaking- “partial” seizures− Loss of consciousness or lapse of awareness with blank

stare or abnormal behavior- “petit mal”

Seizures

May or may not come after a warning period “aura”

Often stress- physical or emotional- will trigger off seizures

Everyone has a “seizure threshold”, thus it is possible in a disaster/evacuation scenario that people may have seizures who never had one before

Seizures

Symptoms:− Often there will be a sudden change in behavior-

typically the person will sudden stop whatever they were doing

− A brief or prolonged stare followed by stiffening of muscles, sometimes severe even to the point of breaking bones or dislocating joints

Seizures

Symptoms− Hard banging movements of the major joints/head with

tongue biting, incontinence, spasm of chest muscles causing cessation of breathing

− Sudden relaxation, often without regaining consciousness right away, or with confusion to the point of combativeness

Seizures

Each stage may last several seconds to minutes or may transition to the next phase so rapidly as to not be noticed.

The “post ictal” stage of confusion or extreme lethargy will usually last much longer than the “ictus” (seizure) typically several minutes up to hours

Seizures

First aid principles− Protect the victim from further harm

Move away from potentially dangerous objects or placements

Turn to side to prevent aspiration of stomach contents if they vomit

Keep people from trying to place spoons or other objects in the victims mouth

Restrain gently if needed during post-ictal confusion phase

Seizures

Like stroke, patient may not be aware of the event

Seizures

After the event, determine if person has a history of seizures.

− If this is a typical event, transfer to hospital may not be needed

− If on medication, make sure they get their medication If this is the first time, look for stroke signs as a

stroke or other brain injury may have triggered the seizure

Consider transfer to hospital setting for patient's safety in case of additional events

Seizures

Most seizures last a minute or two Although frightening, the seizure itself is rarely

life threatening if self limited Seizures lasting more than 5 minutes are true life

threatening emergencies

Neuromuscular failure

Numerous causes, including GBS (Guillain-Barre syndrome), botulism, neurotoxins (nerve gas, insecticide)

Sudden or gradual onset of weakness, often first manifested by inability to stand or lift arms

May end up compromising ability to swallow or even breath

Neuromuscular failure

Always potentially fatal Needs transportation to hospital setting as soon as

possible Victim is often aware, often before it is obvious to

observers that something is wrong− First symptoms may be respiratory

compromise- “air hunger” or shortness of breath

Neuromuscular failure

Little to be done in the first aid setting other than recognizing the seriousness- not just “tired” or intoxicated- and transporting as soon as possible

Metabolic disorders

Most common is hypoglycemia, “low blood sugar” in a diabetic

In older persons, infections such as bladder infection or pneumonia may cause similar symptoms

Metabolic disorders

Person may seem to be “drunk” or “stoned” Confusion, slurred speech, irritability or

combativeness may occur Victim often not aware of situation

Metabolic disorders

Sometimes difficult to distinguish from stroke or post ictal confusion

If left untreated, may be fatal

Metabolic disorders

Unless the person is identified as a diabetic and administering sugar corrects the problem, transportation to medical facility will be necessary

Trauma

Open skull wounds and fractures of spine are typically pretty obvious

Look for sudden paralysis after blow to neck or back

Trauma

Scalp wounds bleed profusely but can usually be stopped by direct pressure.

Although they will need to be seen in ER for closure, not a “drop everything and transport” situation if resources are limited

Trauma

Be aware of a penetrating wound− Whatever cut through the scalp may have

continued on through the skull and into the brain

The pure scalp injury victim will be in pain, but should not have any stroke like symptoms

Summary

Often the person with the neurological emergency is unaware of the problem or at least the severity of it

The most serious are often painless Most are not treatable in the first aid setting, but

awareness of the consequences of not treating emergently will help allocate resources if they are limited

Summary

Because of the stress and disruptions inherent to an evacuation setting, pre-existing disorders, like epilepsy and vascular disease will tend to worsen abruptly and may precipitate a devastating event

Summary

Seizures and scalp wounds tend to look more severe and dangerous than they are

Strokes and neuromuscular problems tend to be quieter and “appear” less severe and dangerous than they really are