Wendell A. Grogan, MD, FAASM Medical Director: Stroke Program, Inpatient Rehabilitation, and Sleep Disorders Center Kingwood Medical Center Kingwood, TX Lt Col, Houston MRG Medical Reserve Brigade, Texas State Guard

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Wendell A. Grogan, MD, FAASMMedical Director
Stroke Program, Inpatient Rehabilitation, and
Sleep Disorders CenterKingwood Medical
CenterKingwood, TXLt Col, Houston MRG Medical
Reserve Brigade, Texas State Guard
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Stroke
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
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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

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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

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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

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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

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Stroke

• Knowing the signs of stroke is useful in every
  day life
• Time is Brain

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Seizures

• Like stroke, patient may not be aware of the event

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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

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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

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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

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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

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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

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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

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Metabolic disorders

• Person may seem to be drunk or stoned
• Confusion, slurred speech, irritability or
  combativeness may occur
• Victim often not aware of situation

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Metabolic disorders

• Sometimes difficult to distinguish from stroke or
  post ictal confusion
• If left untreated, may be fatal

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Metabolic disorders

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

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Trauma

• Open skull wounds and fractures of spine are
  typically pretty obvious
• Look for sudden paralysis after blow to neck or
  back

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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

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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

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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

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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

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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