4.2 Neurological Emergencies

Neurological emergencies involve the brain, spinal cord, or peripheral nervous system. For EMTs, the most critical neurological emergencies are stroke and seizures, both of which require rapid assessment and time-sensitive interventions.

Stroke (Cerebrovascular Accident -- CVA)

Stroke is the 5th leading cause of death in the United States and a leading cause of long-term disability. Early recognition and rapid transport to a stroke center dramatically improve outcomes.

Types of Stroke

Ischemic Stroke (87% of all strokes)

• Caused by a blood clot blocking a cerebral artery
• Two subtypes: thrombotic (clot forms at the site) and embolic (clot travels from elsewhere)
• May be treated with tPA (tissue plasminogen activator) -- a clot-busting drug
• tPA window: within 3-4.5 hours of symptom onset

Hemorrhagic Stroke (13% of all strokes)

• Caused by a ruptured blood vessel bleeding into or around the brain
• Two subtypes: intracerebral (within brain tissue) and subarachnoid (around the brain)
• Often associated with severe headache ("worst headache of my life")
• Higher mortality rate than ischemic stroke
• tPA is contraindicated (would worsen bleeding)

Transient Ischemic Attack (TIA)

• "Mini-stroke" -- symptoms resolve completely within 24 hours (usually within minutes)
• Same signs and symptoms as a stroke
• Warning sign -- approximately 15% of strokes are preceded by a TIA
• Treat and transport the same as a stroke

Cincinnati Prehospital Stroke Scale (CPSS)

The CPSS is a rapid, validated assessment tool. Any ONE abnormal finding suggests stroke with 72% sensitivity.

Last Known Well Time

This is the single most important piece of information for hospital stroke treatment.

• Document the exact time the patient was last seen normal (not when symptoms were discovered)
• Example: Patient found with stroke symptoms at 0800, but spouse reports patient was normal at 0600 -- last known well time is 0600
• If the patient woke up with symptoms, last known well time is when they went to sleep
• This determines eligibility for tPA and other interventional treatments

EMT Assessment and Treatment

1. Perform Cincinnati Prehospital Stroke Scale
2. Document last known well time
3. Check blood glucose (hypoglycemia can mimic stroke)
4. Administer oxygen if SpO2 <94%
5. Position: keep head elevated 15-30 degrees
6. Nothing by mouth (NPO)
7. Rapid transport to the closest stroke center (not just the closest hospital)
8. Provide pre-arrival notification to the receiving facility

Seizures

A seizure is an episode of abnormal electrical activity in the brain. Seizures have many causes and present in various forms.

Types of Seizures

Generalized Tonic-Clonic (Grand Mal)

• Most dramatic and easily recognized
• Tonic phase: muscles stiffen, patient becomes rigid (15-20 seconds)
• Clonic phase: rhythmic jerking of extremities (30-60 seconds typically)
• Loss of consciousness throughout
• May have incontinence, tongue biting, cyanosis

Absence (Petit Mal)

• Brief (5-30 seconds) loss of awareness
• Patient appears to "blank out" or stare
• No convulsive movements
• Most common in children
• Patient usually unaware the seizure occurred

Focal (Partial) Seizures

• Affect only one area of the brain/body
• Simple focal: no loss of consciousness, localized twitching
• Complex focal: altered consciousness, repetitive behaviors (lip smacking, picking at clothes)

Status Epilepticus

Status epilepticus is defined as:

• A seizure lasting longer than 5 minutes, OR
• Multiple seizures without the patient regaining consciousness between them

This is a life-threatening emergency requiring immediate transport. Prolonged seizures can cause brain damage, hyperthermia, rhabdomyolysis, and death.

Seizure Management (EMT Level)

1. Protect from injury -- move hazardous objects away, do NOT restrain
2. Do NOT place anything in the patient's mouth -- they cannot swallow their tongue
3. Time the seizure duration
4. After seizure (postictal phase): position on side (recovery position), suction if needed
5. Administer oxygen -- high-flow via NRB or BVM if needed
6. Check blood glucose
7. Transport and provide reassurance during the postictal period

Postictal State

• Period following a seizure -- may last minutes to hours
• Patient is confused, drowsy, disoriented
• May have headache, muscle soreness
• May have bitten tongue or been incontinent
• Gradually returns to baseline

Altered Mental Status

Altered mental status (AMS) has a wide differential diagnosis. The AEIOU-TIPS mnemonic helps EMTs remember common causes:

Assessment Priorities for AMS

• Scene safety -- AMS patients may be combative
• ABCs -- protect the airway (AMS patients are at high aspiration risk)
• Check blood glucose immediately
• Assess pupils (unequal = possible stroke or head injury)
• Obtain history from bystanders if patient cannot communicate

Syncope (Fainting)

Syncope is a brief loss of consciousness caused by temporary insufficient blood flow to the brain.

Common Causes

• Vasovagal (emotional stress, pain, standing too long)
• Orthostatic hypotension (standing up quickly)
• Cardiac dysrhythmias
• Dehydration

Assessment

• Rule out more serious causes (cardiac, stroke, hypoglycemia)
• Obtain orthostatic vital signs (lying, sitting, standing)
• Assess for injuries from the fall
• Cardiac monitoring if available
• All syncope patients should be encouraged to be transported and evaluated