NEURO + METABOLIC

• What are the signs + symptoms of a HAEMORRHAGIC STROKE?

  • violent headache
  • altered LOC
  • vomiting/diarrhoea
  • rapid deterioration
  • stroke signs + symptoms
• What are typical STROKE signs + symptoms?

  • unilateral or bilateral weakness/paralysis
  • slurred or abnormal speech
  • loss of balance/coordination
  • impairment or vision loss
  • memory loss/confusion
• What is a TIA?

  Transient Ischemic Attack where symptoms resolve. Still use the FAST test and treat as a stroke until symptoms are no longer present
• What are some differentials of STROKE?

  • hypoglycaemia
  • seizures (postictal state)
  • migraines
  • infections
  • hyper/hypothermia
  • trauma (TBI)
  • drugs/alcohol
  • other ALOC causes
• What is the pre-hospital treatment for a stroke?

  Recognition and transport to the most appropriate hospital. TIME IS TISSUE - ambulance or heli?

  ABC support and symptoms management
• How is a migraine defined?

  • recurrent and severe headaches
  • aura
  • worse with activity
  • sensitive to light + noise
  • nausea + vomit
  • uni or bilateral
• If a patient has a headache, what should you do before deciding transport/treatment options?

  Look at the headaches flag table. If any red flags present, then transport to hospital.
• What is VERTIGO?

  • a symptom, not a disease
  • can be a symptom of BPPV, vestibular neuritis, infection, labyrinthitis, Meniere's disease and a cerebellar stroke.
• What is the treatment for VERTIGO?

  • ondansetron is rarely effective
  • keep head as still as possible and close eyes
  • drive smoothly
  • be prepared for vomit
• What is a mnemonic to remember causes of ALOC?

  E = External (trauma, hyper/hypothermia)

  C = circulation (MI, dysrhythmias, shock)

  C = central (stroke, seizure, psychosis, cognitive impairment

  M = metabolic/toxins (hyper/hypoglycaemia, over/underdose, infection, electrolyte, drugs

  O = other (pseudo-coma, unknown)
• What is a common presentation of HYPOGLYCAEMIA?

  • shaky
  • cool, pale, diaphoretic
  • tachycardia
  • light-headed
  • nausea
  • fatigue
  • irritable
  • impaired vision
  • coordination issues
  • confusion
  • appear intoxicated
  • unresponsive
  • stroke like
  • seizures
• What is the treatment for HYPOGLYCAEMIA?

  • can swallow = 10-20g oral glucose sachet (can repeat)
  • cannot swallow = 1mg IM glucagon (adult and once)
  • still not responding = paramedic for IV glucose
• What can cause a SEIZURE?

  • metabolic issues (hypoglycaemia)
  • infection
  • tumor
  • drug overdose or withdrawal
  • stroke
  • brain injury
  • epilepsy
  • hypoxia
• What history would you take for a SEIZURE?

  current seizure:

  • length
  • type
  • events prior

  history of seizures:

  • any past history
  • epileptic?
  • how often
  • how long
  • normal presentation
  • oral trauma or incontinence

  recent mHx:

  • head trauma
  • alcohol/drug use
  • fever, illness, headache

  medication:

  • current
  • changes
• What is the treatment/management of SEIZURES?

  Maintain airway:

  • recovery position
  • do not force adjuncts
  • monitor SpO2 and give O2

  back up:

  • Para for midazolamm
  • airway obstruction/status epilepticus = CCP backup for RSI
• What is the midazolam prep (EMT out of scope)?

  • call clinical desk for advice if para not available
  • 10mg IM midazolam undiluted (adult)
  • ampoule is 15mg/3ml (10mg = 2ml)
• Transport for SEIZURES?

  • check the seizures transport checklist
• Relation between SEVERE TBI and GCS?

  Severe TBI defined as the inability to obey commands, GCS motor score of <6.
• What is the late-stage finding for SEVERE TBI?

  Cushing's Triad:

  • activated by increase in ICP
  • the ICP becomes greater than the main arterial pressure (MAP should be higher than ICP to maintain perfusion of brain tissue)
  • increase in ICP = decreases O2 and blood to the brain

  Compensation:

  • SNS response is activated
  • increase in BP and HR
  • increase in BP signals carotid and baroreceptors to activate the PNS = decrease in HR and BP
  • as ICP increases the brainstem can dysfunction = irregular resp rate = VERY VERY BAD
• What are some signs of a MINOR TBI?

  • difficultly thinking + concentrating
  • difficulty remembering new info
  • headache, nausea, vomiting
  • balance issues, dizziness
  • blurry vision
  • tiredness
  • sensitive to light/noise
  • irritable + sad
  • nervous/anxious
  • more/less sleep
• How do you define a SCI (as per CPGs)?

  • paraplegia
  • quadriplegia
  • clinically significant limb weakness, loss of sensation and shock/vasodilation below injury
• What is spinal shock?

  Immediate (temporary or not) loss or depression of the spinal reflexes below the site of injury. May lay for hours-weeks. Can be thought of as a concussion for the spinal cord.
• What are myotomes and dermatomes?

  Myotome = motor neurons that transmit info from the brain to the skeletal muscles (myo = muscle)

  Dermatome = sensory neurons that transmit sensations such as touch, pressure, pain, temp and vibrations from skin, muscles and joints (derm = skin)
• What is AUTONOMIC DYSREFLEXIA?

  A complication of SCI (above T6) where there is a loss of coordinated responses to HR and vascular tone.

  There is an exaggerated response below level of injury which causes widespread vasoconstriction:

  • stimulates SNS below injury = vasoconstriction + HTN
  • HTN triggers PNS = bradycardia + vasodilation above injury
• What are some stimuli for AUTONOMIC DYSREFLEXIA?

  • bladder distension
  • bowel distension
  • pressure sores/ulcers
  • labour
  • acute injury
• What are the signs + symptoms of AUTONOMIC DYSREFLEXIA?

  • HTN
  • anxiety
  • headache
  • vasoconstriction (cold, clammy skin below SCI)
  • vasodilation (red, sweating, flushed above SCI)
  • bradycardia
  • nausea
• What are some causes for NYSTAGMUS?

  • trauma (TBI, stroke, MS)
  • cataracts
  • focus problems
  • inner ear issues
  • medications

  Cerebellar stroke:

  • nystagmus will remain present after 10 secs of checking pupils
• What are the 12 cranial nerves?

  1. Olfactory (smell)
  2. Optic (visual)
  3. Oculomotor (pupil size)
  4. Trachlear (eyes down and out)
  5. Trigeminal (sensory)
  6. Abducens (side to side eye movement)
  7. Facial
  8. Vestibulocochlear (balance + hearing)
  9. Glossopharyngeal (carotid sinus, reflex control of heart, tongue and soft palate)
  10. Vagus (PNS)
  11. Accessory (shoulders + neck)
  12. Hypoglossal (tongue movements)
• What are the types of SEIZURE?

  • tonic (stiff muscles)
  • clonic (shaking)
  • tonic-clonic
  • atonic (floppy)
  • myoclonic (some muscle contraction)
  • absence
• What are some terms for STROKE to note?

  Receptive dysphasia = may not understand the word but can speak and formulate words (may be out of context)

  Expressive dysphasia = patient understands but cannot answer appropriately

  Nominal/Anomic dysphasia = difficulty naming objects

  Dysarthria = slurred speech

  Aphasia = complete loss of speech
• What does a full NEUROLOGICAL SYSTEM ASSESSMENT involve?

  • LOOK, LISTEN, FEEL
  • cranial nerves
  • pupils
  • FAST test
  • finger nose test
  • rombergs test
  • limb strength test
  • sensation test
  • walking test