Seattle/King County EMT-B Class
Topics
1
Neurological Emergencies: Chapter 13
2
Geriatric Emergencies: Chapter 33
3
Geriatric Assessment: Chapter 34
3
Neurological Emergencies
1
Brain Structure and Function
1
The Spinal Cord
1
Common Causes of Brain Disorder
• Many different disorders can cause
brain dysfunction and can affect LOC,
speech, and muscle control.
• If problem is caused by heart and
lungs, entire brain will be affected.
• If problem is in the brain, only that
portion of brain will be affected.
1
Common Causes of Brain Disorder
• Stroke is a common cause of brain
disorder and is treatable.
• Seizures and altered mental status are
other causes of brain disorder.
1
Stroke
• Interruption of blood flow to the brain
that results in the loss of brain
function.
1
Potential Results of a CVA
• Thrombosis — Clot that
forms at the site
• Arterial rupture —
Rupture of a cerebral
artery
• Cerebral embolism —
Obstruction of a cerebral
artery caused by a clot
that was formed
elsewhere and traveled
to the brain
1
Hemorrhagic Stroke
• Results from bleeding in the brain
• High blood pressure is a risk factor.
• Some people are born with aneurysms.
1
Ischemic Stroke
• Results when blood flow to a particular
part of the brain is cut off by a
blockage inside a blood vessel.
1
Atherosclerosis
1
Transient Ischemic Attack (TIA)
• A TIA is a “mini-stroke.”
• Stroke symptoms go away within 24 hours.
• Every TIA is an emergency.
• TIA may be a warning sign of a larger stroke.
• Patients with possible TIA should be
evaluated by a physician.
1
Signs and Symptoms of Stroke
Left hemisphere
• Aphasia: Inability to speak or
understand speech
• Receptive aphasia: Ability to
speak, but unable to understand
speech
• Expressive aphasia: Inability to
speak correctly, but able to
understand speech
1
Signs and Symptoms of Stroke
Right hemisphere
• Dysarthria: Able to understand, but hard
to be understood
1
Stroke Mimics
• Hypoglycemia
• Postictal state
• Subdural or epidural bleeding
1
Scene Size-up
1. Scene Size-up
• Scene safety remains a
priority.
• Ensure that needed
resources are requested.
• Consider spinal
immobilization.
• Be aware that many
serious medical conditions
can mimic stroke; consider
all possibilities.
1
Initial Assessment
1. Scene Size-up
2. Initial
Assessment
• Chief complaint may
include confusion, slurred
speech, or
unresponsiveness.
• Patient may have difficulty
swallowing or choke on
own saliva.
1
Initial Assessment, continued
1. Scene Size-up
2. Initial
Assessment
• Decide SICK/NOT SICK.
• Ensure adequate airway.
• If unresponsive (and no cspine precaution is
necessary), place in
recovery position.
• Administer oxygen.
1
Focused History/Physical Exam
1. Scene Size-up
• Quickly determine when
patient last appeared
2. Initial
normal.
Assessment
• Medications may give you
a clue to the patient’s past
3. Focused History/
medical history.
Physical Exam
• Patient may still be able to
hear and understand; be
careful what you say.
1
Detailed Physical Exam
1. Scene Size-up
• Perform when time and
conditions permit.
2. Initial
• Generally performed en
Assessment
route to the hospital.
3. Focused History/ • Do not delay transport,
especially due to the time
Physical Exam
sensitivity of stroke
4. Detailed Physical
treatment.
Exam
1
Ongoing Assessment
1. Scene Size-up
• Reassess ABCs,
interventions, vital signs.
2. Initial
• Stroke patients can lose
Assessment
airway without warning.
3. Focused History/ • Relay information to the
hospital as soon as
Physical Exam
possible.
4. Detailed Physical • Report any pertinent
Exam
physical findings, Cincinnati
Stroke Scale, GCS score,
5. Ongoing
any other changes.
Assessment
1
Transport Decision
Thrombolytics may reverse stroke
symptoms or stop a stroke if given
within 3 hours of onset.
• Place patient in a position to maintain
airway.
• Elevate head approximately 6".
• Spend as little time on scene as possible.
Cincinnati Stroke Scale
1
• accurate in identifying patients with stroke
• an abnormal finding in ANY of the 3 tests
strongly suggests a stroke
Test
Normal
Abnormal
facial droop
both sides of the face move
equally
one side of the face does not
move as well as the other
arm drift
both arms move the same or
both arms do not move at all
(palms up, eyes closed)
one arm drifts down compared to
the other or one arm does not
move
speech
patient says correct words
with no slurring of words
patient slurs words, says the
wrong words, or is unable to
speak
1
Cincinnati Stroke Scale
How does this patient appear to you?
facial droop
1
Cincinnati Stroke Scale
How does this patient appear to you?
facial droop
arm drift
1
Cincinnati Stroke Scale
How does this patient appear to you?
facial droop
arm drift
speech
1
Cincinnati Stroke Scale
How does this patient appear to you?
facial droop
arm drift
speech
1
Cincinnati Stroke Scale
How about now?
facial droop
1
Cincinnati Stroke Scale
How about now?
facial droop
arm drift
1
Cincinnati Stroke Scale
How about now?
facial droop
arm drift
speech
1
Cincinnati Stroke Scale
How about now?
facial droop
arm drift
speech
1
Baseline Vital Signs
• Excessive bleeding in the brain may slow
pulse and cause erratic respirations.
• Blood pressure is usually high.
• Excessive bleeding in the brain may
cause changes in pupil size and
reactivity.
1
Interventions
• Based on assessment findings
• If the patient is unresponsive, you may
consider the recovery position to protect the
airway.
1
Emergency Care for Stroke
• Patient needs to be evaluated by
computed tomography (CT).
• Recognizing the signs and symptoms of
stroke can shorten the delay to CT.
• Treatment needs to start as soon as
possible, within 3 hours of onset.
1
Seizures
Generalized (grand mal) seizure
• Unconsciousness and generalized
severe twitching of the body’s
muscles that lasts several minutes
Absence (petit mal) seizure
• Seizure characterized by a brief lapse
of attention
1
Signs and Symptoms of Seizures
• Seizures may occur on one side or
gradually progress to a generalized
seizure.
• Usually last 3 to 5 minutes and are
followed by postictal state
• Patient may experience an aura.
• Seizures recurring every few minutes are
known as status epilepticus.
1
Causes of Seizures
• Congenital (epilepsy)
• High fevers
• Structural problems in the brain
• Metabolic disorders
• Chemical disorders (poison, drugs)
• Sudden high fever
1
Recognizing Seizures
• Cyanosis
• Abnormal breathing
• Possible head injury
• Loss of bowel and bladder control
• Severe muscle twitching
• Postictal state with deep and labored
respirations
1
Postictal State
• Patient may have labored breathing.
• Hemiparesis: weakness on one side of
the body.
• Patient may be lethargic, confused, or
combative.
• Consider underlying conditions:
– Hypoglycemia
– Infection
1
Scene Size-up
1. Scene Size-up
• Spinal immobilization may
be needed with a seizure.
• Ensure that scene is safe
and wear BSI.
• Request ALS assistance
earlier rather than later.
1
Initial Assessment
1. Scene Size-up
2. Initial
Assessment
• Decide SICK/NOT SICK.
• Focus on ABCs.
• Assess LOC using AVPU
scale.
• Expect pulse to be rapid
and deep.
• Pulse should slow to
normal rates after several
minutes.
1
Focused History/Physical Exam
1. Scene Size-up
• Obtain information from
family or bystanders.
2. Initial
• Observe patient for
Assessment
recurrent seizures.
3. Focused History/ • If patient is responsive,
begin with SAMPLE history.
Physical Exam
• If the patient has an
altered mental status,
utilize the Glasgow Coma
Scale.
1
Detailed Physical Exam
1. Scene Size-up
• If life threats are treated,
consider performing
2. Initial
detailed physical exam.
Assessment
• Check patient for injuries,
including tongue.
3. Focused History/
• Assess for weakness or
Physical Exam
loss of sensation on one
4. Detailed Physical
side of body.
Exam
1
Ongoing Assessment
1. Scene Size-up
• Note additional seizure
activity.
2. Initial
• Reassess ABCs,
Assessment
interventions, vital signs.
3. Focused History/ • Include descriptions of
seizure from witnesses if
Physical Exam
available.
4. Detailed Physical • Document whether this is
Exam
first seizure or whether
patient has history of
5. Ongoing
seizures.
Assessment
1
Transport Decision
• It is difficult to package a seizing patient
for transport.
• Monitor ABCs while waiting for seizure to
finish.
• Protect the seizing patient from his or her
surroundings.
• Never restrain an actively seizing patient.
• Not every patient who has a seizure
wishes to be transported.
• Encourage every patient to be seen and
evaluated in the emergency department.
1
Interventions
• Most seizures will be over by the time you
arrive.
• Treat trauma as you would for any other
patient.
• For patients who continue to seize, suction
the airway according to local protocol,
provide positive pressure ventilation,
transport quickly to hospital.
• Consider rendezvous with ALS, who have
medications to stop prolonged seizures.
1
Emergency Medical Care for Seizure
• Most patients should be evaluated by a
physician after a seizure.
• With severe injury, suspect spinal injury.
• Attempt to lower body temperature if
febrile seizure.
• Patient and family may be frightened.
1
Altered Mental Status
• Hypoglycemia
• Brain infection
• Hypoxemia
• Body temperature
abnormalities
• Intoxication
• Drug overdose
• Unrecognized head
injury
• Brain tumors
• Glandular
abnormalities
• Poisoning
1
Assessing Altered Mental Status
• Same assessment
process.
• Patient cannot tell you
reliably what is wrong.
• Be vigilant in ongoing
assessment.
• Monitor for changes or
deterioration.
• Provide prompt transport
to hospital while
monitoring the patient.
Questions
• What questions do you have?
To review this presentation, go to:
http://www.emsonline.net/emtb
2
Geriatric Emergencies
2
Geriatrics
• Geriatric patients are individuals older than
65 years of age.
• Older people are major users of EMS and
health care in general.
• Geriatric assessment has unique challenges.
• Preexisting conditions may affect findings.
Effective treatment will require an
increased understanding of geriatric care.
2
Polypharmacy
Refers to the use of multiple prescriptions
by a single patient.
• The average geriatric patient takes four or
more medications.
• Many medications can have interactions or
counter actions when taken together.
2
Common Stereotypes
• mental confusion
• illness
• sedentary lifestyle
• immobility
Older people can stay fit; most older people
lead very active lives.
2
Medical Emergencies
• Determining chief complaint is
challenging.
• Multiple conditions and complaints.
• Sensation of pain may be diminished.
• Fear of hospitalization
• Conditions may present differently.
Ask what bothers them most today.
2
Common Complaints
• Shortness of Breath (dyspnea)
• Chest pain
• Altered mental status
• Dizziness or weakness
• Fever
• Falls
• Nausea, vomiting, and diarrhea
2
Leading Cause of Death
•
•
•
•
Heart disease
Cancer
Stroke
COPD and other
respiratory
illnesses
• Diabetes
• Trauma
2
Trauma
• An older patient
may have
decreased ability
to localize even
simple injuries.
• Assessment must
include all past
medical
conditions.
2
Trauma, continued
Common mechanisms
of injury:
• Falls
• Motor vehicle
trauma
• Pedestrian
accidents
• Burns
2
Head Injuries
• Assume significant
injury in patients
who have signs and
symptoms of head
injury.
• Suspect brain injury
in patients who take
blood thinners.
• Maintain oxygen
delivery to brain.
2
Injuries to the Spine
• Osteoporosis is a
contributing factor
to spinal injuries.
• Prompt spinal
immobilization can
reduce further
damage and pain.
• Pad void spaces.
2
Injuries to Pelvis and Hip
• Often present as hip
or buttock pain.
• Pelvic injury can
lead to hemorrhage
or internal organ
injury.
• Maintain leg in
position found to
prevent further
injury.
2
Cardiovascular Emergencies
Syncope: Interruption of blood flow to the
brain
Can occur for many reasons:
• Standing up too fast
• Straining to have bowel movement
• Myocardial infarction
• Diabetic shock
2
Cardiovascular Emergencies
Heart Attack
• Classic symptoms are often not present.
• Many have “silent” heart attacks.
Common signs and symptoms:
• Sudden onset of weakness
• Shortness of breath
• Toothache
• Arm pain
• Back pain
2
Shortness of Breath (Dyspnea)
Related to many causes:
• Asthma
• COPD
• Congestive heart failure
• Pneumonia
Provide oxygen immediately for all patients
experiencing shortness of breath.
2
Acute Abdomen
• Older patients
with abdominal
pain have higher
chances of
hospitalization,
surgery, and
death than
younger patients.
2
Acute Abdomen, continued
Abdominal aortic aneurysm (AAA)
• Walls of the aorta weaken.
• Treat for shock and provide prompt
transport.
Gastrointestinal bleeding
• Blood in emesis
• May cause shock
2
Acute Abdomen, continued
Bowel obstructions
• Vagus nerve is stimulated and
produces vasovagal syndrome.
• Vasovagal syndrome can cause
dizziness and fainting.
Patient requires transport to rule out other
conditions.
2
Altered Mental States
Delirium
• Recent onset.
• Usually associated with underlying
cause.
Dementia
• Develops slowly over a period of years.
2
Psychiatric Emergencies
• Depression is common among older adults.
• Physical pain, psychological distress, and loss
of loved ones can lead to depression.
• Women are more likely to suffer depression.
2
Psychiatric Emergencies, cont'd
• Older men have the highest suicide rate.
• Older patients use much more lethal means.
• EMT-Bs should consider all suicidal thoughts
or actions to be serious.
3
Geriatric Assessment, cont.
3
Elder Abuse
• This problem is largely
hidden from society.
• Definitions of abuse and
neglect among older
people vary.
• Victims are often
hesitant to report an
incident.
• Signs of abuse are often
overlooked.
3
Signs of Physical Abuse
• Signs of abuse may be obvious or subtle.
• Obvious signs include bruises, bites, and
burns.
• Look for injuries to the ears.
• Consider injuries to the genitals or rectum
with no reported trauma as evidence of
abuse.
3
Assessment of Physical Abuse
•
•
•
•
•
•
•
•
Repeated visits to the emergency room
A history of being “accident prone”
Soft-tissue injuries
Vague explanation of injuries
Self-destructive behavior
Eating and sleeping disorders
Depression or a lack of energy
Substance and/or sexual abuse
3
Communicating with Patients
• Make and keep eye contact.
• Use the patient’s proper name.
• Tell the patient the truth.
• Use language the patient can understand.
• Be careful of what you say about the
patient to others.
3
Communicating with Patients, cont'd
• Be aware of your body language.
• Always speak slowly, clearly, and distinctly.
• If the patient is hearing impaired, speak
clearly and face him or her.
• Allow time for the patient to answer
questions.
• Act and speak in a calm, confident manner.
3
Geriatric Patients
• Determine the person’s functional age.
• Do not assume that an older patient is
senile or confused.
• Allow patient ample time to respond.
• Watch for confusion, anxiety, or impaired
hearing or vision.
• Explain what is being done and why.
3
Geriatric Patients
Older patients may need a little more
time to process your question.
3
Communicating with Children
• Allow people or
objects that provide
comfort to remain
close.
• Explain procedures
truthfully.
• Position yourself on
their level.
3
Hearing-Impaired Patients
• Always assume that the patient has normal
intelligence.
• Make sure you have a paper and pen.
• Face the patient and speak slowly, clearly
and distinctly.
• Never shout!
• Learn simple phrases used in sign
language.
3
Vision-Impaired Patients
• Ask the patient if he or she can see at all.
• Explain all procedures as they are being
performed.
• If a guide dog is present, transport it also,
if possible.
3
Non-English Speakers
• Use short, simple questions and answers.
• Point to specific parts of the body as you
ask questions.
• Learn common words and phrases in the
non-English languages used in your area.
Questions
• What questions do you have?
To review this presentation, go to:
http://www.emsonline.net/emtb
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