Part 3. Brain emergencies.

[MedicYeti 96]

Each time your heart pumps, about half of the blood goes up into your head, brain and arms. The brain has a lot of blood vessels from fairly large to 1 cell wall thick and everything in between. The other half of your blood takes care of the rest of the body. Your brain requires a lot of blood, oxygen and nutrients in order to function. In the assessment portion I discussed the importance of finding out if your pt can answer questions, inability to answer questions, follow commands or even stay awake hint that the brain isn’t getting the blood, oxygen and nutrients that it needs to function. Some issues can be easily fixed, some can’t be fixed. I’ll go over a few.

 

Stroke. A strove occurs when a portion of the brain isn’t getting the blood it needs. This can be caused by 2 different issues.

A blood clot has moved through the arteries and become stuck somewhere in the brain. Like a dam blocking a river, this blood clot isn’t letting the blood get past and everything down river will suffer. Without blood and it’s goodies the brain will start to die.

The other possibility is a bleed. One of the blood vessels in the pt’s brain has burst and blood is leaking out into the skull. This can happen spontaneously or as a result of a head injury. Again, everything down river of the burst will suffer because it’s not getting blood or it’s getting less blood, think about a cut in a garden hose – some water may come out the nozzle but there’s also plenty squirting out the cut.

When a person has a stroke one of the first things the hospital does it to take the pt to a CAT scan to look at the brain. Most of the hospitals I take people to actually have us keep the person on the stretcher and go straight to CAT scan so there is as little delay as possible. CAT scan is the only way to diagnose a clot vs. a bleed. If a person has a clot then medication to dissolve the clot can be given. Bleeds may require immediate surgery. Giving a clot busting medication to someone who has a bleed will kill them. Aspirin to a stroke victim is a very bad idea.

 

To assess for a stroke remember F.A.S.T..

F-Face, is one side of the face not moving, do they have asymmetrical movement of the mouth? Think Sylvester Stallone, he suffers a facial nerve injury when he was born which limits the lip movement on one side of his mouth.

A-Arms and hands, can the person grip your fingers and squeeze with near equal strength? Can they simply hold their arms straight in front of them for a few seconds?

S-Speech. Can they speak clearly or do they slur their words like a drunk frat boy?

T-Time. This is one of the most important things EMS and the hospital need to know. TIME! When did this start? When was the pt last seen normal? When did someone speak to the pt, when were they seen, were they normal then? Treatment is dictated by the time the symptoms started, if the pt gets to the hospital within 4 hours of the onset time then the hospital will try to fix the issue, if it’s been more than 4 hours the goal is to prevent it from becoming worse. (This is grossly over-simplified and the 4 hours can be extended for some pt’s).

 

Low blood sugar. Is the person a diabetic? Did they take insulin but not eat enough now their blood sugar is too low for their brain to function? These people will present like a stroke but will usually be sweating a lot. It takes days for a person’s blood sugar to climb dangerously high, it takes less than an hour for it to drop dangerously low. If you meet someone who isn’t acting correctly, is sweaty and may have a medic alert tag or tattoo that says “Diabetic” give them sugar. Make sure they are awake enough to swallow and given them soda, OJ with sugar, icing, a doughnut, anything with real sugar (diet soda is not going to help). They will improve fairly quickly. They will need to eat something with protein and complex carbs to prevent the sugar from dropping again.

 

Infection, especially in the elderly population, can mimic a stroke.

 

Breathing problems, especially when they become severe, will rob the brain of oxygen. These people will become anxious and combative while they fight for air. They are not trying to be a jerk, they are dying.

 

Drugs. People like drugs; prescription, synthetic, street and any combination of the above. I may do a separate thing on drugs at a later date.

 

So… You’re having dinner with your parents and while clearing off the table you dad falls. You check him out, he is speaking but not making much sense: “Dad, are you ok?” Dad says “purple” He reaches out to you with his left hand but can’t move his right. With assistance you get him off the floor and onto a chair but you notice he can’t put weight on his right leg.

What do you do?

Take note of the time. If this happened at 5:47 then write down 5:47 onset. Use a sharpee and write it on dad’s forearm, big – it’ll come off.

Take a breath and call 9-1-1. The first question they will ask is “What is your location?” or “where is your emergency?” don’t launch into a full report, answer the questions they ask. They will get to a point where they ask specific questions but then need a location first. Once 9-1-1 gets a location and a little bit of info the ambulance and paramedics will be sent. The units often get sent by someone who is sitting near the person you are talking to, so you won’t generally hear the dispatch. EMS will arrive and check vital signs, move dad to the ambulance and get going to a stroke center. The stroke center may NOT be the hospital right down the road. EMS may sit on scene for a few minutes to get a few things done that will save time once dad gets to the hospital. If the stroke is bad enough and dad can’t control his airway EMS may put him to sleep and take control of his breathing, this is better done with all hands and in a still truck then doing it at 60mph.

Keep dad comfortable, don’t let him fall again, don’t give him food or drink. Try to stay calm. Lock the dogs in a bedroom. If dad is a hoarder then clear a path. Send someone to the street to flag down the first arriving unit. If dad gets worse call 9-1-1 again and give them an update, they may give you instructions.

What if help is delayed? The ambulance crashes into the medic truck, it’s a crazy busy day for EMS, maybe conditions are slowing everything down like in a blizzard. You can consider taking dad to the hospital yourself. In this case the closest hospital should be your destination. Any hospital can do a CAT scan and give clot busters. The hospital can also arrange transferring dad to a specialty hospital if needed.

What if society has collapsed and help isn’t coming? You can move dad to a recliner and sit him back, don’t lay him flat but put him back so he won’t fall over. Keep an eye on his airway and breathing, he may have trouble swallowing and you don’t want him to drown in his saliva. Feel his radial pulse and check it occasionally to see if it’s speeding up or slowing down. Sometimes stroke symptoms resolve themselves – these are known as mini strokes. A mini stroke is a warning that a real stroke is coming but a mini stroke has no lasting effects. If dad’s condition doesn’t get better or worse, for an hour or two it is more likely a clot and in a SHTF situation I would consider giving aspirin to my father. If dad’s condition improves then comes back and becomes worse it is likely a bleed. If dad has a large bleed the blood will compress the brain within the skull until the brain can’t function any longer. Pt’s with big bleeds will seize then try to die. Sadly, there isn’t much you can do for strokes outside of a modern hospital.