Neuro/Psych9 September 2020

Topics● Headache

● Stroke

● Seizure

● ABCs

● Psychiatric Assessment

Headache

Tension Headache● Most common type of headache

● Caused by muscle contractions in the head and neck

● Can be attributed to stress

● Pain described as squeezing, dull, or an ache

Migraine● 3 times more common in women than men

● Pain described as pounding, throbbing, or pulsating

● Can be associated with visual changes or nausea/vomiting

● Can last for several days

Sinus Headache● Caused by fluid accumulation in the sinus cavities

● May be triggered by a cold or allergies

● Pain may increase when bending down or straining

● Sinus Infection

○ May also have nasal congestion, cough, or fever

General Assessment● A&O● Pay attention to pulse ox. and need for O2

● Remove from heat/sunlight and bring to dark room if needed.● Questions to ask:

○ Any triggers?■ E.g. heat/dehydration, stress, recent illness/fever

○ History of migraine/headache?○ What usually helps?○ How long does it last?○ Sudden/gradual onset?○ Any other symptoms?

Stroke

Background● Stroke or Cerebrovascular Accident (CVA)

○ Interruption of blood flow to the brain that results in the loss of brain function

● Types of Strokes

○ Ischemic Stroke

○ Hemorrhagic Stroke

○ Transient Ischemic Attack (TIA)

Ischemic Stroke● 87% of all strokes

● Blood vessels become narrowed or blocked, leading to reduced blood flow (ischemia)

● Stenosis (narrowing of the artery) is caused by atherosclerosis (accumulation of fats, cholesterol, and other substances in and on the arterial walls)

Hemorrhagic Stroke● Intracerebral Hemorrhage

○ Most common type of hemorrhagic stroke

○ Burst artery floods the surrounding tissue with blood

● Subarachnoid Hemorrhage

○ Less common type of hemorrhagic stroke

○ Bleeding in the area between the brain and the thin tissues

that cover it

Transient Ischemic Attack (TIA)● In a TIA, blood flow to the brain is blocked for only a short time—usually no more

than 5 minutes

○ Does not cause permanent damage

● A TIA is a warning sign of a future stroke and in the field there is no method to

differentiate between a TIA and a major type of stroke

● As many as 10% to 15% of people will have a major stroke within 3 months of a TIA.

Lifestyle Risk Factors● Being overweight or obese

● Unhealthy diet

● Stress and depression

● Physical inactivity

● Heavy or binge drinking

● Use of illegal drugs such as cocaine and methamphetamine

Medical Risk Factors● High blood pressure

● Cigarette smoking or secondhand smoke exposure

● High cholesterol

● Diabetes

● Obstructive sleep apnea

● Cardiovascular disease, including heart failure, heart defects, heart infection or

abnormal heart rhythm, such as atrial fibrillation

● Personal or family history of stroke, heart attack or transient ischemic attack

Other Risk Factors● Age — People age 55 or older have a higher risk of stroke than do younger people

● Race — African Americans have a higher risk of stroke than do people of other races

● Sex — Men have a higher risk of stroke than women. Women are usually older when

they have strokes, and they're more likely to die of strokes than are men

● Hormones — Use of birth control pills or hormone therapies that include estrogen

increases risk

Preventive MedicationsAntiplatelet Drugs● The most commonly used anti-platelet medication is aspirin. Your doctor can help

you determine the right dose of aspirin for you.● After a TIA or minor stroke, pt may be prescribed aspirin and an antiplatelet drug

such as clopidogrel (Plavix)

Anticoagulants● These drugs reduce blood clotting. Heparin is fast acting and may be used short-term

in the hospital.● Slower-acting warfarin (Coumadin, Jantoven) may be used over a longer term. ● Other anticoagulants include: dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban

(Eliquis) and edoxaban (Savaysa).

Signs and Symptoms● ALOC● Headache● Elevated blood pressure (ICP, Cushing’s Triad)● Blurred vision, double vision, or loss of vision in one eye● Trouble swallowing or tongue deviation● Aphasia - inability to speak or understand speech● Ataxia - lack of muscle coordination● Hemiparesis - one sided weakness or paralysis

● Strokes can sometimes be mistaken for a postictal state or hypoglycemia

Treatment● Monitor pulse ox and provide oxygen as needed

○ Previously, our protocol was to provide 15 LPM via NRB, but do not do this unless indicated

● Conduct a neurological examination○ Cincinnati Stroke Scale

○ Los Angeles Prehospital Stroke Scale

● Rule out other possible causes, such as a postictal state or hypoglycemia

Cincinnati Stroke Scale● Facial Droop

○ Ask the patient to close their eyes and smile with their teeth

● Arm Drift

○ Hold the patient’s arms in front of them with their palms facing upwards

■ This does not mean you should ask the patient to hold their arms out

○ Ask them to close their eyes and keep their arms in this position

● Slurred Speech

○ Ask them to repeat “the sky is blue in Cincinnati”

● Only need to have 1 out of the 3 to qualify as a stroke, BUT you must ask all 3 questions regardless

● The Los Angeles Prehospital Stroke Screen also tests the strength of the patient’s grip

Seizure

Types of SeizuresPartial/Focal Seizures: affect a localized area of the brain

Generalized Seizures: appear to affect all areas of the brain simultaneously

• Tonic-Clonic

– Tonic: muscles contract, become stiff, lose consciousness (lasts for < 1 min)

– Clonic: muscle spasms → relaxation (few mins)

– Post-ictal state: first unresponsive, gradually regain consciousness (up to 30 mins)

– Status epilepticus: seizures continue every few minutes or last longer than 30

minutes

• Absence (petit mal)

– Last < 15 sec, can be mistaken for daydreaming → regain alertness immediately

Causes of Seizures● Congenital (epilepsy)

● Structural Problems○ Trauma, tumor, infection, stroke

● Metabolic Disorder○ Hypoglycemia, poisoning or drug overdose, alcohol

● Fevers (febrile)

Patient Assessment● History of epilepsy?

● Does the patient take medications for seizures?

○ Do they usually prevent all seizures?

■ If not, how frequently does pt. usually have a seizure?

○ Has pt. been taking medications regularly?

● What did the seizures look like?

● How many seizures did they have?

● How long ago was the last one?

● Was this a “usual” seizure for pt.?

● Ask the patient to describe events/sensations leading up to seizure → may suggest other possible triggers

Treatment

● Place the patient left lateral

● Monitor pulse and respirations

● Maintain a patient airway - suction if needed

Considerations● A&O - Important to reassess!

● DO NOT put anything in the patient’s mouth!

● Important to keep the environment clear (while seizing)

● C-spine precautions

● Rapid trauma assessment

● Anticipate vomiting or combativeness

Parkinson’s Disease● Parkinson’s Disease is a neurodegenerative disorder that affects dopamine-producing

neurons in the substantia nigra region of the brain

● Symptoms begin gradually and become worse over time

Parkinson’s Disease● Symptoms

○ Tremors

○ Stiffness in the limbs or trunk

○ Slowness in movement

○ Impaired balance or coordination

Huntington’s Disease● Huntington’s Disease is an inherited disease characterized by the progressive breakdown of nerve cells

● Motor Symptoms○ Chorea - involuntary jerking or writhing○ Dystonia - rigidity or muscle contractions○ Slow or abnormal eye movements○ Difficulty with speech and swallowing○ Impaired gait, posture, or balance

● Cognitive Symptoms○ Difficulty processing thoughts, finding words, or learning new information○ Lack of impulse control, flexibility, or awareness○ Difficulty organizing, prioritizing, or focusing on tasks

● Psychiatric Symptoms○ Irritability, sadness, apathy, or social withdrawal○ Fatigue, loss of energy, or insomnia

Dementia● Dementia: an umbrella term used to describe a wide range of neurological symptoms

○ Alzheimer’s: a specific type of dementia with common symptoms

Multiple Sclerosis● Multiple Sclerosis: disease of the CNS that can lead to permanent deterioration of the nerves

ABCs

ABCs● Take c-spine precautions as needed

● Check A&O, pulse ox, eyes, and respirations

● Stroke patients may have difficulty swallowing or choke on their own saliva

● Postictal seizure patients may have an increased pulse and respirations

● Look for any foreign-body airway obstructions

● Provide oxygen as needed

● Be prepared to suction or insert an OPA/NPA

Psychiatric Assessment

Important Considerations● Boundaries

● Compassion

● Empathy

● No judgment

● Proper understanding to break down stigma

● Respect

Background

● Behavioral Crisis: any action that interferes with activities of daily living or is deemed unacceptable by the patient, friends, or family

● Psychiatric Emergency: a situation in which a person becomes a threat to themself or others (suicide, medication noncompliance)

● 1 in 5 American adults have a mental illness at any given time.● 1 in 10 EMS calls are psychiatric in nature. ● The DSM has 19 categories for mental disorders.

Common Conditions in EMS● ADD and ADHD● Addiction and Substance Use● Anxiety and Post-Traumatic Stress Disorder● Bipolar Disorder● Depression ● Suicidal Ideation or Attempt● Eating Disorders● OCD and Phobias● Schizophrenia and Psychosis● Sleeping Disorders

Mental Status Examination● An MSE is the psychological equivalent of a physical examination.● Be sure to determine what is normal for the patient.● Components of the Exam (list of examples is not comprehensive)

○ Appearance → alertness, attitude, hygiene○ Behavior → eye contact, movements, psychomotor activity○ Speech → rate, rhythm, volume, content○ Mood → emotional state as described by the patient○ Affect → emotional state as observed by the EMT○ Thought Process → rate, flow, connection○ Thought Content → preoccupations, hallucinations, ideas○ Cognition → attention, concentration, memory○ Judgment and Insight → awareness, understanding consequences

Psychiatric Holds

● Allow EMTs to restrain a patient against their will.● They cannot refuse treatment even if they are A&Ox3.● 5150

○ 72 hour hold for DTS/DTO/GD■ DTS → danger to self■ DTO → danger to others■ GD → grave disability

○ Who can order a hold in LA County?■ LACDMH personnel■ Peace Officers■ Probation Officers (on their OWN clients)

● 5585 → 5150 for minors● 5250 → extending a previous hold to 14 days

Safety and Legal Considerations

● If a patient is not mentally competent, the law gives you implied consent.

● Safety comes first! Restrain the patient if they become a threat to you or to themself. Call for additional resources (DPS).

● Obtain help from law enforcement if needed.● You will not get in trouble if you harm your patient while trying

to restrain them (within reason).● Document injuries present before and after restraints, monitor &

record CMS on all 4 extremities every 15 minutes

Preparation● Non-psychiatric calls involving trauma or patients with psychiatric histories can

easily progress to psychiatric emergencies.● Emotionally Traumatic Situations

○ Sexual or physical assault○ Experiencing or witnessing a major injury or death○ Surgery or life threatening illness○ Natural disaster or MCI

● Non-Suicidal Self Injury (NSSI) attempts can appear to be accidents.

Prevention● Invoke a rapport of compassion:

○ Watch your demeanor: genuity, respect, empathy○ Concreteness: establish a baseline & intensity○ Hx: psychiatric, previous harm to self or others ○ Watch THEIR demeanor for (direct or indirect warning signs)○ ALWAYS monitor your patient and never take your eyes off them during

treatment.

Treatment● Establish a compassionate rapport● Initiate grief normalization (but don’t try to sort through those feelings)● Facilitate understanding of critical incident processing (don’t be afraid of comforting

touch but be aware of how helpful it may be to that person)● Assist in mobilizing support systems (family, parent, roommate..try to make it local,

so they have easy access to it)● Encourage follow-through!

Treatment● Be mindful of the treatment you are offering

○ Take psychiatric history into account just as you would a heart condition or an allergy. Don’t let it define your treatment, but don’t neglect it either.

● Watch for agitated behavior, which can quickly progress to combative behavior ■ Don’t take anything they might say personally, remember to be an advocate

for your patient at all times

Treatment Tools● Verbal de-escalation

○ 1st: verbally engage the patient○ 2nd: establish a collaborative relationships○ 3rd: once the patient is de-escalated from their agitated state, watch for relapses

into agitation/negative thought● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298202/ ● Emotional first aid:

https://www.jems.com/2015/09/28/provide-emotional-first-aid-when-responding-to-sexually-assaulted-patients/○ Reassure privacy and confidentiality○ Have only necessary personnel on scene

Treatment Tools● Sexual Assault

http://taasa.org/wp-content/uploads/2016/01/EMS-Fact-Sheet-SAAPM-2015.pdf○ Use active listening and non-blaming language○ There is no right or wrong way for a patient to react○ You may be the first safe face for this patient○ Explicitly explain every action you take before touching the patient; treat on a

permission basis● The patient’s options:

○ To seek medical treatment at an ER/rape crisis center○ To either report or not report to law enforcement○ To have forensic evidence collected WITH OR WITHOUT a police report.

Evidence stored for 2 years.

Treatment Tools● Preserving evidence

○ Always wear gloves○ Encourage patient not to use the bathroom, shower, remove clothes, drink/eat○ If possible, have them sit on a sheet that can be taken to the hospital with them

● Your questions○ Should be solely medically-concerned (this involves emotional and mental

health, too)○ Should be open-ended

● Document accurately (down to the time on scene)

Debrief● Short-Term:

○ During Call: be aware, actively listen, acknowledge○ After Call: acknowledge, realize, reflect

● Long-Term:○ Acknowledge warning signs of unhealthy coping○ Avoid retreating, pulling back from support; check in with your crew○ If it lingers, seek support○ Normal v abnormal recognition: when do abnormal moments build up to

an abnormal baseline?

Self-Care (notes from our consultant)● Burnout is common amongst mental health professionals● It is important to be empathetic, but also professional and firm in your boundaries● Always debrief with your team and colleagues● Have a self-care routine at home

○ Mindfulness has been proven to improve wellbeing in the general population○ Self soothing – baths, massage, yoga, exercise, connecting with a friend/family

member, maintaining good sleep hygiene ○ Being kind and compassionate towards yourself! Reward yourself for having

undertaken work in the field

Mindfulness (notes from our consultant)● One way of ‘re-wiring’ the brain – from maladaptive to adaptive neural pathways● More focused attention & positive shifts in mood● Relaxation● Enhanced self-awareness● Improved health and well-being● Less anxiety, depression, and pain. (Goyal et al., 2014)● Reduced negative emotions and neuroticism, comparable to the impact of behavioural

treatments and psychotherapy on patients. (Chetelat et al., 2018)

Resources for You and Your PatientsStudent Counseling Services (SCS) – (213)-740-7711 – 24/7 on call: Free and confidential mental health treatment for students, including short-term psychotherapy, group counseling, stress fitness workshops, and crisis intervention.https://engemannshc.usc.edu/counseling/

National Suicide Prevention Lifeline – 1-(800)-273-8255: Provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week. http://www.suicidepreventionlifeline.org

Relationship & Sexual Violence Prevention Services (RSVP) – (213)-740-4900 – 24/7 on call: Free and confidential therapy services, workshops, and training for situations related to gender-based harm. https://engemannshc.usc.edu/rsvp/

Student Support & Advocacy – (213)-821-4710: Assists students and families in resolving complex issues adversely affecting their success as a student Ex: personal, financial, and academic. https://studentaffairs.usc.edu/ssa/