20240518004

Stroke is a leading cause of death and disability in the US, especially in older adults. Factors like family history, race, hypertension, smoking, and alcohol use contribute to stroke risk. New treatments like mechanical thrombectomy can restore blood flow to the brain. Seizures and altered mental status can also occur due to head injuries, brain tumors, metabolic problems, or intoxication. The brain is divided into different parts, each with specific functions. The cerebrum is the largest part and controls conscious thought. The brainstem controls basic functions like breathing and heart rate. The cerebellum coordinates muscle movements. We only use about 13% of our brain's capacity, but it can relearn and make new connections. The right side of the brain controls the left side of the body and vice versa. Speech is usually controlled on the left side of the brain. Cranial nerves and spinal nerves are responsible for transmitting signals between the brain and the body. is a neurological emergency. A brain trauma, or I should say, a brain injury is a brain injury is a brain injury. The difference is how it's affected. Is it a traumatic brain injury, or is it medically-induced brain injury? But the brain acts the same way. And that's what we're going to talk about some of this here anyway. So stroke is the fifth leading cause of death and a leading cause of adult disability in the United States. It's one of the top three. It's cancer, heart disease, cancer. There used to be heart disease, cancer, and stroke. Now it's heart disease, cancer, respiratory emergencies, and then stroke. It's like the whole. Common in geriatric patients, it's a numbers game. The older we get, the more likely we are to come about. Contributing factors for stroke include family history and race, hypertension, smoking, alcohol use. New treatments are available. UMass University, just within the last two years, got their accreditation. They can do what they call mechanical thrombectomy. It's radiological intervention. You go in, just like PTCA, pure cutaneous transluminal coronary angioplasty, they can do the same thing in the brain. So large vessel occlusions, they go through the radial artery, go right up into the brain, find the occlusion, and they can kind of roto-root it out. And that can restore blood flow to the brain. And remember that term, tinnitus tissue, we talked about that with the heart? Same with the brain. If you reperfuse the brain, you reperfuse those tissues, the patient has a great chance of surviving. So seizure and ultimental status also may occur. Seizures may occur as a result of recent or prior head injuries. I've known people that whacked a noodle when they were 12, and they have seizure activity in their 30s because of scar tissue. A brain tumor. I've taken patients to the hospital before, 25 years old, never had a seizure, all of a sudden had a seizure, take them in, they get a CAT scan, and they've got a brain tumor. Metabolic problems, hyper-hypocalcemia, hyper-hypokalemia, hyper-hyponatremia, hypoxemia, hypoglycemia. What would you consider somebody with a mental disability that is based off of stress? An anxiety disorder? Well, yeah, maybe stress or maybe something traumatic after them or something. Like, is that medical or traumatic trauma? That's behavioral, behavioral. So that would be under a medical, behavioral. Fever, we call febrile seizures, common in children six months to six years, as well as patients have a genetic predisposition for it. What do you call a patient that has no etiological reason why they have seizures, they just have them? What do we call it? Epilepsy. Epilepsy, that's right, that's what epilepsy is. Seizure activity of unknown etiology. Don't know why I get them, but I get them. It's epilepsy. Possible cause of altered mental status include intoxication, alcohol, or drugs. You can have water intoxication. Head injury, hypoxia, which is low oxygen, strokes. Patients with a stroke can have what they call a post-ictal state. After the stroke ends, the body kind of resets itself. And it can appear, patients appear very abundant, as well as metabolic disturbances. Treatments vary based upon what the problem is with the patient, right? It could be any number of things based upon what the problem is with the patient. I've covered altered mental status. I gave you ATIOU tips, correct? You guys remember that? OK, good. Let me turn my phone down a bit. The brain is the body's computer. It's the central processing center, or the motherboard. It controls all of the functions of life, from breathing, speech, bodily functions. It's broken into three main parts, the brainstem, the cerebrum, and the cerebellum. The cerebrum is the largest part of the brain. About 75% to 80% of the brain mass is the cerebrum. That's where most of conscious thought comes from. So remember this slide here? So we're going to just kind of review it real quickly. First of all, this is the frontal lobe. This is the frontal bone of the skull. This is the frontal lobe. The frontal lobe is emotions, emotions tied to memory. The hippocampus, which is right over here, controls our self-control, self-determination, hunger, things like that. We have up here the parietal region. Right in here, this is the parietal bone. Underneath that is the parietal lobe. And that controls our psychomotor skill set, everything that we can do psychomotor-wise, playing the piano, riding a bike, ventilating patients, and things like that, doing CPR. The back of the skull, this is the occipital region here. The most pronounced part of the skull is called the occiput. And this is the region where vision is controlled, your visual cortex and your visual association area. This is the cerebellum. The cerebellum is the cauliflower-like pedicle on the back of the brain stem. And that is your gross motor coordination, your spatial relations. This is your mesencephalon, the diencephalon. This is your thalamus, and then your hypothalamus. The hypothalamus is the main controlling gland. It doesn't control any other parts of the body, or it only controls the other six endocrine glands. They control most of the organs and tissues in the body with endocrine hormones. And then in the parietal, we have the region right here called the temporal regions right here. You have your auditory association and your auditory cortex for hearing. On the right side of the brain, you have the area where motor speech is formulating, where I can, my mouth actually makes speech. On the left side in the temporal region, you have the broca, B-R-O-C-C-A, broca's area of speech, where speech is formulated and understood. So I can speak. I can make words because of that side. And then, of course, in the temporal region as well, right along the base of the brain is where your ocular motor nerve that controls the dilation and constriction of the pupils. And then you have the medulla and the upper pons. The medulla is where your vegetative functions of life, heart rate, breathing, blood pressure. In your upper pons is the reticular activating system that controls our sleep-wake cycle, our area of consciousness, so to speak. And from there, the brain travels to the foramen magnum and then out down the spinal cord. Remember, the spinal cord does no calculations or computations. It's simply a bus line. It takes signals from the brain to the body and vice versa. The brain stem controls most basic functions of life, breathing, blood pressure, swallowing, pupillary constriction. This is one of the reasons why people with massive cortical damage, remember, the outside of the brain, the right outside of the brain, this is what we call the cerebral cortex. And the cerebral cortex is where motor function processes. So patients can have massive cortical damage where they're unresponsive, comatose, but yet they can still breathe and the heart rate still works because the brain stem is still in there. The cerebellum controls muscle and body coordination. Again, that gross motor coordination where it is the upper part of the brain controls fine motor coordination. And it says that we use about 13% of our brain. It's not that we use this 13%. We use the whole brain, but we only use about 13% of its capacity. So everybody ever see the movie Lucy with Morgan Freeman and Pat Johansson, whatever his name is, Scarlett Johansson? Good flick, watch that movie. But it's about a woman who takes this drug and she starts using more and more percent into her brain. It's a good flick. I don't know how realistic it is, but it's a good flick. But we only use, and the brain, that's one of the reasons why people can have damage and injuries and massive strokes, and they can learn to walk and talk again because the brain can reboot neurological connections. Just like we talked about, the heart can make collateral circulation around blockages. Your brain can do collateral connections around broken connections. So your brain, you can relearn things. The cerebellum is divided into the right and left hemisphere and it's divided into central sulcus and then basically at the mesencephalon, that's kind of the central sulcus. That's where the brain is divided into the right and left hemisphere. And then you have four lobes. The upper lobe, the lower lobe's divided in the middle. And the right side of the brain is the artistic, the left side is the analytical. That happens in about 12 years of age or so where people actually have that divining, which side becomes more dominant. So we also say each side, each controls activities in the opposite side of the body. We say same side face, opposite side body. Remember I talked about that. So if I have an injury, mass, lesion, tumor on the right side of my brain, my right pupil is gonna become dilated as it becomes affected by the pressure. My right side of my face will probably droop and I'm gonna have a ton of health. But the left side of my body will have deficits because right above the level of the brainstem, the brain switches. The front of the cerebrum controls the motion of the thyroid, the middle sensation of movement. Again, the parietal regions and the back parts of the brain. In most people, speech is controlled on the left side of the brain, near the middle of the cerebrum. Basically right about here on the left side of the brain is what we call Broca's area of speech. And that's where speech is formulated and understood. That's what you're sensual from the brain, travel through nerves. We talked about the 12 cranial nerves. Remember we covered those? The rest of the nerves join the spinal cord and exit the brain through the large opening at the base of the skull called the craniovagum. So your cranial nerves are up here, right? And they all affect from the neck up. And then you have the spinal nerves which run down the spinal cord and they innervate through the 31 pairs of peripheral nerves. But then you also have the vagus nerve which does not leave the spinal cord but comes out of the spinal cord and follows a different track and follows your elementary canal. That's your parasympathetic response. Inch vertebrae and inch vertebrae in the neck and back, two nerves branch out called spinal nerves. Those are your peripheral nerves. And they carry signals to and from the body. So we look at it right here, you have 31 pairs of peripheral nerves. This is why the spinal cord gets thinner as it goes down because it breaks down into branches. And what happens is as those come out because there's so many nerves, they kind of overlap. This is when you get referred pain. This is one of the reasons why if I get liver or a gallbladder irritation, I get shoulder pain because they kind of overlap up here in what we call the brachial plexus. Then you have the thoracic plexus, the lumbar plexus. Down here we call that the lumbosacral plexus or the cauda athena because it looks like a horse's tail ripping, right? That's why at the level of L4, L5, the great cistern that collects all the cerebral spinal fluid is circulated. We can draw that out by needle, we can aspirate that. And the reason, and it's safe to do it or safer to do it there because there's no really spinal cord at that point. It's just nerves. Many different disorders can cause brain dysfunction and may affect the patient's level of consciousness, speed, or voluntary control. And we know that the brain is sensitive to changes in oxygen, glucose, and temperature. I can pinch off your internal carotid arteries and within 30 seconds, it's good night, Irene, you're sleeping. It's called the sleep problem, right? The brain does not store oxygen and glucose. It's very sensitive. It's also very sensitive to temperature. One of the reasons why the number one cause of ultimate mental status in the elderly is urinary tract infection. Why? Because the fever. Because the fever causes alterations. So hyper or hypothermia can cause alterations in mental health. Headache, one of the most common complaints. Yeah, we get calls for the headache. Can't be a symptom of another condition or a neurological condition on its own. A very small percentage of headaches are dangerous. But can you tell which one is which? Not usually. Not based upon what the patients tell you. Always assume, if you get called 911 to a headache, take it seriously. Transport the patient to the hospital. You call the hall. I would never discount a headache on a patient. For the one chance that you do, 99 times out of 100, it's gonna be benign. But that one chance out of 100, it could be a hemorrhagic stroke. So tension headaches, migraine headaches, and sinus headaches are the most common. So we're gonna run through those. First of all, tension headaches. All of you here have jobs, you go to school, family. You all know what a tension headache is. God bless the person that doesn't know what a tension headache is, right? We know it starts in the neck and it kind of wraps around right here. And it's stress. You can feel it. Your neck and your shoulders are all tight. Pain is usually described as squeezing, dull, or an ache. Usually doesn't require attention. Like I said, if somebody calls and wants to go to the hospital and it turns out they have an attention headache or they've never had one before, God bless them. Migraine headaches. This is thought to be caused by changes. One of the main causes, they say, is changes in the blood vessel sign at the base of the brain. We know that when the internal carotids come up at the base of the brain, they enter what we call a rotary, called the circle of Willis, from a rotary. So that way, any blockages, blood will still travel. It's Mother Nature's rotary, right? So, what happens is, in the base of the brain, those blood vessels dilate. Now, we know that the skull is in a closed vault-like structure that holds cerebral spinal fluid, venous and arterial blood, and brain matter. And it's in there at a pressure of about seven to 12 millimeters of arterial pressure. So, if all my blood vessels dilate in my skull, what is that gonna do to your cranial pressure? It's not that my skull's not gonna stretch. The pressure's gonna go in. It's gonna cause pressure in the brain, increasing your cranial pressure, causing a headache. So, one of the reasons why, if you take a nitroglycerin pill, you're gonna have one hell of a headache. And that's why, because it dilates the blood vessels in the brain. So, they believe that is one of the more common causes of migraine headaches, is dilation of blood vessels. That is why one chemical is the most common migraine medication for over-the-counter. There's this one chemical that's in migraine medication. It's the most common additive. Caffeine. Caffeine, very good. Caffeine is a xanthine derivative. Just like epinephrine, it causes nasal constriction. It's an alpha-1 agonist. So, you'll see caffeine, you'll see aspirin, and you'll see tolenol. That's excedrin migraine. That's what it is. And it causes nasal constriction. It's often associated with nausea and vomiting, and could be preceded by visual changes. Dysmorphia, double vision, blurred vision. Some patients can tell when you're having it. Some patients, we're gonna talk about this, they develop this aura around things. Like, you ever heard somebody tell you, oh, you're sad today, you got a dark aura, right? That's not what it is, but it's just a haze on everything. Usually that can be kind of a warning sign. It can last for several hours to days. I know a lot of older providers will think that a migraine, oh, it's just a headache. Suck it up on a cup. That's not true. A migraine can be debilitating. I have a friend, she was a cop in Sturbridge for years. She used to be a UMass cop. And she got migraines, and literally, she'd be out for 24 hours. She'd have to lay in bed with a cold compress, all the windows closed, and she couldn't move until it went away. It can be extremely debilitating. Yeah, I can get on those. It's just awful. It's horrible, horrible. Unless you've had them, you don't have any idea what it's like. With migraines, if you don't take anything, is it dangerous? No, a migraine is not, no. As long as it's truly a migraine and not a headache of another etiology, a migraine itself isn't gonna hurt. It's like a seizure. It's not gonna hurt you, but it's gonna hurt. You know, it's gotta be uncomfortable. I guess that's all I can say. What's that? Yeah, you get the same type of thing. You have dilational blood vessels in your stomach. I get like these blurriness in the side first. Yeah, it starts on the side and it works as well. I know it's coming. Yeah, and you can tell. Yeah, I know it's coming. Ever heard the thing about chugging as much water as you can drink when that first happens? You ever heard that one? I've heard it, but I don't know if it works. It seems to work for me, but I don't know if it's just like a placebo effect or what. Sometimes, if a placebo works, take it. There was a MASH episode, and I talked about different shows we used to watch. I mentioned MASH. It works for me. And Clinger was the one that used to dress up like a woman because he wanted Section 8. So he was wearing all these thin clothes because it was very hot. And so Burns told him, you need to stop wearing a uniform because it was all hot. So what Hawkeye did was he had these sugar pills. Because they ran out of pain meds. So he said, watch, this works. And so he gave it to Clinger and said, look, I'm gonna give you these. It's really powerful, but just take one of these and the heat will go away, and you'll feel very comfortable. And he was walking around all the time. Oh, it's beautiful out. Everybody's all, it's so hot. He's like, oh, this is great. He had a jacket on. So the placebo effect, I mean, granted, that's television, but the placebo effect does work. Sinus headache caused by pressure that is a result of fluid in the sinus cavities. Anybody who's had a cold, you get that sinus buildup. The number one way to tell a sinus headache is number one, two ways. You push on the face, palpate the forehead and the cheeks, and it hurts. And then have the patient bend over. And they're gonna be like, oh my God, that hurts. Classic sinus. Usually it's preceded by a cold, allergies, something along that. Something with stuffing, you know, runny nose, we call that rhinitis, watery eyes, some kind of cold-like symptoms. Existing hospital care is not required, but I will tell you that if you get, sinusitis means fluid and congestion in the sinus cavities. If they become impacted, that can be a medical issue. Not necessarily a medical emergency, but it can be something that needs to be treated medically. Serious conditions that include headaches could be things like hemorrhagic strokes, brain tumors, and meningitis. We talked about meningitis, we know what that is. Brain tumor, I explained that to you, as well as the hemorrhagic stroke. This is the problem, the hemorrhagic stroke. What it is is blood, it's just a ruptured blood vessel, an aneurysm, it pops, that's what a hemorrhagic stroke is. Bleeding in the brain causes an inflammatory response, because the brain doesn't like fine blood. So it rushes fluid to the area to splint it, to stop the bleeding. So it increases intracranial pressure, that's when you get the headache. So patients with hemorrhagic strokes will have what they call a thunderclap headache, which is like I felt a pop, and then a terrible headache in my head. Oh, it's like the worst headache I've ever had. If anybody ever tells you they're having the worst headache they've ever had, that is a sign of concern. Especially with any kind of neurological condition, like paresis, or paralysis, or dizziness, or altered levels of consciousness. So a stroke, a stroke is also called a cerebral vascular action. Actually, that is not correct. A stroke is a cerebral vascular accident. You have a CVA, and it reduces stroke-like symptoms. So it's actually a CVA, but we use the term stroke because the general public, you can't teach them what a cerebral vascular accident is. That's too much for them to see. But a stroke is one syllable, that's easy, stroke. So it's easy to remember, so we say you're having a stroke. But you're actually having stroke-like symptoms from a CVA. Interruption of blood flow to an area within the brain results in loss of brain function. And remember, time is tissue. There are two types, there's the ischemic and the hemorrhagic. Ischemic means lack of oxygen, a blockage, either amyloid or thrombus. Hemorrhagic means you've got a ruptured blood vessel, you're bleeding in your brain. That's a different etiology. Can you have both at the same time? Can you have a blockage and then somewhere else? You could, potentially. I'm sure somebody's had one, I don't see why not. And this will explain it to you, it really doesn't add up one way or the other, because about 87 to 90% of strokes are ischemic strokes. They're blockages. And they can be hemorrhagic after that? An ischemic won't become a hemorrhagic. They'd have to be two separate incidents. You wouldn't have an ischemic become a hemorrhagic. But you could have a hemorrhagic, you could have some kind of stress causing a rupture and then causing a blockage at another time. That's possible. So about 87 to 90% of all strokes are ischemic strokes. All are potentially reversible. Every ischemic stroke is potentially reversible. It's about time, time is tissue. So getting the patient to where they need to be. For large vessel occlusions, they can do what they call mechanical thrombectomy. Get them to UMass University, they get them right up to surgery and a wire guided wiring and they can bore it out and clean it out and you're good to go. Smaller ones, they can give you fibrinolytics. Like TPA for the heart, they can give you fibrinolytics that will break up the clot in the brain. The quicker you get the patient to the hospital, the better off they are. In UMass, they want door to cap or door to mechanical thrombectomy and fibrinolytics within 30 minutes. So you go in, they want you on the table under the procedure within 30 minutes. Again, reperfuse the tissue, less loss of brain function. Symptoms can range from nothing, so it comes from about 87 to 90% of strokes results from thrombosis or embolus. A thrombosis is a blockage that builds up in a blood vessel. It's there, it stays. If it breaks free, it becomes an embolus, it travels. So you can have an embolus stroke or thrombotic stroke. One of the number one causes of strokes, ischemic strokes, are embolus strokes due to diagnosed or undiagnosed atrial fibrillation. That's when the atria just quivers. Now, normally, if I have AFib, yeah, I'm probably not gonna be fully energetic, I'm gonna be tired all the time. But my atria still pumps to my ventricle, gravity helps, but it just, it doesn't work properly. So what happens is, what happens when blood doesn't properly travel through the blood vessels, it kind of pools, what does it do? When blood pools, what does it do? Clots, right? Does blood clot when it pools? So what happens is the upper left corner of the left atria, your little pocket, that was from when you were in utero, before you were born. This little pocket actually had a connection to the aorta, it was called the ductus arteriosus. So when blood came from your umbilicus into your heart, it went through the foramen ovale, which was a hole between the right atria, left atria, right ventricle, left ventricle. And then from there, it actually went right into the atria. So oxygenated blood went right into the aorta without going through the lungs, because the baby's lungs, they're not breathing, right? They're getting all their oxygen from the umbilicus. So that's called fetal circulation. The moment you're born, those holes all close. And then the blood starts traveling normally, and that ductus arteriosus closes, and actually forms part of the ductus arteriosus, forms part of the ligamentum arteriosus, that actually holds the aorta against the spinal cord. It actually does two things. So what happens is, if you develop AFib, blood tends to pool in that pocket, and so it develops these microemboli. Now all of a sudden, your AFib stops, or a lot of stress in your atria pumps really hard, and the blood travels up, all those microemboli start traveling through your body, and they lodge in your brain, and they can cause embolic strokes. One of the most common causes is undiagnosed or diagnosed atria. That's why patients on AFib are on blood thinners. If you're on AFib, you're on Coumadin, or Levinox, or Berlinta, have blood thinners to keep your blood from clotting and emboli. So symptoms can range from nothing at all to complete paralysis. We're gonna talk about the BFAST mnemonic. Right, the BFAST mnemonic stands for a balanced eyes, facial groove, ponderous, slurred speech, and time. Right, we're gonna cover that. That's a big, large vessel occlusion. Many strokes are not. Many strokes can be subtle, loss of vision in one eye, a blurred vision in one eye, maybe just a weakness in the hand, or maybe just a slight memory loss. I have two friends that have strokes. One of my friends, he was one of my medics in the army. He was a cop in Worcester, he retired. And his father owned a house that I rented from, an apartment I rented from, so he's very friendly with him. And he called me one time, he's like, my dad got home from lunch. And this is what happened, he walked home from lunch, and his wife said, so how was lunch? I don't remember. Well, what did you have? I don't know. Where'd you go? I don't know. Who'd you have lunch with? I don't remember. This was like 15, 20 minutes ago. So she's like, this is wrong. So she called him, because he was a medic. He said, Greg, what do you think? I said, well, it could be a number of things, but it could be a stroke. I said, you should get it checked out. Sure enough, he went in, and it was a small stroke in a specific area of the brain. So they treated it with fibrinolytics, and he was fine, because he got in quickly. He didn't let it fester. Some people, they will ignore the signs, and that's why they have long-term or even lifelong deficits. That's why people die from strokes, because they ignore the symptoms and don't realize it. I had another friend who was a medic for me. He's still working as a medic now. And he just had done a call, I don't know, Daily Bagel over here. He had just gone by to a call, and the girl at the Daily Bagel who knew him and his partner, she saw him go by. So when he came into order, she's like, I saw you guys go by. Did you go to a good call? And he's like, I don't remember. And she's like, are you okay? And he's like, I don't know. And he turned to his partner. He said, something's not right. This partner was smart. We gotta get going. We're taking you right to the hospital. Went to the hospital. Turns out he had a tumor, cancerous tumor, that was pressing on his carotid artery, causing lack of blood flow. So they repaired it, took out the tumor, and now he's perfectly fine. These scans are great. We missed it, so thanks God. But these are things where you've got to look for subtle, subjective changes. Don't look for the big, I'm falling on the ground, typical of the type of thing. It could be something very, very simple or very, people could almost overlook it. Atherosclerosis in blood vessels is often the cause. It's one of the main causes. That's that buildup of plaques that causes.