three

The main ideas from this information are: - The importance of notifying the receiving facility about a patient's chief complaint and assessment. - The use of CT scans to determine if there is bleeding in the brain for a patient with a suspected stroke. - The risk-benefit ratio of using fibrinolytics to dissolve clots in stroke patients. - The significance of knowing the last time a patient was known well, especially for stroke cases. - The need for patients who have had a seizure to go to the hospital for evaluation. - The importance of providing supplemental oxygen and protecting seizure patients from further harm. - The use of collars and ALS intervention for patients with ongoing seizures. - The concern for sudden, severe headaches and other symptoms that may indicate a more serious injury. - The protocols for treating migraines and strokes. - The designation of stroke centers and the availability of different levels of stroke care. - The importance of evaluating and treating patien but that could be the sign of an impending herniation or an impending bleed. Notify the receiving facility of patient's chief complaint and assessment. Sometimes chief complaint can change. ED physicians determine if there's bleeding in the brain for a patient with suspected stroke. Using a CT, computerized tomography, it's a magnetic picture of the brain or any part of the body. If there is no bleeding present, if you don't have a bleeding issue, then you can receive medication to dissolve the clot. It's called fibrinolytics. But it's a risk-benefit ratio because if I give you fibrinolytics and you have a GI bleed or you have some other bleed, it could get worse. You won't clot, you could bleed internally. So they have to confirm you don't have a bleeding disorder and you're not bleeding anywhere before they give it to you. Notify the hospital regarding the last time known well. This is very important for a stroke because it used to be outside of three hours, they would do minimal intervention because they figured, okay, the damage is done. Now, the new feeling, especially some of the younger, more aggressive neurologists and neurosurgeons, will go up to 24 hours and they'll treat. But it's very important to tell them the last time known well. Now, I talked about the husband and wife having coffee, the wife drops her cup, she can't hold her arm, calls 911, we arrive within 15 minutes and the patient's to the hospital within 20. That's easy. Last time known well 20 minutes ago. Woo-hoo! Get her up, mechanical thrombectomy or maybe, you know, fibrinolytics and she repercusses her brain, no deficits. What about the person that went to bed last night, no deficits, woke up with one-sided freeze of paralysis? Did they have it when they went to bed? Did they have it during the night? Did they have it when they woke up? We don't know. So, it's always the last time known well. I did a call in Gardner once where I had to climb up to a second floor window and I found the guy lying on bed, naked, holding a phone. My boy. I don't know how long he had been there. He could have been there. The phone wasn't beeping. How do you leave a phone on for, and after five minutes it jumps off? Literally was nothing. He could have been lying there for hours. I went to, he might have been trying to call 911 for all I know. The husband, the son showed up and the son was, we bring the patient out and I said, when was the last time you saw your father? And he said, oh my God, this was a Saturday. And he said, I haven't seen, I haven't seen my father since Monday. So, when I brought the patient to Hayward, the nurse was like, when was the last time known well? I said, Monday. Like I was, didn't do my job, like that's what the son said. Last time he lived alone, last time he was known well was that Monday. That's what you give him. That's all you have. You don't know. Now, granted, most likely he was going to the bathroom to take a shower maybe. That's why he was naked. And he felt something happened and he picked up the phone. But, was it an hour? Was it two hours? Was it three hours? I don't know. I can only tell him the last time was Monday. Patients who have had a seizure require definitive evaluation and treatment. That's why we always try and get a patient to go to the hospital. If your patient is awake after the seizure, they're not, probably not going to go. If they're a regular epileptic or a regular seizure patient, they're going to be like, nah, I just, I forgot to take my meds or whatever. They really should go and get evaluated. So, during a seizure, supplemental oxygen is highly, is strongly advised. Put them on a non-rebreather. Put them on a non-rebreather. Put an N94. I will do the Heimlich one. Do you have water? No. I have saliva. That works. Would you like some water? No. Put them on oxygen with a... Non-rebreather? No, put them on a non-rebreather with an NPA. That's what I meant to say. I couldn't spit it out. Literally. For patients having seizures, protect them from further harm. Make sure you protect around them. You don't want them to whack their headband and they're going to fall down the stairs. Maintain a clear airway. If your patient is suctioning, have suction available. If your patient is vomiting, or if they're having a seizure, have suction available. Because they could start aspirating. Provide oxygen as quickly as possible. For head or neck trauma, put a collar on. And again, you can put a collar on a seizing patient. So, go ahead and put it on. It's cheap, it's easy, it's effective. The patient doesn't like it. For patients who continue to have a seizure, as is static epilepticus, you should have ALS on the way. If a patient is having a seizure, ALS should be coming. We can give them Vivalium. We can give them Versed. We can give them medications to stop the seizure. Suction the airway. Provide positive pressure ventilation. You know, you could bag a patient while they're seizing, right? Or at least put them on an army breather. Transport 50 to the hospital and try and link up with ALS. We'll stay on scene because they need definitive care. But we'll definitely hope ALS will reach us by the time we get there. You should always be concerned if a patient complains of a sudden, severe headache. Oh my God, something popped in my head. I've never had a headache so bad. That's a bad, that's a warning sign. Sudden, severe headache. Especially with the presence of a fever, seizure, ultimental status, or following trauma. It could be a brain bleed. It could be meningitis. It could be toxicological. Always assess the patient for other signs and symptoms that might indicate a more serious injury. Right? And remember, they could have trauma involved in it as well. High flow OSU. Provide a dark and quiet environment. Do not use lights and sirens. This is for a migraine. You don't want to go, you know, two wheels, lights and sirens around corners and things. Nice and calm. This is not life threatening. You know, turn the lights off. Put a cold compress on the head. Keep them calm. For a stroke, support the ABCs and provide rapid transport to a stroke center. We want to maintain SPO levels of at least 94% or greater. We do not put a patient on oxygen unless they need it. If they're less than 94%, if they're short of breath, if they're altered, we will, but otherwise we don't. Just like cardiac cells, neural cells, cells in the brain, will be damaged by high concentrations of oxygen. So we don't want to put oxygen on a patient that doesn't need it. And a stroke center. All hospitals are considered stroke centers in the area, except Memorial. Memorial Hospital on 110 Belmont Street. What was it? 113 Belmont Street. They are not, because St. Dean's is an advanced stroke center that does mechanical thrombectomy, and so doesn't UMass. So you can go within two miles in either direction in a hospital that's an advanced stroke center. Why would they do it? So they don't do it. They're the only hospital in the area that doesn't. All of the hospitals in the area are stroke centers. They can be a basic stroke center or an advanced stroke center. A basic stroke center has, they have to have CAT scan capability, because they have to see if the patient has a bleed or not, and then they have to have capability for fibrinolytics, which is clot-busting drugs. So what will happen is you'll come in to Haywood or Lemonster. You'll be with the ER doc, and he'll bring in a computer or like a video camera computer thing, and he'll dial up the neurologist, the neurosurgeon at UMass or whatever affiliate hospital they use. I think St. Dean's uses Tufts, right, and they use UMass. They'll dial up and the doctor, the neurologist, will talk to the patient and will ask the doctor to perform certain tests while he watches. And then he'll make a determination, I want that patient to me, or no, you can do fibrinolytics. He can review the radiology report and the CAT scan right away so he can see what needs to be done for the patient. So any hospital is a stroke center, but if you know it's a brain bleed, if the patient says, oh my God, my head, something popped in my head and I would go to UMass or something like that because they're going to need neurosurgery. For a seizure, the patient may get a postnatal status upon your arrival. The patient may be having a seizure. Continue to assess and treat any APC issues and protect from further harm. If the patient refuses transport, call medical control and follow up with a protocol. I'm going to try and get that patient to go. They should go to the hospital and get evaluated. There's a reason they had a seizure when they shouldn't. You should be able to control seizure activity. But if a patient is not postnatal and they say, I don't want to go to the hospital, get them on the radio. You can talk to them, you know, call medical control, get them on the cell phone. Will you talk to my doctor? If the doctor can't convince them to go, you're not going to convince them to go. Take a review. For ultimate mental status, determine the cause if you can. You may not be able to. Provide spinal mobilization. Provide airway and ventilatory support. Transport to the appropriate facility. Really, any facility closest to appropriate facility for ultimate mental status. Make sure you check the blood sugar, pulse oximetry. Keep the patient warm because hypothermia can cause ultimate mental status. So a 41-year-old man presents with slow irregular breathing, hypotension, and dilated pupils. Where is his dysfunction? Where is the pressure? Those are all what type of functions of the body? Brainstem. Those are vegetative functions of life. Those are the basic functions. Those all come from the brainstem. Breathing, blood pressure, pupils, heart rate. An acute ischemic stroke. Acute means rapid onset. An ischemic stroke is caused by a blocked cerebral artery. A 56-year-old man experiences a sudden severe headache and then became unresponsive. And has a history of high blood pressure. What are we thinking? Unlike an ischemic stroke, a transient ischemic attack is characterized by all the following except... Right, because they will last less than 24 hours. And if you have a patient that has symptoms and they result in a severe headache, Right, because they will last less than 24 hours. And if you have a patient that has symptoms and they resolve and the symptoms come on again, that's a full-blown stroke. That's not a TIA. That means that the body broke up the clot, but then pieces of it traveled down further and occluded further on down. So that's a full-blown stroke. A patient with a suspected stroke presents with slurred speech that is difficult for you to understand. What do you call it? Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphasia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia. Dysphagia.