Neurological Emergency Care: Stroke - Brain Attack

An emergent crisis in the neurological system can be the most challenging to monitor and evaluate, perhaps because of our inability to control it as easily as we do a cardiopulmonary event. The neurological system is virtually out of control when it is injured. Neurological crisis are the most frustrating cases for nurses because we are accustomed to being able to monitor, chart progress, report to physicians when changes occur and carry out orders to improve conditions whereas declines in neuro status are often not fixable and we are obliged to make the patient comfortable, watch the condition worsen, and many times allow them to die. The most common neurological emergent crisis is Stroke (Cerebral Vascular Accident or Brain Attack as it is referred to today.) Neurological assessment includes interview, physical exam, and condition specific tests.

Stroke Animation


In many cases the patient is unable to answer and we must rely on family or friends to describe onset and development of symptoms. It is important to make sure there is a clear understanding of information being provided. The time of onset of symptoms is paramount. When investigating onset be sure to ask questions to review a patients earlier behavior. Ask if there is a history of past neurological disorders and document initial symptoms of the current event . Use caution not to suggest symptoms and use open ended questions, You can ask specific questions for clarification purposes. Document any progression of symptoms and be sure to ask if there have been any recent illnesses that may influence the current status, such as a head cold, sore throat, falls, or any accident involving the head. Include inquiry into any recent change in prescription medication, over the counter medications, and herbal remedies.

Include a review of current medications when taking a history and make sure the patient has been compliant with prescribed medications especially if they are taking an anti-seizure medication. Failure to take prescribed amounts can cause anything from a focal seizure to a more severe grand mal seizure. If the patient is over medicating he may experience mental slowing, drowsiness, lethargy and more seriously non responsive states. There are many underlying conditions that can affect the nervous system: diabetes mellitus, pernicious anemia, cancer, chronic infections, thyroid disease, substance abuse, renal failure, hypertension, dehydration, alcoholism and a host of others.

A physical examination should follow with a focused neurological exam including the Glascow Coma Scale. Laboratory tests should include routine blood tests especially electrolytes and blood sugar to rule out any physiological abnormality that can be treated and would reverse the neurological symptoms. Computerized Tomography and Magnetic Resonance Imaging can be done to visualize blood vessels, brain edema, infarction, identify blood accumulation or tumor presence. If the situation warrants, a lumbar puncture should be done. All of the data collected may give enough information to determine the cause of the insult.

Golden hour of Treatment


Stroke Assessment

Glascow Coma Scale

Opening eyes	Spontaneous--open with blinking at baseline	4
	Opens to verbal command, speech, or shout	3
	Opens to pain, not applied to face	2
	None	1
Verbal Response	Oriented	5
	Confused conversation, but able to answer questions	4
	Inappropriate responses, words discernible	3
	Incomprehensible speech	2
	None	1
Motor Response	Obeys commands for movement	6
	Purposeful movement to painful stimulus	5
	Withdraws from pain	4
	Abnormal (spastic) flexion, decorticate posture	3
	Extensor (rigid) response, decerebrate posture	2
	None	1

For children under 5 the verbal response criteria is adjusted as follows

SCORE	2 to 5 YRS	0 TO 23 Mos.
5	Appropriate words or phrases	Smiles or coos appropriately
4	Inappropriate words	Cries and consolable
3	Persistent cries and/or screams	Persistent inappropriate crying &/or screaming
2	Grunts	Grunts or is agitated or restless
1	No response	No response

Points to remember.

A score of 15 is the highest and 3 is the lowest.
A score of 7 or less indicates coma.
Abnormal flexion, or decorticate posturing is evidenced by adducted and flexed arms with wrists and fingers flexed in the chest.
In extension , or decerebrate posturing, the arms are adducted and extended with wrists and hands pronated and the fingers flexed.
An easy way to remember the difference between the two terms is that decorticate is toward the core or center of the body and the arms are also bent inward toward the core.

Decorticate vs. Decerebrate

Cranial Nerves

Nerves in Order	Modality	Function
Olfactory	Special Sensory	Smell
Optic	Special Sensory	Vision
Oculo-motor	Somatic Motor Visceral Motor	Levator palpebrae, superioris, superior, medial & inferior recti muscles Parasympathetic to ciliary & pupillary constrictor muscles
Trochlear	Somatic Motor	Superior oblique muscle
Trigeminal	Branchial Motor General Sensory	Muscles of mastication Sensory for head/neck, sinuses, meninges, & external surface of tympanic membrane
Abducens	Somatic Motor	Lateral rectus muscle
Facial	Branchial Motor Visceral Motor General Sensory Special Sensory	Muscles of facial expression Parasympathetic to all glands of head except the parotid Sensory for ear and tympanic membrane Taste anterior two-thirds of tongue
Vestibulo-cochlear	Special Sensory	Hearing and Balance
Glosso-pharyngeal	Branchial Motor Visceral Motor Visceral Sensory General Sensory Special Sensory	Stylopharyngeus muscle Parotid Gland Carotid Body Sensation posterior one-third tongue & internal surface of tympanic membrane. Taste posterior one-third tongue
Vagus	Branchial Motor Visceral Motor Visceral Sensory Special Sensory	Muscles pharynx & larynx Parasympathetic to neck, thorax, & abdomen Sensory  from pharynx, larynx & viscera Sensory from external ear
Spinal Accessory	Branchial Motor	Trapezius & sternocleidomastoid muscles
Hypo-glossal	Somatic Motor	Tongue muscles except palatoglossal

5 Point Neuro Check


Syncope


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