EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.
Issue link: https://emsworld.epubxp.com/i/658705
48 APRIL 2016 | EMSWORLD.com TABLE 2: OPQRST FOR POSSIBLE CAUSES OF NEURO EMERGENCIES Ischemic Stroke General description—Loss of brain function in one or more areas, including vision, motor function and sensation, coordination/balance and speech among the most often afected. Onset—Sudden onset, usually constant but can be waxing and waning. Palliative/provocative/previous—None. Quality—Loss of one or more areas of brain function, including vision, motor, sensation, coordination/balance, speech. Radiation/region—Varies with location of stroke. Severity—Ranges from mild loss of sensation to coma with loss of speech and motor. Timing—Sudden onset, usually constant, occasionally waxing and waning. Associated—Usually painless, may have mild head discomfort. Hemorrhagic Stroke General description—Severe thunderclap headache described as worst of life. Onset—Sudden onset, increasing in severity over time. Palliative/provocative/previous—None. Quality—Often extreme headache associated with loss of one or more areas of brain function, including vision, motor, sensation, coordination/balance, speech. Radiation/region—Pain may radiate to posterior neck. Severity—Generally severe headache with increasing stroke defcits as bleeding continues. Severe cases may have decreased LOC and herniation syndrome. Timing—Sudden onset, progressively worsening. Associated—Severe headache, decreasing LOC, brain herniation syndrome. TIA General description—Transient loss of brain function in one or more areas. Neurological defcits are similar to those of an ischemic stroke. Symptoms typically last less than 5 minutes but can last up to 24 hours. Onset—Sudden onset, improves usually in a few minutes but may last up to 24 hours. Palliative/provocative/previous—None. Quality—Generally transient loss of one or more areas of brain function, including vision, motor, sensation, coordination/ balance, speech. Radiation/region—Varies with location of TIA. Severity—Usually identical to stroke, but symptoms resolve. Timing—Sudden onset, improving with time. Associated—N/A. Bell's Palsy General description—Isolated unilateral weakness of the muscles of the face. Characterized by the inability to raise the eyebrow on the afected side. There may be some minimal slurring of speech, but patients do not have aphasia or extremity weakness. Symptoms will worsen within the frst 48 hours. Onset—Generally increasing gradually over 48 hours. Palliative/provocative/previous—None. Quality—Isolated unilateral weakness of facial muscles, including the muscles controlling eyelids and eyebrows. Radiation/region—One side of face. Severity—Mild, localized to one side of face. Timing—Gradual, increasing over 48 hours, then improving over six weeks. Associated—Loss of taste on afected side, pain behind ear on afected side may precede weakness by several days. to each side and note how the eyes track it. The eyes should track smoothly, without saccades (a jerking of the eyes), and should be able to move freely all the way to each side. Lack of ability to move the eyes to one side of the body is known as a gaze preference and is a sign of stroke. Once your finger reaches approximately 50 degrees, hold the position momentarily and observe for nystagmus. Repeat to the opposite side. To test for vertical nystagmus, hold your finger midline in front of the face as you slowly move it up and down, pausing momentarily to observe for nystagmus. Nystagmus causes uncontrolled repetitive rapid oscillation of the eye and is best seen on a lateral or vertical gaze. Nystagmus can be horizontal (side to side), vertical (up and down) or rotatory (circular). Assess for it in patients who complain of dizziness or an unsteady gait. Causes of nystagmus include peripheral vertigo, labyrinthitis (inflammation of the inner year), drugs (seizure medication, ben- zodiazepines), alcohol and head trauma. When the nystagmus is horizontal or rotary, it is more likely due to a benign condition. How- ever, vertical nystagmus can be an ominous sign of CNS pathology. Causes of saccades include drug ingestion, drowsiness, cerebellar disorders and degenerative disorders of the central nervous system (e.g., multiple sclerosis). Facial weakness, CN VII ( facial nerve)—To observe the facial muscles for symmetry, ask the patient to smile. Note any facial drooping. Next ask the patient to raise his or her eyebrows, and then tightly shut both eyes. Note any asymmetry. With each of these tests, look for subtle weakness by examining the depth of the wrinkles on each side of the face, including the nasolabial folds (the deep line going from the nostril to the lateral lip). Compare the depth and number of wrinkles on each side of the face. Similar to BOTOX injections, the affected side will have weakened/paralyzed muscles and fewer wrinkles. Cerebellar Function Assessing for cerebellar function can help identify less-common posterior circulation strokes.