Neurological Emergencies

Intracranial haemorrhage, seizures, ischemic stroke, and running a Code Stroke from recognition to tPA.

Neurological Emergencies

Intracranial Hemorrhage

• Bleeding occurs within the skull, either within the brain or in its surrounding structures. The blood places pressure on surrounding structures and increases ICP (Intracerebral Pressure). The increase in pressure irritates and reduces perfusion to the brain. If the bleeding is severe and ongoing, it places so much pressure on the brain that it can herniate (pops out of where its supposed to be) and critically reduces perfusion. o Causes can include head trauma, ruptured aneurysms, hypertension and use of anticoagulants. o These patients can present with severe sudden headaches, altered or comatose, nausea and vomiting, seizing (the blood and pressure irritate the brain), and with other neurological deficits such as weakness, numbness, coordination and vision issues. o There are different types of brain bleeds including Epidural, Subdural, Subarachnoid, and intracerebral hemorrhages. Epidural bleeding is from an artery (so it may continue expanding and be rapid onset). A subdural bleed is from a vein, so it may be slow in onset. A subarachnoid bleed is typically from a ruptured aneurysm. • Specifics of the workup o Point of care glucose: to rule out hypoglycemia as cause of symptoms o Head CT: This is the key workup as providers are able to clearly visualize the location and size of the bleeding. A non-contrast head CT will also help assess for other conditions that may cause similar symptoms and if nothing is found, it may prompt the providers to order additional testing such as a perfusion study o Coagulation: To help assess coagulopathies, and if present, providing reversal agents like Kcentra or FFP depending on cause. Reversing is important to prevent ongoing bleeding. o CBC: Ensure no abnormalities with platelets, or other issues like anemia or increased WBCs o BMP (Chemistry): helps assess for any abnormalities with electrolytes, kidney function and overall imbalances • Treatment o ABCs: If the patient is comatose or a rapidly decreasing GCS, intubation should be considered for airway protection o Blood Pressure Control: Goal is to maintain an SBP less than 140 ▪ Nicardipine Drip ▪ Labetalol Slow IV Push o Seizure Prophylaxis: Keppra (Levetiracetam) o Anticoagulant Reversal ▪ Depending on agent being reversed: Vitamin K, FFP, Kcentra, Platelets, Protamine Sulfate o If impending herniation ▪ Mannitol and Hypertonic Saline: helps draw fluid out of brain tissue, creating more space within the skull to lower ICP. Hypertonic saline is most commonly used. o Surgical Intervention ▪ Depending on the type of bleed, neurosurgery can drill a hole and evacuate the bleed/hematoma. Or even remove an entire section of the skull to alleviate the increase in pressure within the skull • Nursing o If neurosurgery will be placing a drain, have the drainage device ready ▪ Be prepared to go to CT immediately after to verify placement of drain ▪ Know how to zero and level the device, an ICP above 20 is critical, if up trending, also notify the team o Cerebral Perfusion Pressure (CPP): MAP - ICP. CPP should remain above 60. If not, communicate with the team to figure out interventions. ▪ To obtain ICP, neurosurgery will need to insert an intraventricular device (IVD) o A repeat head CT will be done 6 hours after to assess whether the bleed has gotten bigger or if it stayed the same o Closely monitor blood pressure and titrate nicardipine as directed. Notify the team if nicardipine is maxed out and BP is still not under control o Neuro assessments Q1 hour and or more frequent if needed

Seizures

• Uncontrolled/abnormal electrical activity within the brain that typically involves loss of consciousness and jerking-like movements. If prolonged seizure activity or multiple seizures in a short amount of time, damage to the brain can occur as a result of changes in blood flow and oxygenation combined with an increased metabolic demand. o There are different types of seizures and each can present differently. However, in the ER we will focus on seizures that present with jerking like movements, alterations in mentation and confusion. Patients also very commonly present with oral(tongue) trauma from accidentally biting it, and incontinence. During the seizure, patients will become tachycardic, so keep an eye on the cardiac monitor for sudden increases in heart rate as your patient could be having a seizure. o Causes can include underlying seizure disorders where the patient has not been taking their medications or there has been a change in them, hypoglycemia, hyponatremia, delirium tremens, brain bleeds, toxins and even brain infections. • Specifics of the workup o Point of Care Glucose Check: Rule out hypoglycemia as the cause o BMP (Chemistry): Assess electrolytes, such as sodium as hyponatremia can cause seizures. Helps also assess any other abnormalities present o CBC: Help determine if an infection is present if the wbcs are high (meningitis etc). I've also had patients in the past who had an underlying seizure disorder and seized as a result of their hgb being low o Urine Tox Screen: Assess for drugs that are uppers and promote seizure activity in those susceptible, drugs like cocaine and meth o Head CT: Especially useful in first time sz, to rule out a brain pathology like a tumor, to help rule out brain bleeds, brain abscesses and other conditions o EEG: Helps assess electrical abnormalities of the brain (like an ecg for the heart this is for the brain). Useful to determine if patient is continuously seizing, prompting more aggressive treatment and management o Lumbar Puncture: If rest of workup inconclusive, an LP may be useful for ruling out conditions like meningitis • Treatment o Active Seizure: Turn the patient onto their side and place oxygen. Notify your provider and prepare to give medications to help stop the seizure o Medications ▪ First line medications are benzodiazepines. Intramuscular Midazolam if not IV access is present. Intravenous Lorazepam if IV is present. IV Lorazepam is preferred as it will start to work fast and will have long lasting anti-seizure effects. However, if an IV is not present, IM Midazolam works faster to control a Sz compared to IM Lorazepam. ▪ Second line medications can include levetiracetam, phenytoin and valproic acid. Most commonly, levetiracetam (keppra) is used. It is given IV. • By this point, after giving a benzo and keppra, most seizures stop. ▪ If the seizure is ongoing or the patient continues to have additional seizures repeatedly, intubation may be considered in order to provider more aggressive treatment which can include medications like infusions of propofol and midazolam, as they both have antiseizure properties. Phenobarbital may also be used. o Treat the underlying cause! ▪ If it's as a result of hypoglycemia, give dextrose. If Its hyponatremia, give some hypertonic saline. If it's because the patient has not been taking their meds, give a loading dose. If it's a brain bleed, proceed down that pathway. If an infection, give antibiotics. Again, the important thing will be to treat the underlying cause of the sz, so keep that in mind while you are doing the interventions. • Nursing o If the patient came in confused (post ictal) continuously monitor and chart their progress. o Have seizure precautions in place. Padded side rails, gurney in lowest position, patient within nursing station view if possible. o Ask your provider ahead of time if the patient has another seizure, what medication and dose would they like to be administered. o Memorize the questions to ask for seizures (review guide to questioning)

Ischemic Stroke

• A blood clot blocks blood flow to a region of the brain and within minutes brain tissue can begin to die due to lack of oxygen, glucose and other substances. It is crucial to rapidly restore blood flow to prevent permanent brain damage o Symptoms can vary depending on the location of obstruction and how much of the brain is affected. Common symptoms will include unilateral numbness or weakness, facial droop, slurring or difficulty understanding speech, coordination issues, headaches and dizziness. • Specifics of the workup o The physical examination is the main key to recognizing a stroke. o Poc Glucose: to rule out hypoglycemia as the cause o Head CT: To rule out other causes of the patients symptoms, especially to rule out an intracranial hemorrhage. The head noncon CT needs to happen prior to the rest of radiological studies and any other interventions. o CT angiography and perfusion study: Using contrast, will be able to visualize arteries to locate where the occlusion is occurring o MRI: Will be useful to clearly see where there is damage in the brain. MRI's are specifically useful with wake up strokes, so we can assess whether there is any tissue left to be saved. If the tissue has died off and we give a thrombolytic, we can cause a brain bleed through the dead tissue o Coagulation Studies: To assess for coagulopathies that may be a contraindication to thrombolytics o CBC and BMP: To assess for any other abnormalities that may be present • Treatment o Thrombolytic administration within 4.5 hours of symptom onset and after head CT to rule out brain bleed ▪ Know absolute contraindications and relative contraindications ▪ Know what your facility uses whether TNK or TPA as they have different protocols for administration. o Endovascular Thrombectomy ▪ Interventional radiology will remove blood clot using a catheter/wire typically inserting through the groin ▪ Used when the blood clot is big as a thrombolytic may not be enough to fully break it down. ▪ Typically very useful within 4-6 hours, but may be done up to 24 hours if indicated based on the imaging o If patient does not meet criteria for Thrombolytic therapy or thrombectomy ▪ Permissive Hypertension: Allow the bp to go as high as 220/120 to help maintain perfusion to the area, hoping no additional brain tissue dies from lack of perfusion ▪ Physical Therapy, Occupational Therapy and Speech Therapy ▪ Prevent further strokes • Nursing o Memorize the symptoms of a stroke and activate the stroke protocol when necessary o Know the contraindications of thrombolytics o Thrombolytics should be administered within 4.5 hours of symptom onset o Know when the last seen normal was o Check a poc glucose first to rule out hypoglycemia o Place the IV in the AC or upper Forearm. 18 G is ideal for angiogram and perfusion study. At least two IV's prior to thrombolytic, the patient should not have anything invasive after due to risk of bleeding o Obtain a set of vitals early on as hypertension (above 180/110) is a contraindication for thrombolytics. An antihypertensive would need to be given such as Labetalol SIVP o Obtain an accurate patient weight as both TNK and TPA are weight based medications ▪ If you gave a thrombolytic, that patient would become a 1:1 patient o The risk for significant and deadly bleeding is always present. Closely monitor your patient and if they have a sudden decrease in mentation or change in status, notify your team. I've had several of my patients in the past develop an intracranial hemorrhage after thrombolytic administration

CODE STROKE

Code Stroke: Recognition and Early Action

As an ER nurse, it's essential to be familiar with your facility's stroke protocols—because when it comes to strokes, time is brain. Even a few minutes without cerebral perfusion can cause irreversible damage, so the faster a stroke is recognized, the sooner your patient can receive life-saving treatment. The general steps in a Code Stroke include: 1. Recognizing stroke-like symptoms 2. Activating a Code Stroke alert 3. Transporting the patient to CT 4. Implementing appropriate treatments and interventions

Recognizing a Stroke

Stroke recognition can happen in multiple ways:

1. EMS Notification (Prehospital Recognition)

If a stroke is identified in the field, EMS will often call ahead to notify the ER. This gives the team time to prepare and activate a Code Stroke in advance. You might hear an announcement like: "Code Stroke, Ambulance Bay. ETA 10 minutes."

2. In-Hospital Recognition

Strokes can also be identified by ER staff, especially at triage or anytime during the patient's stay. Recognition often starts with the nurse, which is why your awareness is key. Be aware that each facility has its own protocol: • Some require a provider to assess the patient first before a Code Stroke is activated. • Others encourage nurses to activate the stroke alert as soon as symptoms are identified. → Know your facility's policy, and when in doubt, ask your preceptor or charge nurse.

Common Stroke Symptoms

Be alert for: • Facial droop • Slurred speech or aphasia (difficulty speaking, understanding, or expressing language) • Unilateral weakness or numbness (face, arm, or leg) • Drift (inability to hold an arm or leg elevated for 10 seconds) • Sudden dizziness or loss of balance (especially in brainstem or cerebellar strokes) • Vision changes (e.g., blurred vision, loss of visual field) If your patient displays any of these symptoms, a Code Stroke may need to be activated. → If you're unsure, never hesitate to ask a provider or experienced nurse to assess the patient. It's better to be cautious than miss a stroke. While you're learning, your preceptor should always be with you to help guide these decisions safely.

After Code Stroke Activation: What Happens Before CT

Once a Code Stroke is activated, the most critical next step is getting the patient to CT—but a lot needs to happen in the short window between recognition and imaging.

Key Personnel Involved

The following team members should respond promptly: • ER Provider • Neurology • ER Nurses • Radiology/CT Techs – CT must prioritize this patient immediately

Initial Actions (Happening Simultaneously)

• Address the ABCs: Just like with any patient, airway, breathing, and circulation must be addressed. o If the patient is altered with a GCS ≤ 8 and unable to protect their airway, they must be intubated before going to CT. • Check a blood sugar immediately: This should be one of your top priorities, as hypoglycemia can mimic stroke symptoms. You never want to be the nurse who gave tPA without ruling out low blood sugar—that's a major error. • Hook the patient up to a portable monitor: You need a full set of vitals, especially blood pressure, which plays a critical role in stroke management and tPA eligibility. • Call CT to confirm readiness: CT needs to know a Code Stroke is en route so they can clear the scanner and prepare for immediate imaging.

Neurological Assessment & Timeline Questions

• Begin your NIH Stroke Scale (NIHSS) assessment. o This standardized tool quantifies stroke severity—higher scores indicate more significant deficits. o If you're not yet NIHSS certified, it's highly recommended—learn it and get certified. • Ask about last known well (LKW): o This is one of the most important questions for stroke care. o Ask the patient, family, or EMS: "When was the patient last seen normal?" o If the patient woke up with symptoms, the LKW is the time they went to sleep. o tPA can only be given within 4.5 hours of symptom onset, so knowing the exact time is crucial.

During Transport to CT

As you head to CT, continue multitasking: • Confirm blood sugar has been checked • Monitor vital signs continuously • Continue neuro assessment and NIHSS • Gather more of the patient's history, including: o Medical history o Medication use o Allergies, especially contrast dye allergies If the patient was intubated, it should have been completed before leaving for CT. If time allows: • Establish an IV and draw initial labs • If an IV isn't placed yet, one can usually be inserted between the non-contrast head CT and the CTA

CT Imaging and Ischemic Stroke Treatment Pathways

Once your patient arrives at CT, the first scan performed will be a non-contrast head CT. This is used to determine whether the stroke is ischemic or hemorrhagic. Key Point: Up until this step, the process is the same for both hemorrhagic and ischemic strokes.

CT Angiogram (CTA)

If the non-contrast CT rules out a hemorrhagic stroke, the next step is a CT Angiogram (CTA). During this scan: • Contrast dye is injected to visualize the blood vessels in the brain • The goal is to identify whether there is a blockage, and more importantly, where it is If a large vessel occlusion (LVO) is found, the patient may be a candidate for a mechanical thrombectomy—a procedure where interventional radiology removes the clot by threading a catheter, usually from the femoral artery. IV Access Tip: Place an 18-gauge IV, preferably in the AC, or at minimum, in the forearm—this is required for contrast administration during the CTA You can also draw initial labs at this time Ischemic Stroke Treatments: TPA and Thrombectomy 1. Thrombectomy • Mechanical removal of a large clot via catheter • Window of eligibility: up to 24 hours from last known well (LKW) • Most facilities call a Code Stroke for patients within 24 hours of symptom onset to evaluate for thrombectomy

Know your facility's protocol

2. tPA (Tissue Plasminogen Activator) • A clot-busting medication • Must be given within 4.5 hours of LKW • Has strict inclusion/exclusion criteria

Nursing Responsibilities for tPA

If your patient is being considered for tPA, here's what you need to do: • Review contraindications: You're the one administering tPA—make sure the patient meets criteria • Verify consent: This is the provider's responsibility, but you must ensure it happens • Prepare at least two IVs before administration—no poking after tPA is given • Obtain accurate weight, as tPA dosing is weight-based • Send labs, especially coagulation studies • Have a second nurse verify the dose with you • Be ready to give blood pressure medications to meet eligibility thresholds • Know that tPA patients are 1:1—this becomes your only patient due to the level of monitoring required Reminder: tPA carries serious risks, including intracranial bleeding. Make sure the patient and/or family understands the risks, and that this is documented through informed consent.

Updated 2 Sep 2026