Neurological Emergencies: Stroke, Increased ICP, Seizures

Neurological Emergencies: Stroke, Increased ICP, Seizures

A Practical Guide for Nurses & Clinicians

What Is This?

Neurological emergencies—stroke, increased intracranial pressure (ICP), and seizures—are life-threatening conditions requiring rapid assessment and intervention. This guide provides a high-yield, actionable framework for recognizing, stabilizing, and managing these emergencies in clinical settings.

Why use it today? Neurological emergencies account for 1 in 10 deaths worldwide and are a leading cause of disability. Early recognition and intervention can preserve brain function, reduce mortality, and improve outcomes—but delays cost lives.

Why It Matters

• Stroke: Every 40 seconds, someone in the U.S. has a stroke; 1 in 4 strokes occurs in people who’ve had one before.
• Increased ICP: Can lead to brain herniation (fatal in minutes) if untreated.
• Seizures: 1 in 10 people will have a seizure in their lifetime; status epilepticus (seizures >5 min) has a 20% mortality rate.
• Time = Brain: For stroke, every minute of delay costs 1.9 million neurons.

Core Concepts

1. Stroke: FAST & Beyond

• Ischemic Stroke (87% of cases): Blocked artery-brain tissue dies from lack of oxygen.
• Hemorrhagic Stroke (13%): Bleeding into/around the brain-mass effect + ICP.
• Transient Ischemic Attack (TIA): "Mini-stroke" with no permanent damage but high risk of full stroke (10% in 90 days).
• FAST (Face, Arm, Speech, Time):
• Face drooping (ask to smile)
• Arm weakness (ask to raise both arms)
• Speech difficulty (ask to repeat a phrase)
• Time to call 911 (or activate stroke protocol)

2. Increased Intracranial Pressure (ICP)

• Monro-Kellie Doctrine: The skull is a fixed space—brain (80%), blood (10%), CSF (10%). If one increases, others must decrease or ICP rises.
• Cushing’s Triad (Late Sign of Herniation):
• Hypertension (widened pulse pressure)
• Bradycardia
• Irregular respirations (Cheyne-Stokes)
• Early Signs:
• Headache, nausea/vomiting, altered mental status (AMS)
• Papilledema (swollen optic disc on fundoscopy)
• Late Signs:
• Posturing (decorticate/decerebrate)
• Fixed/dilated pupils (CN III compression)
• Herniation-death

3. Seizures & Status Epilepticus

• Seizure Types:
• Focal (partial): One brain region (e.g., arm twitching, déjà vu).
• Generalized: Whole brain (e.g., tonic-clonic, absence).
• Status Epilepticus (SE):
• Seizure >5 min OR ?2 seizures without recovery between.
• Medical emergency-hypoxia, brain damage, death.
• Causes:
• Metabolic (hypoglycemia, hyponatremia)
• Structural (tumor, stroke, trauma)
• Infectious (meningitis, encephalitis)
• Toxic (drugs, alcohol withdrawal)

How It Works (Clinical Pathways)

1. Stroke Workflow

1. Recognize (FAST)-Activate Stroke Alert
2. Last Known Well (LKW) Time (critical for tPA eligibility: <4.5 hours for most patients).
3. Imaging:
4. Non-contrast CT head (rule out hemorrhage).
5. CTA/MRA (if large vessel occlusion suspected).
6. Treatment:
7. Ischemic Stroke:
   • tPA (alteplase) if <4.5 hours from LKW.
   • Mechanical thrombectomy if large vessel occlusion (LVO) and <24 hours from LKW.
8. Hemorrhagic Stroke:
   • BP control (SBP <140 mmHg).
   • Reverse anticoagulation (if applicable).
   • Neurosurgery consult (for evacuation if needed).

2. Increased ICP Management

1. Assess (GCS, pupils, vitals, imaging).
2. Immediate Interventions:
3. Elevate HOB 30° (improves venous drainage).
4. Hyperventilate (temporary) (PaCO? 30–35 mmHg-cerebral vasoconstriction).
5. Mannitol (0.25–1 g/kg IV) or hypertonic saline (3% NaCl) (osmotic diuresis).
6. Avoid hypotonic fluids (D5W, 0.45% NS-worsens edema).
7. Definitive Treatment:
8. Neurosurgical decompression (craniectomy, EVD placement).
9. Treat underlying cause (tumor, hemorrhage, hydrocephalus).

3. Seizure & Status Epilepticus Protocol

1. Stabilize (ABCs):
2. Airway: Position (recovery position), suction, O?.
3. Breathing: Monitor SpO?, intubate if needed.
4. Circulation: IV access, check glucose.
5. First-Line Meds (Benzodiazepines):
6. Lorazepam (0.1 mg/kg IV, max 4 mg) OR
7. Midazolam (10 mg IM if no IV access).
8. Second-Line (If Seizure Persists):
9. Fosphenytoin (20 mg PE/kg IV) OR
10. Valproate (40 mg/kg IV) OR
11. Levetiracetam (60 mg/kg IV).
12. Refractory SE (Seizure >30 min):
13. Intubate + continuous EEG monitoring.
14. Propofol, midazolam, or pentobarbital infusion.

Hands-On / Getting Started

Prerequisites

• Knowledge: Basic neuroanatomy, GCS scoring, NIH Stroke Scale (NIHSS).
• Equipment: IV access, O?, suction, glucometer, BP cuff, CT scanner (for stroke).
• Medications: tPA, mannitol, benzodiazepines, antiepileptics.

Step-by-Step: Stroke Code Simulation

Scenario: 65M presents with right-sided weakness and slurred speech (LKW 1 hour ago).

1. Assess (FAST):
2. Face: Right side droops when smiling.
3. Arm: Right arm drifts downward.
4. Speech: "You can’t teach an old dog new tricks"-slurred.
5. Time: Activate stroke alert.
6. Vitals & Labs:
7. BP: 180/100 mmHg (do not aggressively lower—permissive hypertension for tPA).
8. Glucose: 120 mg/dL (rule out hypoglycemia).
9. CT head: No hemorrhage-proceed to tPA.
10. Administer tPA:
11. Dose: 0.9 mg/kg (max 90 mg).
12. 10% as bolus over 1 min, remainder over 1 hour.
13. Monitor:
14. Neuro checks q15min x2h, q30min x6h, q1h x16h.
15. Avoid anticoagulants/antiplatelets for 24h.
16. CT if worsening (risk of hemorrhage).

Expected Outcome: - Improved NIHSS score (e.g., from 12-4). - No tPA complications (e.g., intracranial hemorrhage).

Common Pitfalls & Mistakes

Best Practices

Stroke

• Door-to-needle time <60 min for tPA.
• Door-to-puncture time <90 min for thrombectomy.
• Avoid aggressive BP lowering (SBP <185 for tPA, <140 for hemorrhage).

Increased ICP

• Keep head midline (avoid jugular compression).
• Avoid hyperthermia (fever worsens ICP).
• Monitor for DI/SIADH (common post-TBI).

Seizures

• Check glucose first (hypoglycemia mimics seizures).
• Do not restrain (risk of injury).
• Time the seizure (status epilepticus = >5 min).

Tools & Frameworks

Real-World Use Cases

1. EMS: Prehospital Stroke Recognition

• Scenario: Paramedics use FAST + LAMS (Los Angeles Motor Scale) to triage stroke.
• Action: If LVO suspected (LAMS ?4), divert to thrombectomy-capable center.

2. ED: Rapid ICP Management

• Scenario: 25M with TBI, GCS 6, fixed/dilated pupil.
• Action:
• Intubate, hyperventilate, mannitol, neurosurgery consult.
• CT shows subdural hematoma-craniectomy.

3. ICU: Refractory Status Epilepticus

• Scenario: 45F with seizures >30 min despite lorazepam + fosphenytoin.
• Action:
• Intubate, propofol infusion, continuous EEG.
• MRI to rule out structural cause (e.g., tumor).

Check Your Understanding (MCQs)

Question 1

A 72M presents with left-sided weakness and aphasia (LKW 2 hours ago). CT head is negative for hemorrhage. BP is 190/110 mmHg. What is the next best step?

A. Administer tPA immediately. B. Lower BP to <185/110 mmHg before tPA. C. Give aspirin 325 mg PO. D. Obtain MRI before treatment.

Correct Answer: B Explanation: tPA requires SBP <185 mmHg to reduce hemorrhage risk. Lower BP first (e.g., labetalol 10–20 mg IV), then give tPA. Why the Distractors Are Tempting: - A: tPA is correct after BP control. - C: Aspirin is contraindicated in the first 24h post-tPA. - D: MRI is not needed for tPA decision (CT is sufficient).

Question 2

A 30F with TBI develops Cushing’s Triad (BP 220/120, HR 40, irregular respirations). What is the most likely cause?

A. Hypovolemic shock B. Brain herniation C. Sepsis D. Opioid overdose

Correct Answer: B Explanation: Cushing’s Triad = late sign of increased ICP-brain herniation. Why the Distractors Are Tempting: - A: Hypovolemia causes tachycardia + hypotension (opposite of Cushing’s). - C: Sepsis causes tachycardia + hypotension (not bradycardia). - D: Opioids cause bradypnea + hypotension (not hypertension).

Question 3

A 50M with alcohol withdrawal has a tonic-clonic seizure lasting 6 minutes. He is postictal but breathing spontaneously. What is the next priority?

A. Administer lorazepam 4 mg IV. B. Check glucose and electrolytes. C. Intubate immediately. D. Start phenytoin infusion.

Correct Answer: B Explanation: Hypoglycemia and electrolyte imbalances (e.g., hyponatremia) are common causes of seizures in alcohol withdrawal. Treat the underlying cause first. Why the Distractors Are Tempting: - A: Benzos are second-line (after correcting metabolic causes). - C: Intubation is not needed if breathing is adequate. - D: Phenytoin is third-line (after benzos + correcting metabolic issues).

Learning Path

Further Resources

• Books:
• Adams and Victor’s Principles of Neurology (Ropper)
• The NeuroICU Book (Suarez)
• Courses:
• ENLS (Emergency Neurological Life Support) – neurocriticalcare.org
• AHA Stroke Certification – heart.org
• Tools:
• NIHSS Calculator – mdcalc.com
• GCS App – [iOS/Android]

30-Second Cheat Sheet

1. Stroke = FAST + LKW time-tPA if <4.5h, thrombectomy if LVO.
2. Increased ICP = Cushing’s Triad (HTN, bradycardia, irregular respirations)-elevate HOB, mannitol, avoid hypotonic fluids.
3. Seizure >5 min = status epilepticus-lorazepam-fosphenytoin-propofol.
4. GCS <8 = intubate.
5. Never give tPA without a CT.

Related Topics

1. Traumatic Brain Injury (TBI) – Concussion, diffuse axonal injury, ICP management.
2. Neuroimaging (CT/MRI) – How to read head CTs for stroke, hemorrhage, herniation.
3. Neurocritical Care – Vasospasm, SAH, brain death determination.