Chapter 10 Management of neurological emergencies
Introduction
Neurological emergencies are common but require careful assessment to avoid the pitfalls of missing a serious diagnosis, for example headache presents a particular diagnostic challenge, to avoid missing the one subarachnoid haemorrhage amongst the other benign headaches. This chapter discusses the main neurological conditions and outlines assessment and management based upon current best guidance (Box 10.1).
The primary survey positive patient
The unconscious patient
Ensure the airway is clear and minimise the risk of aspiration by nursing the patient on their side. Give oxygen (15 litres via a non-rebreathing mask) and establish IV access if possible. Transfer to definitive care. Check the blood glucose and assess the Glasgow Coma Score (GCS; Box 10.2). Hypoglycaemia will respond either to 10% glucose IV or IM glucagon administration.
Box 10.2 Glasgow Coma Score
Maximum score = 15, Minimum score = 3
A patient is defined as unconscious with scores ≤8
Poisoning and overdose are an important cause of unconsciousness. This is covered more fully in Chapter 14; however it is important that the patient is examined for evidence of IV drug use which might respond to naloxone therapy.
The fitting patient
The fitting patient can provide a significant challenge to the practitioner and attempts should be made to stop the fitting and assess further as required. The National Institute for Health and Clinical Excellence (NICE) has published guidance on fit management1 (Box 10.3).
Box 10.3 NICE guidance on fit management
If convulsive seizures lasting 5 minutes or longer or three or more seizures in an hour:
Always measure the blood sugar to exclude a hypoglycaemic episode.
Febrile seizures are any seizure occurring in an infant or young child (6 months to 5 years of age) with a fever, or history of recent fever, and without previous evidence of an afebrile seizure or underlying cause. These occur in between 2–4% of all children at some point and a positive family history occurs in up to 40%.2 They can often recur and parental education on treatment can decrease attendance at A&E.
Dealing with these cases can be difficult as parents are often very upset and frightened by the event, requiring a calm and reassuring approach by the healthcare professional. Most children have ceased fitting on arrival and benzodiazepines should be reserved for prolonged seizures – a useful guide is if the child is still fitting on the arrival of assistance. Parents should receive advice regarding febrile seizures after any episode (Box 10.4).
Headache
The assessment of the patient with headache is difficult even for the most experienced clinician. Headache lends itself very well to assessment via the SOAPC system as by following a careful assessment process an accurate evaluation can be made.3
Subjective assessment
The history is often the most important factor in headache assessment with all information assisting in the final evaluation and decision-making (Box 10.5).
Headache history: The patient who has had regular headaches for many years is more likely to have a migrainous or tension type headache, while the acute onset of headache in a patient who has never had similar previously may indicate serious pathology such as a subarachnoid haemorrhage. In between is the grey area, which is more difficult to interpret accurately, and must trigger caution.
Frequency and duration
Related posts:
Childhood illness – assessment and management of primary survey negative children
The ill child – assessment and identification of primary survey positive children
Introduction, summary, the system of care
The assessment and care of musculoskeletal problems
The system of assessment and care of the primary survey positive patient
Abdominal pain, abdominal pain in women, complications of pregnancy and labour
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