Management of neurological emergencies

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Chapter 10 Management of neurological emergencies

Carole Gavin, James Gray

Introduction 159
The primary survey positive patient 160
The unconscious patient 160
The fitting patient 160
Headache 162
Subjective assessment 162
Objective assessment 164
Analysis 165
Plan and communication 165
Transient ischaemic attack and stroke 167
Subjective and objective assessment 167
Summary 169

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).

Box 10.1 Conditions covered in this chapter

image The primary survey positive patient
image Fitting – including febrile convulsion
image Headache
image Stroke – including transient ischaemic attacks (TIA)

The primary survey positive patient

The two main problems causing a positive primary survey are the unconscious patient and the fitting patient.

The unconscious patient

It is very difficult to make an accurate neurological assessment of the unconscious patient and these patients will need a full hospital assessment. Call for back up to assist in initial management and transfer.

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

Eye response

4 – open spontaneously

3 – open to command

2 – open to pain

1 – no eye opening

Verbal response

5 – fluent and orientated

4 – confused speech

3 – inappropriate words

2 – incomprehensible sounds

1 – no verbal response

Motor response

6 – obeys commands

5 – localises to pain

4 – withdraws from pain

3 – flexion to pain

2 – extension to pain

1 – no motor response

When communicating the GCS to secondary care it can be very usefully broken down into its separate components to give a clear impression of neurological status.

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:

image Secure the airway
image Assess respiratory and cardiac function
image Give rectal diazepam in most cases, with buccal midazolam an alternative
image Call emergency services if required by the situation or the response to treatment, and particularly if:

image seizures develop into status epilepticus
image there is a high risk of recurrence
image this is the first episode
image there may be difficulties monitoring the person’s condition

Airway management in the fitting patient can be difficult. A nasopharyngeal airway can help provide an airway as oropharyngeal airways may be difficult to use due to jaw spasm. Often parents or carers of patients with frequent fits may already have used rectal diazepam.

Always measure the blood sugar to exclude a hypoglycaemic episode.

If a patient who is a known epileptic has made a full recovery and there is no evidence of injury (to head/shoulder/back), it may be possible to leave them at home if they have suitable home support and there is no evidence that the fits are becoming more frequent or associated with another illness. In general all unconscious patients except those who are known to be epileptic, are fully recovered and have a carer at home.

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).

Box 10.4 Advice to parents following a febrile convulsion

image A febrile convulsion is due to a fever causing your child to become too hot
image Febrile convulsions are common, generally harmless and do not indicate epilepsy or cause brain damage
image They often occur in the first 24 hours of a febrile illness but if they recur the child should be re-evaluated
image They generally last less than 1 minute but can last longer
image Simple treatment includes lying your child on its back, removing clothing and sponging with tepid water to cool the child down
image Do not place anything in the child’s mouth
image They can recur with further febrile illness
image If the seizure is lasting more than 5 minutes ring 999 for immediate assistance

If the episode is a recurrence and the parents are happy and confident in the management of the patient then treatment can be as above at home, with instructions to ring for help if a seizure becomes prolonged.

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).

image 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.
image Frequency and duration

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