Management of neurological emergencies

Published on 10/02/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 1613 times

Chapter 10 Management of neurological emergencies

Carole Gavin, James Gray

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.

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 management ¹ (Box 10.3).

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).

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).

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: This is important to distinguish the types of recurrent headache. Migraine often shows a regular pattern of recurrence, while frequent headaches in a short period of time followed by a long, sometimes years, period of remission may indicate cluster headaches. Tension headache has no particular pattern and is often at a background level constantly.

Time of onset: Migraine often causes the patient to wake whilst cluster headaches often occur at certain times. More serious causes have no specific time pattern.

Mode of onset: Migraine often has precipitants ranging from an aura (usually visual but may include other focal neurological symptoms), to a feeling of something wrong. Sudden onset or thunderclap headache is suspicious of conditions such as subarachnoid haemorrhage.

Site: Migraine, cluster headache and trigeminal neuralgia are commonly unilateral whilst tension headache feels like a tight band around the entire head. Subarachnoid haemorrhage can start locally but usually is generalised and may spread to the neck.

Quality: Headache can be constant, pulsatile or stabbing.

Associated symptoms: Migraine can commonly give gastrointestinal symptoms, photophobia suggests migraine, meningitis or subarachnoid haemorrhage. Neurological symptoms can occur with migraine but suspicion should be raised about intracranial pathology.

Precipitating and aggravating factors: Are there any specific triggers the patient can identify? Specific foods, classically chocolate and cheese, can trigger migraine. Aggravation by head movement or coughing/straining suggests raised intracranial pressure.

Relieving factors: Patients with a migraine often prefer to lie down in a darkened room whilst patients with cluster headache prefer to move about.

It is important to complete the history with a thorough assessment of the patient’s general health and wellbeing including smoking, alcohol and family history.

Objective assessment

Examination of the patient with headache should include a general examination as well as a detailed neurological exam (Box 10.6).

General systems examination: As numerous systemic problems can contribute to headache a full examination is important and may pick up rarer conditions such as endocrine disorders or Marfan’s syndrome.

Mental state/alertness: Depressive affect may be apparent, which is a risk for chronic headache conditions. Drowsiness or confusion suggest intracranial pathology or infection.

Speech: Speech disturbance can occur in migraine but a stroke must also be considered.

Skull: In infants the key finding to look for is a bulging fontanelle, which might indicate intracranial pathology. In adults, especially older, palpation of the temporal arteries may reveal evidence of arteritis. Look for evidence of head injury.

Neck and other tests: Neck stiffness usually indicates meningeal irritation from infection or blood. Kernig’s and Bradzinski’s sign are useful tests for evidence of meningitis.

Eyes: Evidence of glaucoma should be sought as this can present with headache. Fundoscopy should be performed to look for papilloedema or optic atrophy. The cranial nerves controlling eye movements and visual fields can also be tested at this time.

ENT: It is important to ask about loss of smell and examine the ears for any obvious pathology such as otitis media. Many upper respiratory tract infections have a mild headache as part of their presentation and the throat should be examined for signs of tonsillitis.

General neurological: A full generalised neurological examination should be performed in order to finish the patient assessment.

Box 10.6 Objective assessment of headache

General systems examination

Mental state/alertness

The cause of most headaches will be clear from the history and examination may add little to the differential diagnosis. Box 10.7 gives the common differential diagnosis of headache. In general, all headaches of acute sudden onset will require immediate investigation in secondary care. The subacute causes of headache will require urgent investigation, either immediately if severe enough or in an urgent outpatient assessment.

Plan and communication

Suspected meningitis, subarachnoid haemorrhage

If the patient has sudden onset of severe headache then they will require immediate secondary care assessment to rule out a sinister cause such as subarachnoid haemorrhage.

If meningitis is suspected then immediate treatment with benzylpenicillin is warranted unless there is a clear history of immediate anaphylactic reaction following administration previously (Fig. 10.1).

Fig. 10.1 Treatment of suspected meningitis in the community

In the case of headaches of subacute onset the history and examination should point toward the likely diagnosis. If a space occupying lesion is suspected then an urgent neurosurgical consultation is required and consultation with the patient’s general practitioner should allow a 2-week wait consult to be arranged.

If migraine is suspected then treatment can be started with a non- steroidal anti-inflammatory medication such as diclofenac along with an anti-emetic such as metoclopramide or, if this has been tried and is unsuccessful, a triptan (e.g. sumatriptan) may be given if the patient is less than 65 years old and has no history of heart disease or hypertension.⁴

If the cause of the headache is not thought to be sinister, reassurance, simple analgesia and referral back to the patient’s general practitioner may well be all that is required. In doing so it is important that a communication is made with the GP to alert them to the findings on this occasion so any change at follow-up can be ascertained.

Temporal arteritis

The one other condition to be cautious of is temporal arteritis, which can often present as a headache of unclear cause in patients over 55 years of age. Untreated it can lead to blindness. If suspected on examination then urgent communication of this suspicion with the GP is required to arrange urgent investigation and treatment.

Transient ischaemic attack and stroke

Transient ischaemic attack (TIA) is a clinical syndrome characterised by an acute loss of focal cerebral or ocular function with symptoms lasting less than 24 hours. It is thought to be due to inadequate blood supply to these areas as a result of low flow, thrombosis, or embolism associated with diseases of the blood vessels, heart or blood.

The main concern with TIA is it is associated with very high risk of stroke in the first month following the event and up to one year after. It affects around 35 people per 100 000 per year.

Acute stroke (CVA) is defined as a clinical syndrome, of presumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral function lasting more than 24 hours or leading to death.

Studies put its incidence at 174–216 per 100 000 of the UK population annually and it accounts for 11% of all deaths in England and Wales.⁵ Approximately 85% of strokes are due to ischaemia and 15% are due to haemorrhage.

The Intercollegiate Stroke Working Party has set out guidelines for the acute management of stroke and TIA ⁶ which are used as the basis for this text.

Subjective and objective assessment

History and examination help define if the symptoms are consistent with a focal neurological deficit from brain ischaemia. Symptoms are more usually negative, e.g. loss of function, rather than positive, e.g. tingling or involuntary movements. Non-focal signs and symptoms such as loss of consciousness, dizziness, weakness, confusion and incontinence are rarely due to a TIA.⁷

The most sensitive features associated with diagnosing stroke are facial weakness, arm weakness and speech disturbance, with 80% of strokes demonstrating these three features (the FAST assessment – Box 10.8).⁸

Box 10.8 The FAST assessment

Facial weakness

Arm weakness

Speech Test

Most areas will have a local protocol for the management of TIA in the acute stages. The difficulty can be distinguishing stroke and TIA in the early stages and unless the patient is clearly recovering hospital assessment is required (Box 10.9). If the patient has recovered then assessment and investigation should be arranged in a specialist clinic, usually within 7 days. In the meantime it is advised that patients have an anti-platelet commenced, with the evidence favouring aspirin 300 mg immediately followed by 75 mg daily due to the increased risk of stroke in the first few days post TIA. If the patient has recurrent episodes of TIA then the regimen should be changed in line with best practice which would generally recommend the addition of dipyridamole.^10,¹¹ If there is a second TIA within 7 days then the patient requires hospital admission.