Management of neurological emergencies

Chapter 10 Management of neurological emergencies






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 management1 (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


Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Management of neurological emergencies

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