Acute Neurological Conditions

General Medical Emergencies 87

(iii) Control seizures with midazolam 0.05–0.1 mg/kg up to 10 mg

i.v., or diazepam 0.1–0.2 mg/kg up to 20 mg i.v., or lorazepam

0.07 mg/kg up to 4 mg i.v., after excluding hypoglycaemia.

(iv) Refer the patient to the medical team.

2 Delirium tremens
(i) This is uncommon, occurring 72 h after abstinence. There is
clouding of consciousness, terrifying visual hallucinations, gross
tremor, autonomic hyperactivity with tachycardia and cardiac
arrhythmias, dilated pupils, fever, sweating, dehydration, and
grand mal seizures that may be prolonged (status epilepticus).
(ii) Delirium tremens is a medical emergency
(a) control seizures with midazolam, diazepam or lorazepam i.v.
(see doses above)
(b) exclude other causes of status epilepticus such as head injury
and meningitis (see p. 91).
(iii) Replace fluid and electrolyte losses, avoiding excessive normal
saline in liver failure. Give thiamine 100 mg i.v. once daily.
(iv) Refer all patients immediately to the ICU.

ACUTE NEUROLOGICAL CONDITIONS

The following neurological conditions frequently present to the ED:
● Syncope (faint)
● Seizure (fit)
● Generalized convulsive status epilepticus
● TIA
● Stroke.
Headache is covered separately on page 97.

Syncope

DIAGNOSIS

1 Syncope or ‘faint’ is a sudden, transient loss of consciousness and postural tone
due to reduced cerebral perfusion, with subsequent spontaneous recovery.
(i) A brief tonic-clonic seizure may follow if cerebral perfusion
remains impaired.

Warning: never dispense a benzodiazepine supply or chlormethiazole

(clomethiazole) capsules in the ED to take home. They are reserved for

inpatient detoxification programmes only.

!