Emergency Medicine

ACUTE NEUROLOGICAL CONDITIONS

General Medical Emergencies 89

(vi) Vasovagal (neurocardiogenic) – ‘simple’ faint, triggered by heat,

pain or emotion. Do not diagnose if over 45 years old, but look

first for the more sinister causes above.

(vii) Hypoglycaemia (relative).

4 Examine all patients carefully, looking for hypotension (including postural), a
cardiac lesion, an abdominal mass or tenderness, and focal neurological signs.

5 Check the blood glucose test strip for hypoglycaemia, and perform an ECG.

6 Request other investigations only as indicated clinically such as FBC, U&Es,
cardiac biomarkers, pregnancy test, CXR and CT scan.

MANAGEMENT

1 Refer the patient to the medical (or surgical) team for admission if a serious
cause is possible, particularly a patient aged over 75 years. Be sure to admit
patients with any one or more of:
(i) History of congestive heart failure.
(ii) Shortness of breath.
(iii) Triage systolic BP <90 mmHg.
(iv) Abnormal ECG.
(v) Haematocrit <30%.

2 Refer other patients with no clear inciting history, a normal examination and
a normal ECG for outpatient follow-up if no immediately life-threatening
cause for syncope is found.
(i) A 24-hour ambulatory ECG (Holter monitor) may help,
particularly in unexplained recurrent syncope.

3 Inform the GP by fax or letter if the patient is discharged and arrange early
follow-up.

Seizure (Fit)

DIAGNOSIS

1 An eye-witness account is essential to establish the correct diagnosis. Helpful
indicators of an epileptic seizure having occurred, rather than a faint, a fall
or an episode of vertigo are:
(i) Preceding aura, or proceeding drowsiness.
(ii) Bitten tongue, urinary incontinence.
(iii) Known seizure disorder.

2 The most common causes of a seizure in a known epileptic are:
(i) Not taking their medication, or rarely medication toxicity.
(ii) Alcohol abuse, either excess or withdrawal.
(iii) Intercurrent infection (remember meningitis).
(iv) Head injury.
(v) Hypoglycaemia.