Emergency Medicine

ACUTE NEUROLOGICAL CONDITIONS

96 General Medical Emergencies

(b) subarachnoid haemorrhage from ruptured berry aneurysm or

arteriovenous malformation.

2 Presentation may give a clue to aetiology:

(i) Cerebral thrombosis is often preceded by a TIA and the

neurological deficit usually progresses gradually. Headache and

loss of consciousness are uncommon.

(ii) Cerebral embolism causes a sudden, complete neurological

deficit.

(iii) Intracerebral haemorrhage causes sudden onset of headache,

vomiting, stupor or coma with a rapidly progressive neurological

deficit.

(iv) Subarachnoid haemorrhage is heralded by:

(a) sudden, severe ‘worst headache ever’, sometimes following

exertion, associated with meningism, i.e. stiff neck,

photophobia, vomiting and Kernig’s sign (see p. 99)

(b) confusion or lethargy, which are common, or focal

neurological deficit and coma, which are rare and serious.

3 Record the vital signs, including the temperature, pulse, blood pressure,

respiratory rate and GCS score (see p. 30).

4 Perform a full neurological examination, recording any progression of

symptoms and signs.

5 Gain i.v. access and send blood for FBC, ESR, coagulation profile, ELFTs and

blood sugar. Attach a cardiac monitor and pulse oximeter to the patient, and

catheterize the bladder.

6 Obtain an ECG and CXR, and arrange an urgent CT head scan.

(i) This CT scan may initially be normal with a cerebral infarct.

MANAGEMENT

1 This is essentially supportive. Make certain a bedside blood glucose test strip

has been done and give 50% dextrose 50 mL i.v. if it is low.

2 If the patient is unconscious:

(i) Open the airway by tilting the head and lifting the chin, insert an

oropharyngeal airway, give high-dose oxygen via a face mask and

pass a nasogastric tube (NGT).

(ii) Place the patient in the left lateral position. Get a senior ED

doctor help.

(iii) Consider endotracheal intubation if there is respiratory depression,

deteriorating neurological status and/or signs of raised intracranial

pressure. Discuss this with the intensive care team.

3 Otherwise, commence oxygen, and aim for an oxygen saturation above 94%.

4 Keep nil by mouth (NBM) until a swallowing assessment is completed

within the first 24 h.