Neurological Emergencies

This is a page devoted to common neurological emergencies encountered in both hospital and office settings. You should be able to identify, diagnose, and begin to treat some of the conditions which you will find here, while rousing up the help. Many of these conditions have other algorithms for treatment which may vary from the ones below, but learn one and modify it with your experience.

Coma

You are called to the ER to see a patient "who is unresponsive." When you get there, the EMTs say they had a call for a man who was "laying on the sidewalk." When they got there, he would neither speak nor move.

This 30's looking man just got transferred onto a cart in your ER. He is clearly comatose.

What do yo do now?

Take a moment, think about it (by the way, "take a moment and think about it" precede everything else in an emergency algorithm), and write down your actions in order.

Algorithm

Status epilepticus

You are called to the ER to see a 40's woman who was brought in by the EMTs after "having a seizure" in a grocery store. The EMTs say she was seizing 10 min ago when they got there, and has continued to seize in the ambulance. As she is transferred to the ER cart, you notice that she is still having generalized tonic clonic seizures.

What is status epilepticus?

What do you do? Take a minute, think about it, then write down the actions you would take in order.

Algorithm.

Subarachnoid hemorrhage

You are called to the ER (getting monotonous? wait till you're sleep deprived...) to see a 45 YO man who screamed, grabbed his head, then collapsed. By the time the ambulance arrived, he awakened, but now complains of a terrible headache, nausea, and says the light bothers his eyes. He refuses to turn his head or touch his chin to his chest because it makes his head and neck hurt too much. He has no past medical history to speak of. He repeats that this is the worst headache of his life, then vomits all over your nice new shoes (shoulda worn shoe covers...).

What is going on?

How do you make sure?

So what do you do now?

Pituitary apoplexy

You are called to the ER to see a 45 YO man who screamed, grabbed his head, then collapsed. Sound familiar? Read on...

Physical exam shows him to be awake, complaining of severe headache. He says that he can't see you very well, and you notice that he has no light perception in his right eye, and hand-wave in his left eye. He also has markedly dysconjugate eyes which resolve into bilateral third nerve palsies with a sixth nerve on the left.

The nurse says "I'm glad you're here: his blood pressure is 60/zip." You have her repeat it and it comes back at 60/nothing. This man is sick. He is trying to check out. You need to do something, but what?

What is going on?

How does it differ from the previous case (what in history, what in physical)?

What do you do now?

Cervical Spinal Cord Injury

Go to these two pages, part of our spinal levels torture page.

The bottom line: be very wary of cervical spinal cord injury. Keep the collar on. The bad results from keeping a collar too long on are minimal. The bad results of taking a collar off too soon are potentially disastrous.

This person, who now is in your ER, is very hypotensive. BP 70/zip. There is no external bleeding, no blood/pneumothorax on the CXR, no major orthopedic trauma.

"Spinal shock" says a Revered Attending, "Start some dopamine at 5 mikes per minute."

"I dunno" you say.

"Well, Dr. Cushing," he continues,"where is he bleeding? Feel the belly: it's soft. So no blood there. Start the dopamine."

"I dunno" you say.

Who is right?

Guillain Barre Syndrome

A 45 year old man comes into your emergency room by ambulance, virtually quadriplegic. He says he had a bad cold a few weeks ago, but got over it OK. He is otherwise healthy. But last night, when he got up to go to the bathroom, his legs felt "very wobbly, I had to hang onto the wall to steady myself." This morning, when the alarm clock rang, he couldn't get his arm over to turn it off. His wife finally came in and called EMS after ascertaining that this was for real.

So there he lies on your ER cart, 0/5 in the legs, 1/5 deltoids, and nothing else. Reflexes are down, but sensation is pretty much intact.

What is going on?

What to do?

Acute mental status changes in a hospitalized patient

You are the orthopedic resident on call. It is 0300 and you are indulging yourself in 15 min of sleep when the beeper goes off. It is a call from the charge nurse on the joint-replacement floor.

"Mrs. Wilson is sundowning" she says,"She had a total hip replacement 5 days ago and was OK until tonight. In fact, she looked OK at midnight, but now it's 0300 and she's off the wall. She's lying there, screaming at people who aren't there, thrashing around, and scaring her neighbor in the bed next to her."

You mumble incomprehensibly.

"I need an order for Haldol, 2 mg IM now and q2h PRN" she continues, "you can sign it on morning rounds."

Sounds tempting. Should you OK it?

"All right, Dr. Kildare, "she continues,"if you don't like my idea, drag yourself up here and take a look at this lady yourself."

What is going on? What should you do?

Cauda equina syndrome

You are called to the ER to see a 35 YO man who was moving a refrigerator up some stairs with his friend when he had the sudden onset of terrible back pain radiating down both legs. It was a hot day and they had been drinking a few brews merely to replenish fluid lost during the exertions. This happened 2 hours ago, and he's lying in your ER, obviously a nice guy, and obviously in agony. His motor exam, best as you can tell with the pain, is intact. Sensation is intact except for decreased pinprick in his perineum, reflexes look OK. You continue your general exam, and note that his lower abdomen looks like he is 12 weeks pregnant. He denies being pregnant.

What is going on?

What do you do to test your hypothesis?

What do you do after you take care of immediate problems?

Metastatic spinal cord compression

You are the overworked medicine resident in the medicine clinic at the VA hospital in Anywhere, USA ("Classic VA" story)...

...a 65 year old man comes in, complaining of back pain and "my feet are unsteady." Looking at his chart, you note that he has about a 6 million pack-year smoking history. He was in last month for back pain, given Tylenol with codeine, came in 2 weeks ago, was given oxycodone and a cane, and now shows up with the same pain and gait difficulty. He says the back pain is "like a toothache between my shoulderblades" and that he has to hold the wall to walk to the bathroom at night. You examine him and get a questionable pin level at T6 bilaterally, plus some slight weakness of the lower extremities, maybe.

What is going on?

How do you figure out what is going on?

What do you do about it?