Neurological emergenciesSarah RamsayDept of Anaesthesia and ICU

Neurological emergencies
Sarah Ramsay
Dept of Anaesthesia and ICU


Are you in a coma or only
sleeping??
Approach to the unconscious patient
Specific conditions


Simultaneous….
Assessment AND treatment
Avoid secondary injury


Purpose of assessment
• To document the level of consciousness
and other brain functions so that the
patient's progress can be followed
• To localize pathology and narrow the
differential diagnosis


Not sleeping….
• General examination
• Neurological examination
– GCS
– Brain stem function (pupils, gag etc)
– Other cranial nerves
– Peripheral nervous system (motor &

sensory)


GLASGOW COMA SCALE
• Verbal
• Motor
• Eyes


GLASGOW COMA SCALE
• Verbal
• Motor
• Eyes


Verbal
•
•
•
•
•
•

Orientated
Confused
Inappropriate
Incomprehensible
Nil
(T=intubated)

Motor
•
•
•
•
•
•

Obeys commands
Localizes to pain
Flexion to pain (withdrawal)
Abnormal flexion
Extensor response
Nil


Eyes
•
•
•
•

Spontaneous
To speech
To pain
Nil


Assessment

• General examination
• Neurological examination
– GCS
– Brain stem function (pupils, gag etc)
– Other cranial nerves
– Peripheral nervous system (motor &
sensory)


History
• Known systemic disease & medication
• Previous neurology
• Circumstances of onset (?trauma, ?
drugs)


After assessment…
? Non-traumatic coma
? No focal or lateralising signs
? meningism
? no meningism
? Focal or lateralising signs


Investigation
•
•
•
•

Glucose, RFTs, LFTs, ABGs, CBC, coag
ECG, baseline CXR
CT +/- contrast
Others: Infection screen, TFTS, blood
alcohol level, toxicology,
LP (rare)
EEG, MRI


Treatment
• Resuscitation = ABC (2o injury; c-spine)
• Emergency treatment (glucose; thiamine;
?drug antagonists)
• Make a diagnosis
• Specific treatment
• On-going assessment
• Optimize outcome (good nursing care;
nutrition)


Causes…
• Coma due to injury or compression of
the reticular activating system
= STRUCTURAL COMA.
• Coma due to generalized impairment
of cerebral cortex (+/- the brainstem)
= METABOLIC COMA.
Structural coma more urgent than
metabolic

Non-traumatic coma

- no focal or lateralising signs

With meningism
• SAH
• Meningitis
• Encephalitis

Without meningism
• Anoxic ischaemic
conditions
• Metabolic disturbance
• Intoxication
• Systemic infections
• Hypo/hyperthermia
• Epilepsy
• Behavioural


Non-traumatic coma

- focal brainstem or lateralising
cerebral signs
= structural coma

•
•
•

•

Cerebral
Cerebral
Cerebral
Cerebral

tumour
haemorrhage
infarct
abscess



Subdural



Extradural



Infection


Toxins and drugs
•
•
•
•

•
•

Sedatives
Narcotics
Alcohol
Poisons
Psychotropic drugs
Carbon monoxide
Overdose (deliberate & accidental)
Withdrawal states