Ebook The practice of emergency and critical care neurology: Part 1

T H E P R AC T I C E O F   E M E R G E N C Y
AND CRITICAL CARE NEUROLOGY


SECOND EDITION

T H E P R AC T I C E
OF EMERGENCY
AND CRITICAL CARE
NEUROLOGY
E E L C O F. M . W I J D I C K S , MD, PhD, FACP, FNCS, FANA
Professor of Neurology, Mayo Clinic College of Medicine
Chair, Division of Critical Care Neurology
Consultant, Neurosciences Intensive Care Unit
Mayo Clinic Hospital, Saint Marys Campus
Mayo Clinic Rochester, Minnesota

1


1
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© 2016 Mayo Foundation for Medical Education and Research
First Edition published in 2010

Second Edition published in 2016
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Library of Congress Cataloging-in-Publication Data
Wijdicks, Eelco F. M., 1954- , author.
The practice of emergency and critical care neurology / Eelco F.M. Wijdicks. — Second edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978–0–19–025955–6 (alk. paper)
I. Title.
[DNLM: 1.  Critical Care—methods.  2.  Neurologic Manifestations.  3.  Central Nervous System Diseases—diagnosis.
4.  Central Nervous System Diseases—therapy.  5.  Emergency Treatment—methods. WL 340]
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CONTENTS

List of Capsules
Preface to the Second Edition 
Preface to the First Edition 
Acknowledgments 

vii
ix
xi
xiii

PART I:  General Principles of Recognition
of Critically Ill Neurologic Patients in the
Emergency Department

1. The Presenting Neurologic Emergency 

3

2. Criteria of Triage 

9

PART II:  Evaluation of Presenting Symptoms
Indicating Urgency

3. Confused and Febrile 

17

4. A Terrible Headache 

25

5. Blacked Out and Slumped Down 

36

6. See Nothing, See Double, See Shapes 

43

7.Spinning 

53

8. Moving, Jerking, and Spasm 

58

PART III:  Evaluation of Presenting

Symptoms Indicating Critical Emergency

9. Can’t Walk or Stand 

67

10. Short of Breath 

78

11. Seizing 

92

14. The Neurosciences Intensive
Care Unit 

147

PART V:  General Principles of Management
of Critically Ill Neurologic Patients in the
Neurosciences Intensive Care Unit

15. General Perspectives of Care 

157

16. Agitation and Pain 

177

17. Mechanical Ventilation 

191

18. Nutrition 

205

19. Volume Status and Blood Pressure 

218

20. Anticoagulation and Thrombolysis 

231

21. Fever and Cooling 

243

22. Increased Intracranial Pressure 

250

PART VI:  Technologies in the Neurosciences
Intensive Care Unit

23. Monitoring Devices 

271

24. Transcranial Doppler Ultrasound
and Neurophysiology 

287

25. Multimodal Monitoring
and Biomarkers 

309

PART VII:  Management of Specific
Disorders in Critical Care Neurology

26. Aneurysmal Subarachnoid
Hemorrhage 

317

27. Ganglionic and Lobar Hemorrhages 

347

PART IV:  Organization of the Neurosciences
Intensive Care Unit

28. Cerebellum and Brainstem
Hemorrhages 

370

13. The Responsibilities of the
Neurointensivist 

29. Major Hemispheric Ischemic Stroke
Syndromes 

384

12. Comatose 

104

139


vi

Contents

30. Acute Basilar Artery Occlusion 

414

53. Acute Kidney Injury 

722

31. Cerebellar Infarct 

429

54. Endocrine Emergencies 

730

32. Cerebral Venous Thrombosis 

439

33. Acute Bacterial Meningitis 

453

34. Brain Abscess 

468

35. Acute Encephalitis 

481

36. Acute Spinal Cord Disorders 

500

37. Acute White Matter Disorders 

517

38. Acute Obstructive Hydrocephalus 

532

39. Malignant Brain Tumors 

542

40. Status Epilepticus 

551

41. Traumatic Brain Injury 

566

42. Guillain-​Barré Syndrome 

587

43. Myasthenia Gravis 

608

PART VIII:  Postoperative Neurosurgical
and Neurointerventional Complications

44. Complications of Craniotomy
and Biopsy 

629

45. Complications of Carotid
Endarterectomy and Stenting 

641

46. Complications of Interventional
Neuroradiology 

652

PART IX:  Emergency Consults in the General
Intensive Care Unit

47. Neurology of Transplant Medicine 
48. Neurology of Cardiac and
Aortic Surgery 

55. Management of Pulmonary
Complications 

739

56. Management of Cardiac
Complications 

753

57. Management of Acid–​Base
Disorders, Sodium
and Glucose Handling 

772

58. Management of Gastrointestinal
Complications 

791

59. Management of Nosocomial
Infections 

803

60. Management of Hematologic
Complications and Transfusion 

816

61. Management of Complications
Associated with Vascular Access 

823

62. Management of Drug Reactions 

829

PART XII:  Decisions at the End of Life
and Other Responsibilities

63. The Diagnosis of Brain Death 

839

64. Donation after Cardiac Death 

857

65. Organ Procurement 

864

66. Ethical and Legal Matters 

868

663
PART XIII:  Formulas and Scales

674

49. Neurology of Resuscitation Medicine  688
50. Neurology of Pregnancy 

PART XI:  Management of Systemic
Complications

698

PART X:  Critical Care Support

51. Shock 

707

52. Cardiopulmonary Arrest 

716

Formulas and Tables for Titrating Therapy  881
PART XIV:  Guidelines

Guidelines, Consensus Statements,
and Evidence-​Based Reviews Related
to Critical Care Neurology 

891

Index 

897


LIST OF CAPSULES

1.1

Injury Severity Score 

5

15.2

Intensive Care Resources and Bed
Rationing 

Preventing Deep Vein
Thrombosis 

2.1

167

10

16.1

Patient-​controlled Analgesia 

185

3.1

DSM-​5 Diagnostic Criteria for
Delirium 

18

17.1

Ventilator Bundle 

194

4.1

Acute Serious Headache in the
Emergency Department 

18.1

Obesity and Critical Illness 

206

26

19.1

The Frank-​Starling Curve 

220

4.2

Blood in Cerebrospinal Fluid

31

20.1

The Fibrinolytic System 

236

5.1

Autonomic Control in Neurally
Mediated Syncope 

21.1

Origin of Fever 

244

39

22.1

6.1

Degree of Visual Loss 

44

Brain Edema: Physiology and

Pathology 

252

7.1

Systemic Illness and Drug-​induced
Dizziness 

22.2

54

Brain Compartments and
Consequences 

257

8.1

Rigidity and Hyperthermia 

62

23.1

9.1

Localizing Spinal Cord
Lesions 

Cerebral Blood Flow and Brain
Tissue Oxygen 

277

70

24.1

10.1

Neural Control of Breathing and
Abnormal Patterns 

80

Continuous
Electroencephalographic
Monitoring 

298

11.1

No Intravenous Access 

98

24.2

Spreading Depolarization 

299

11.2

Antiepileptic Drugs and Side
Effects 

25.1

Requirements for Monitoring 

310

99

26.1

Aneurysmal Rupture 

318

12.1

Ascending Reticular Activating
System 

27.1

112

Cerebral Amyloid Angiopathy
and Cerebral Hemorrhage 

354

12.2

Mechanisms of Toxin-​induced
Coma 

28.1

118

Surgical Options in Pontine
Hemorrhage 

378

12.3

Functional MRI in Coma

127

29.1

13.1

The Neurocritical Care Society 

140

Decompressive Hemicraniectomy
and Outcome 

404

13.2

Simulation Training

143

30.1

The Classic Brainstem
Syndromes 

415

14.1

Costs of ICU Care 

151

31.1

Vascularization of the Cerebellum  430

15.1

The Pathophysiology of Being
Supine 

164

32.1

Pathology of Cerebral Venous
Occlusion 

446


viii

List of Capsules

33.1

Pathogenesis of Acute Bacterial
Meningitis 

455

50.1

Putative Mechanism of
Eclampsia 

700

34.1

Neuropathology of Abscess 

469

51.1

Mechanism of Sepsis 

708

35.1

Paraneoplastic Neuronal Antineural
Antibodies and Encephalitis
485

51.2

Fluids and Shock 

710

36.1

Injury Mechanism in Acute
Spinal Cord Injury 

52.1

Feedback of CPR with
Capnography 

718

37.1

Diagnostic Clinical and
Laboratory Criteria for Multiple
Sclerosis 

53.1

Pathogenesis of Acute Renal
Injury

723

526

53.2

38.1

Pathophysiology of Acute
Hydrocephalus 

Osmotic Shifts and Treatment of
Kidney Injury

728

534

54.1

Glucose and the Brain 

731

39.1

WHO Grading of Tumors
of the Central Nervous System 

55.1

Bronchoscopy in the NICU 

742

545

56.1

40.1

Neuronal Damage Associated
with Status Epilepticus 

Autonomic Nervous System
and the Heart 

754

553

56.2

Asystole and Aneurysmal Rupture 756

41.1

Gunshots to the Head 

578

57.1

The Vaptans 

782

42.1

Immunoglobulin 

598

57.2

43.1

Molecular Footprint
of Myasthenia Gravis 

Cerebral Salt Wasting Syndrome
and Fludrocortisone 

783

614

58.1

Stress-​related Mucosal Disease 

792

44.1

Pathophysiology of Remote

Hemorrhages After Craniotomy 

631

59.1

Antibiotic Template 

810

45.1

Carotid Endarterectomy 

642

60.1

Anemia and Brain Physiology 

818

46.1

Pericoil Edema 

655

61.1

Teaching Procedures 

824

47.1

Mechanism of Brain Edema
in Fulminant Hepatic Failure 

62.1

DRESS Syndrome 

833

668

63.1

International Brain Death Criteria 840

48.1

Cardiopulmonary Bypass
and Changes in pH

64.1

676

Maastricht Classification
of Non-​Heart-​Beating Donors 

858

48.2

Vascular Anatomy of the
Spinal Cord

65.1

682

49.1

Neuronal Destruction from
Anoxic-ischemic Injury

UNOS Board of Directors
Recommendations on Organ
Donation

865

689

Self-​fulfilling Prophecy
in Neurocritical Care 

870

513

66.1


P R E FAC E TO   T H E S E C O N D E D I T I O N

A legitimate subspecialty allows neurointensivists to manage patients with acute and critical
neurologic disease. Here is what I think—​
the
neurointensivist is now a more recognized
specialist and provides better care of patients
with large scale clinical problems associated with
acute neurologic disease. The disorders that shape
this field are better defined, and all of us in the
trenches, so to speak, have now a good idea of how
to approach these problems. Revisions of textbooks—​and also this one—​are required to assimilate and critique new information and to put more
modern approaches into practice. Single authored
textbooks will remain useful not only because it
forces the author to discipline approaches to
patient management, but also to bring a consistent practical perspective to the whole of it’s care.
I hope this book not only provides an adequate
grounding for newcomers, but also appeals to a
broad audience of experienced practitioners.
This new edition of The Practice of Emergency
and Critical Care Neurology continues the same
organizational principles. My approach has been
to pose the significant questions differently: How

does the patient with an acute neurologic condition present to us? What are the distinguishing
characteristics of the clinical picture, and how
do we best anticipate clinical worsening? What
do we do to stabilize the patient neurologically
and medically? This book is much less about
theorizing and more about management—
progressing from an initial relatively straight­
​
forward approach to more complex decisions in a
rapidly deteriorating situation. What practitioners
need is an operational definition of the degree of
deterioration and what can lead to bad outcomes.
The chapters have been revised to incorporate
new information and new ideas. The management

of the patient changes when information changes.
Because there is a considerable proportion of
patients with a new medical critical illness after a
neurocritical illness, I have added a new section on
critical care support adapted to the critically ill neurologic patient. Such an addition is needed to update
neurointensivists on practice changes in critical care
medicine. Other new sections are on multimodal
monitoring, cooling techniques, and on the quality
improvement in the NICU—​topics that have been
heavily written about in the years since the previous edition. Although a companion monograph on
the neurological complications of critical illness has
been published, (Neurologic Complications of Critical
Illness (Contemporary Neurology Series) third edition
Oxford University Press, 2009) I felt it necessary to
summarize common requests for consults in other

ICUs in four new chapters.
In total this new edition has 12 new chapters,
over 50 new original illustrations and neuroimaging figures and I have added numerous new
sections, subsections and capsules, which further
complete the work. As with prior editions, this
book has a pocketbook with a selection of the
most relevant tables and figures. This pocket book
can physically accompany practitioners, but it is
also easily downloaded on portable devices.
This book before you is as recent and updated
as possible, and we will be planning future editions every 5 years to keep the information fresh.
All that said, I hope this textbook—​a work
which originally started as a 3 volume work and
now is condensed in a nearly 1000 page volume—
will continue its lineage. So what follows I hope is
a book which provides practical and data-​driven
advice to any physician caring for seriously ill
neurologic patients.
E. F. M. Wijdicks


P R E FAC E TO   T H E F I R S T E D I T I O N

The specialty of critical care neurology considers
its province acute neurologic disease presenting
in the emergency department or the neurosciences intensive care unit and neurologic complications of medical or surgical critical illness.
The Practice of Emergency and Critical Care
Neurology combines two monographs previously
published with Oxford University Press, amalgamating the unique structure of each book, but
in a more condensed form after eliminating overlap. I believe that with these changes, it is now a

many-​sided textbook on the management of a
patient with an acute, definitely serious, and primarily critical neurologic disorder. (The neurologic complications of medical or surgical critical
illness have been published last year in a companion monograph, also with Oxford University
Press and now in a third edition.)
The Practice of Emergency and Critical
Care Neurology follows patients from the very
moment they enter the emergency department
(ED)—​where the neurologist makes on-​the-​spot
decisions—​to their admission to the neurologic
intensive care unit (NICU)—​where mostly specialists in the neurosciences assume full responsibility for patient care. This book differs from
conventional textbooks by specifically following
the time course of clinical complexities as they
emerge and change.
Part I introduces the presenting neurologic
emergency and the responsibilities of specialists
interacting in the ED. Triage of acute neurologic
disease has been defined arbitrarily, but many neurologists opt for brief observation in an intensive
care setting rather than admission to the ward.
Guidance for more appropriate triage is provided.
Part II encompasses the evaluation of presenting symptoms that indicate urgency, and

their conversational titles echo the patient’s main
concerns or common requests for urgent consultation. As one would expect, the differential diagnosis of these symptoms is very broad. However,
the intentionally brief chapters emphasize the red
flags. They are intended only to orient readers,
and to set the priorities and direction of the clinical approach.
Part III discusses the four most common presenting symptoms that indicate a critical neurologic emergency and, above all, require prompt
action. These conditions often need immediate care even before the patient is triaged out of
the ED.
Part IV discusses the organization of intensive

care units (ICUs), including options for different
types and models that can be used in ICUs all
over the world. In some hospitals, the closed unit
form fits nicely; in others, logistics, manpower,
and economics may not allow such a model. In
two chapters, the main attributes of a physician
practicing critical care neurology and the organization of NICUs are explained. These chapters are
included for readers who want to pursue a career
in this field or set up a NICU.
Part V is devoted to the basic treatment of
patients with critical neurologic illness and, next
to the section on complex nursing care, includes
the basic principles of pain and agitation management, mechanical ventilation, nutritional
requirements, and fluid management. The use of
anticoagulation, or its reversal in some instances,
and the current practice of thrombolytic therapy
in acute ischemic stroke are presented in detail.
All these measures may have an impact on existing
brain injury, and therefore this section concludes
with the management of increased intracranial
pressure.


xii

Preface to the First Edition

Part VI encompasses the technology
used in the NICU and the current monitoring capabilities—​
of which some are standard,

whereas others are experimental and still being
tested for usefulness and cost-​effectiveness. It has
been a truism that clinical examination trumps
any monitoring device; however, the neurologic
assessment of ongoing brain injury continues to
be an approximation, and much better technology
is needed.
Part VII is the core of the book and is devoted
to specific disorders in critical care neurology.
Each chapter is structured in a unique way, in that
it focuses on diagnosis, interpretation of neuroimaging, first steps in management, problem solving
for deteriorating patients, and an estimation of
outcome.
Part VIII contains three chapters on the management of common postoperative neurosurgical
and neurointerventional complications, but I have
abbreviated these sections to match their scope to
the needs of neurologists.
Part IX comprises chapters on medical complications that can be expected for any patient
with an acute serious neurologic illness. These
complications involve a consuming part of day-​
to-​day care and may endanger the patient in many
ways. Practical advice is provided to manage them
effectively.
Part X concentrates on the diagnosis of brain
death and the assessment of irrevocable damage
to the brain. These situations lead to withdrawal
of support, and may lead to organ donation. This
section also highlights some of the current ethical
controversies and legal risks.
Part XI closes the book with dosing tables and

equations.
Finally, in order to show commitment to
evidence-​
based medicine, useful references to
academy and society guidelines pertaining to critical care neurology have been included.
In an attempt to present the field in its entirety
and to fill some of the gaps, seven new chapters
have been written for this new edition. They
include a chapter on the role of the neurologist
in the ED and how to collaborate effectively with

colleagues of other disciplines. New chapters on
specific neurologic conditions, management of
complications in the NICU, and end-​of-​life care
(the DCD protocols) have been added.
My main focus has been not only to inform
the reader about the presentation of acute neurologic illness but also to assist directly in its management. I have expanded the information on the
pathophysiology of brain injury and used a special format (capsules) to set it apart from the text.
These capsules will be helpful for quickly understanding certain topics without cluttering the text
with impractical information. Some can be used
for teaching pearls during rounds.
Buyers of the book can expect even more
changes. First, more than 1,000 references and
over 100 new figures—​many in full color—​have
been added. This book again comes with a pocketbook of selected tables and figures. The contents
of this pocketbook also can be uploaded to any
mobile device for quicker searching capability.
I hope that its text, without being too unwieldy
to carry or too dense to read, has wide appeal and
is a source of answers to clinical questions. This

book not only amasses and interprets the available
literature but is also based on our published clinical research at Mayo Clinic for nearly 2 decades.
As promised, it is tailored toward neurologists
and neurosurgeons, neurointensivists, medical
and surgical intensivists, emergency physicians,
residents in neurology and neurosurgery and fellows in critical care. Any newly arrived neurointensivist may use this information to study for a
certification exam. I hope the information in this
book is also a useful resource for neuroscience
nursing staff, respiratory therapists, physical therapists, ICU pharmacists, and other allied health
providers.
This book serves as a reference on care of the
patient with a critical neurologic disorder, at risk
of deterioration, and in need of immediate attention. But there is more than that. I  wish for this
book to contribute to the best possible care of
patients with a critical neurologic disorder. That
remains my main motivation.
E. F. M. Wijdicks


AC K N OW L E D G M E N T S

I am indebted to many persons over the years, but
I  have to single out those who made considerable
contributions in the research and compilation of
this book. I have enjoyed the advantage of access to
Mayo Library, Media Support Services and Section
of Presentation and Design. These are incredible
resources. I have worked together on many projects
with David Factor, whose wonderful color drawings
are again interspersed throughout the book. I very

much value his creativity, and it is difficult to thank
him adequately. Paul Honermann (scientific illustrator) expertly formatted the neuroimaging and other
photographs. Kevin Youel (presentation designer)
was very helpful in modernizing the algorithms and
other drawings. The cover created by Jim Rownd is
inspired by the “untitled” paintings of Willem de
Kooning. It is a great privilege to work with him
through multiple ideas and he has been responsible
for many of my book covers over the years.
I thoroughly thank Lori Reinstrom who was
kind enough to type parts of the text, format,
and reference. She lived with my books for many
years. Writing is one thing, proofing is another
(the writer’s bane). In the final stages of the book

production Newgen Knowledge Works diligently
worked through several proofs until we felt it was
right. I would like to express my gratitude to all
involved.
I benefit greatly from the insights of my
Mayo neurointensivist’s colleagues (Alejandro
Rabinstein, Sara Hocker, and Jennifer Fugate), but
also the neurosurgery and neuroradiology staff
admitting to the NICU (mostly notably Giuseppe
Lanzino, Harry Cloft, and David Kallmes). Their
friendship means much to me.
My deepest gratitude is to the neurosciences
nursing staff. For all the time here at Mayo Clinic
they have stood with me, and I have never seen such
compassion and determination to patient care.

I am honored to be connected with Oxford
University Press and greatly thank my editor Craig
Panner, I appreciate their continuing interest in
publishing my books.
This book is dedicated to my dearly loved
wife Barbara and admirable children Coen
and Marilou. They have been continually and
crucially supportive.
E. F. M. Wijdicks


PART I
General Principles of Recognition
of Critically Ill Neurologic
Patients in the Emergency
Department


1
The Presenting Neurologic Emergency

A

cute neurologic disease is bound to get worse.
In some it is critical and unquestionably life-​
threatening. Acute neurologic conditions can be
seen everywhere in the hospital, but this chapter
introduces the emergency department (ED), with
all its complexities, as seen from a neurologist’s
perspective.28

Acute neurologic manifestations are a consequence of major trauma, acute stroke, emerging
infection, or intoxication. Patients may also come
to the hospital as an urgent referral or even as a
walk-​in. In these circumstances, acutely unfolding neurologic signs are obvious, yet difficult to
interpret, and physicians feeling “uncomfortable”
with such a progressive neurologic picture have
a low threshold for sending patients to the ED.
A major reason for the ED admission of patients
with a critical neurologic manifestation lies in the
fact that the ED may provide immediate advanced
care and triage. But in other situations, patients
with a not yet known neurologic emergency may
present with nonspecific symptoms, such as weakness, twitching, agitation, dizziness, or headaches,
or they may be simply not reacting and staring
into space. All these symptoms carry a broad differential diagnosis and therefore are a serious test
to any physician in any field.
Generally, emergency physicians are often
faced with diagnostic scruples, but their uncertainty is most apparent with acute neurologic
conditions. Emergency physicians are trained to
recognize acute neurologic disease, but often they
consult a neurologist for such cases. The American
Board of Emergency Medicine has identified core
competencies for critical neurologic disorders
that include demyelinating disorders, acute headaches, acute hydrocephalus, central nervous system infection, dystonic reactions, Guillain-​Barré
syndrome and myasthenia gravis, seizures, spinal
cord compression, stroke, and traumatic brain
injury.20 However, this list leaves out a gamut of
other disorders that, if unrecognized and unmanaged, may lead to neurologic morbidity.28 This

chapter promotes close communication between

neurologists and emergency physicians to achieve
maximal effectiveness.

THE EMERGENCY
D E PA R T M E N T
The ED is a separate place in the hospital, staffed
by emergency physicians, and functions under
unique characteristics. Emergency physicians are
routinely required to make a string of decisions
in rapid succession. The department is characterized by high activity levels, frequent interruptions
and distractions, shift work, and a need to work
in teams. The ED may handle both critical conditions and less-​emergent presentations. In the
United States and many other countries, the ED
is also where the uninsured, needy, and poverty
stricken go for medical help.
The physical structure of the ED is highly dependent on location, and EDs in inner-​city locales have
a different patient mix when compared with rural
areas. Many EDs are packed: This crowding is a
multifaceted problem and includes such causes as
nonurgent visits, patients who frequent the ED for
trivial reasons (“frequent flyers”), viral epidemics
(e.g., influenza season), inadequate staffing, inpatient boarding, and hospital bed shortages. These
conditions have led to the notion of compromised
care and poor patient satisfaction.2,10,12,26,29
The ED has a designated critical care area where
a patient’s condition is stabilized and the patient is
resuscitated and readied for triage (Figure 1.1). In
each emergency center, levels of trauma activation
have been defined and customized.
Trauma activation provides a strictly circumscribed number of skilled personnel who

are available for different categories of medical
severity. A level 1 trauma activation may suddenly
deplete the nursing staff, and thus nurses may not
be immediately available to assist other patients in
unstable physical condition (Table 1.1).
Severity scales and scores for certain neurologic disorders have been proven to facilitate


4

Part I: General Principles

FIGURE 1.1:  

View of the critical care area of the emergency department.

TABLE 1.1.   LEVEL 1 TRAUMA

ACTIVATION: RESPONSE OF STAFF
FOR INITIAL RESUSCITATION OF THE
ACUTELY INJURED ADULT PATIENT
AT MAYO CLINIC
Trauma consultant
Emergency physician
Trauma critical care and general surgery resident
or trauma physician assistant or nurse practitioner
Radiology technician
Phlebotomist
Respiratory therapist
Transfusion medicine registered nurse

Urology technician
Emergency medicine registered nurse

understanding, treatment, and triage.6 Most recognizable for first responders are the Glasgow
Coma Scale and the National Institutes of Health
Stroke Scale (NIHSS).19 A  commonly used scale
is the Injury Severity Score (Capsule 1.1), but
this scoring system undervalues the impact of
trauma to the brain.18 Severity scales may be helpful because they assist the physician in testing the
most important elements of a neurologic examination. Unfortunately, guidelines for other many
acute neurologic conditions are inadequate in

assisting emergency physicians, and some guidelines have not yet been developed because solid
data are not available.9,21,22

THE NEUROLOGIC
EMERGENCY AND
ITS ASSESSMENT
A neurologic consultation is often triggered by
the presence of any obvious localizing sign or
abnormal responsiveness. A  neurologic emergency is defined by certain clinical manifestations, abnormality on neuroimaging, and, most
important, by a progression of symptoms. In
most instances, the presentation is dramatic,
attracts attention, and requires specialty care.
The condition of some patients worsens rapidly, and in these cases an acute neurosurgical
intervention is necessary. Typical examples are
an acute hemispheric lesion with mass effect,
resulting in brainstem displacement or acute
spinal cord compression.
Neurologic symptoms often fluctuate, and an

improvement in symptoms may not necessarily mean that the patient is improving. A  classic
example is a patient with a basilar artery occlusion who presents with a transient hemiparesis,
only to have the symptoms re-​emerge with acute
unresponsiveness and abnormalities of brainstem
reflexes. Fluctuating consciousness may indicate
ongoing seizures rather than a postictal state.


Chapter 1: The Presenting Neurologic Emergency

5

CAPSULE 1.1    INJURY SEVERITY SCORE
Injury severity scoring systems have included neurologic findings but with little detail. Scoring systems
may include the Glasgow Coma Scale, Acute Physiology and Chronic Health Evaluation (APACHE), or
may simply note the presence of cerebral contusion (Injury Severity Score [ISS]). The ISS has continued
to be the most useful test for trauma severity and has been summarized by a calculation that takes the
three highest scores and adds the squares of these three scores to an injury severity score. It defaults
to the highest score of 75 if injury is assigned 6 (unsurvivable). An example is shown below. The major
weaknesses of ISS are that different injury patterns yield a same score, and substantial errors in scoring may exist. Any patient with an ISS of more than 16 should be treated in a tertiary level 1 trauma
center; Other scoring systems have been used, such as TRISS (a combination of revised trauma score,
ISS, and age) and a severity characterization of trauma (ASCOT), without gaining sufficient acceptance.
The APACHE scoring system includes comorbid conditions and an acute physiology score; however, it
underestimates the probability of death when patients are transferred to the ICU and is less certain in
predicting death for injured patients.18
Region

Injury Description

AIS

Head and neck
Face
Chest
Abdomen

Cerebral contusion
No injury
Flail chest
Minor contusion of liver
Complex ruptured spleen
Fractured femur
No injury

4
0
4
2
5
3
0

Extremity
External

Rating for the Abbreviated Injury Scale (AIS)
AIS Score

Injury

1
2
3
4
5
6

Minor
Moderate
Serious
Severe
Critical
Unsurvivable

To obtain an injury severity score, square the 3 highest scores and add them. In this example
25 + 16 + 16 = 57

A neurologic emergency can be deconstructed
according to the acute presentation of certain signs,
but it also can be defined by a need for immediate
diagnostic or therapeutic action (Table 1.2).
Four neurologic tests—​
computed tomography (CT) scanning, magnetic resonance imaging
(MRI), cerebrospinal fluid (CSF) examination,
and electroencephalography (EEG)—​
should be
immediately available and may narrow the diagnostic evaluation substantially. CT and CT angiogram (or MRI and MR angiogram) of the brain
are mandatory in the timely evaluation of a stroke.
CSF examination and EEG are needed when

TABLE 1.2.   SIGNS AND SYMPTOMS THAT

MAY CONSTITUTE A NEUROLOGIC
EMERGENCY
Worsening and changing neurologic signs
Acutely dilated pupil or anisocoria
Acute eye movement abnormality
Abnormal level of consciousness
Seizure
Severe, unexpected, split-​second headache
Acute vertigo
Acute cranial nerve deficit
Inability to stand or walk


6

Part I: General Principles

certain clinical suspicions (e.g., central nervous
system infection or inflammation, nonconvulsive status epilepticus) are strong. None of these
studies can replace a neurologic examination,
however, and emergency physicians would benefit
from some guidance in the proper procedure for
this type of evaluation.
Few studies have addressed the effectiveness
of the neurologist in the ED. Prior studies have
suggested that neurologists are rarely involved in
the management of ischemic stroke4,11 and that
this lack of involvement potentially could lead to

a delay in and a lack of treatment with thrombolytic agents. However, over the last few years the
involvement of neurologists has increased due to
Telestroke programs, which have increased the
number of patients treated with IV thrombolytics and guided ED physicians to triage the patient
to endovascular neurointervention.8 Few institutions have a neurology resident in the emergency
room, and even less often is a neurologist physically present in the ED to assess the urgency of
a case. Far more often, physicians send patients
to the ED to be seen by emergency physicians,
only to have a neurologist called in because of
conspicuous neurologic manifestations.
Ideally, a neurologist with expertise in acute
critical neurologic illness would visit patients
who are going to be triaged to an intensive care
unit (ICU). This situation applies not only to
patients admitted to specialized neurologic
ICUs (NICUs), but also to patients with an
acute neurologic illness who are transferred
to a surgical, medical, or more general ICU.
Neurointensivists are in a good position to
expand their role in the ED and to become more
directly involved in the management of acute
neurologic conditions. Having such specialized
neurologists ready to see patients during the so-​
called golden hour following initial presentation
of symptoms may lead to improved assessment
and, ultimately, to improved care and outcome.
Their presence when decisions are made may
also reduce second-​guessing. The reality, however, is different, and we suspect that neurologists are rarely called in except when part of a
designated management protocol (e.g., a rapid-​
response stroke protocol).3

Cross-​
training is equally important for
resident emergency physicians rotating in the
NICU and for neurology residents and fellows
spending time in the critical care section of the
ED. Additional training of emergency physicians in critical care neurology may be helpful,

but may be resisted in a currently cramped
curriculum.20,23,24
The relationship between a neurologist and an
emergency physician has been a subject of discussion, but much of it is hyperbole.11 Some experts
have argued that neurologists are rarely available on an urgent basis. In a large urban tertiary
teaching hospital and trauma center, consultation
with a neurologist increased the length of stay in
the ED by an average of 3.5 hours.10 Others have
argued that emergency physicians are out of their
depth on acute neurologic issues15 and that failure of the timely presence of a neurologist may
increase errors in the recognition and management of a neurologic emergency.5,15

CLINICAL JUDGMENT
IN THE EMERGENCY
D E PA R T M E N T
There are plenty of potential errors to consider
(Table 1.3), and emergency physicians are often
subject to blame and critique.27 Some have categorically and unfairly characterized the ED as a
“natural laboratory for the study of error.”7 Studies
of diagnostic errors and management failures
have been retrospective, biased, and confrontational (i.e., usually resulting in finger-​pointing at
ED physicians). Diagnostic errors are difficult to
gauge, particularly when the diagnosis has been

deferred to the accepting physician in charge of
further workup.16 There continues to be a broad-​
brush characterization of the ED as insufficient
neurology of any kind, but it serves no purpose.
A frequently reported misjudgment is the
diagnosis of subarachnoid hemorrhage (SAH).
This finding is curious because many EDs may see
on average two SAHs a month. A recent study in

TABLE 1.3.   ERRORS THAT MAY OCCUR

IN THE EMERGENCY DEPARTMENT
Failure to recognize acute brain injury on computed
tomographic scanning
Failure to perform a cerebrospinal fluid examination
Failure to recognize acute hydrocephalus
Failure to recognize locked-​in syndrome
Failure to recognize brainstem involvement
Failure to recognize status epilepticus
Failure to recognize spinal cord compression
Failure to recognize neurointerventional options
Failure to recognize brain death and potential for
organ donation


Chapter 1: The Presenting Neurologic Emergency

FIGURE 1.2:  

7

Examples of stationary or mobile robotic devices used in emergency departments..

Canada found that 1 in 20 cases of SAH were not
recognized, but most of these involved a missed
diagnosis in a nonteaching institution, followed
by its recognition in another ED visit (often on
the same day). The mortality rate was higher in
the missed cases.25
Recognition of TIA or ischemic stroke in the ED
has been an area of concern, and some experts have
noticed a failure to recognize cerebellar ischemic
stroke in patients presenting with “dizziness.”5,13,14
Medication errors in the ED largely involve
dosage miscalculation; an inappropriate dosage,
drug, or route; and, rarely, failure to identify a
drug interaction. Having a pharmacist assigned to
the ED resulted in a 60%–​75% decrease in medication errors.4
At issue is whether ED physicians have a sufficient comfort level in the management of critically
ill neurologic patients. The worst-​case scenario is
that of an ED physician who handles an acute neurologic emergency, orders neuroimaging tests and
interprets them without neurologic expertise, then
intubates, sedates, or even paralyzes the patient (and
thus making a neurologic examination pointless).
The best-​case scenario is that of a specialist in the
neurosciences seeing any acute neurologic or neurosurgical emergency and handling it competently
together with the attending ED physician, and in
fact, our experience is just like that. Tertiary centers
should have (or should develop) this expertise.

In rural areas, telemedicine may become
a solution, once the logistics and technology
can be put in place. Telemedicine involves a
hub-​and-​spoke model. The hub is in an urban
hospital with an expert neurologist on staff,
and the spokes are hospitals without a readily
available neurologist (may be up to 30 hospitals). Spoke hospitals are selected on the basis
of volume of patients with acute neurologic
disease. Communication is through interactive audiovisual teleconferencing equipment.
Multiple hospitals from remote areas can communicate with one single hub. Robots are available and reliable (Figure 1.2). There is growing
experience with stroke and ICU telemedicine
in Europe and the United States, and some preliminary studies suggest reliable assessment of
the NIHSS via high-​quality videoconferencing
and reliable neuroimaging interpretation over
teleradiology systems, and thus eventual benefit
to the patient. However, in the United States the
costs of telemedicine implementation and support personnel, cross-​
state licensing barriers,
and malpractice threats remain real.1,8,17

CONCLUSIONS
• Neurologic symptoms often fluctuate,
and an improvement in symptoms may
not necessarily mean that the patient is
improving.


8

Part I: General Principles

• Signs and symptoms indicating a neurologic
emergency are worsening or changing
neurologic signs, any abnormal level of
consciousness, acute split-​second onset
headache, acute vertigo, acute cranial nerve
deficit, and an inability to stand or walk.

REFERENCES

1. Audebert HJ, Schultes K, Tietz V, et al. Long-​term
effects of specialized stroke care with telemedicine support in community hospitals on behalf
of the Telemedical Project for Integrative Stroke
Care (TEMPiS). Stroke 2009;40:902–​908.
2. Bogner MS. Human Error in Medicine. Hillsdale,
NJ: Lawrence Erlbaum Associates; 1994.
3. Brown DL, Lisabeth LD, Garcia NM, Smith MA,
Morgenstern LB. Emergency department evaluation of ischemic stroke and TIA:  the BASIC
Project. Neurology 2004;63:2250–​2254.
4. Brown JN, Barnes CL, Beasley B, et al. Effect of
pharmacists on medication errors in an emergency department. Am J Health Syst Pharm
2008;65:330–​333.
5. Caplan LR. Dizziness:  how do patients describe
dizziness and how do emergency physicians use
these descriptions for diagnosis? Mayo Clin Proc
2007;82:1313–​1315.

6.
Chawda MN, Hildebrand F, Pape HC,
Giannoudis PV. Predicting outcome after multiple trauma:  which scoring system? Injury
2004;35:347–​358.

7. Croskerry P, Sinclair D. Emergency medicine:  a
practice prone to error? CJEM 2001;3:271–​276.
8. Demaerschalk BM, Miley ML, Kiernan TE, et al.
Stroke telemedicine. Mayo Clin Proc 2009;84:
53–​64.
9. Fuller G, Lawrence T, Woodford M, Lecky F. The
accuracy of alternative triage rules for identification
of significant traumatic brain injury: a diagnostic
cohort study. Emerg Med J 2014;31:914–​919.
10. Han JH, France DJ, Levin SR, et  al. The effect
of physician triage on emergency department
length of stay. J Emerg Med 2010;39:227–​233.
11. Hemphill JC, 3rd, White DB. Clinical nihilism
in neuroemergencies. Emerg Med Clin North Am
2009;27:27–​37, vii–​viii.
12.Hoot NR, Aronsky D. Systematic review of

emergency department crowding:  causes,
effects, and solutions. Ann Emerg Med 2008;52:
126–​136.
13. Kothari RU, Brott T, Broderick JP, Hamilton CA.
Emergency physicians: accuracy in the diagnosis
of stroke. Stroke 1995;26:2238–​2241.

14. Kowalski RG, Claassen J, Kreiter KT, et al. Initial
misdiagnosis and outcome after subarachnoid
hemorrhage. JAMA 2004;291:866–​869.
15. Manno EM. Safety issues and concerns for the
neurological patient in the emergency department. Neurocrit Care 2008;9:259–​264.
16. Moulin T, Sablot D, Vidry E, et al. Impact of emergency room neurologists on patient management

and outcome. Eur Neurol 2003;50:207–​214.
17. Schwamm LH, Holloway RG, Amarenco P, et al. A
review of the evidence for the use of telemedicine
within stroke systems of care: a scientific statement
from the American Heart Association/​American
Stroke Association. Stroke 2009;40:2616–​2634.
18. Senkowski CK, McKenney MG. Trauma scoring
systems: a review. J Am Coll Surg 1999;189:491–​503.

19.Stead LG, Bellolio MF, Suravaram S, et  al.
Evaluation of transient ischemic attack in
an emergency department observation unit.
Neurocrit Care 2009;10:204–​208.

20.Stettler BA, Jauch EC, Kissela B, Lindsell CJ.
Neurologic education in emergency medicine training programs. Acad Emerg Med 2005;12:909–​911.
21. Stuke LE, Duchesne JC, Greiffenstein P, et al. Not
all mechanisms are created equal: a single-​center
experience with the national guidelines for field
triage of injured patients. J Trauma Acute Care
Surg 2013;75:140–​145.
22. Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R.
Trends and characteristics of US emergency department visits, 1997–​2007. JAMA 2010;304:664–​670.

23.Teixeira PG, Inaba K, Hadjizacharia P, et  al.
Preventable or potentially preventable mortality at a mature trauma center. J Trauma
2007;63:1338–​1346.
24. Thomas HA, Beeson MS, Binder LS, et  al. The
2005 Model of the Clinical Practice of Emergency
Medicine:  the 2007 update. Ann Emerg Med

2008;52:e1–​17.
25. Vermeulen MJ, Schull MJ. Missed diagnosis of
subarachnoid hemorrhage in the emergency
department. Stroke 2007;38:1216–​1221.
26.Vieth TL, Rhodes KV. The effect of crowding
on access and quality in an academic ED. Am J
Emerg Med 2006;24:787–​794.
27. Wears RL. The error of counting “errors.” Ann
Emerg Med 2008;52:502–​503.
28. Wijdicks EFM, Menon DK, Smith M. Ten things
you need to know to practice neurological critical
care. Intensive Care Med 2015;41:318–​321.
29. Yoon P, Steiner I, Reinhardt G. Analysis of factors influencing length of stay in the emergency
department. CJEM 2003;5:155–​161.


2
Criteria of Triage

I

deally, the main priority for physicians with a
patient with acute neurologic disease is to quickly
triage to the neurosciences intensive care unit
(NICU). In many medical institutions without a
specialized ICU, patients are admitted to a general
ICU or, depending on the cause of injury and neurosurgical involvement, to a trauma or surgical ICU.
By its nature, the NICU is used for the medical and
neurosurgical management of critical neurologic
disorders and for the postoperative care of neurosurgical patients. As befits any major emergency,

an active neurologic problem belongs in the NICU,
but admission may also be strongly considered with
severe physiologic derangements or any other progression of a prior medical illness.3 The ICU case
mix may differ among locations and may involve differences in utilization according to patient age and
do-​not-​resuscitate status.2,4
Uniform criteria for admission to the NICU
are difficult to establish, and some ambiguity will
always remain. As may be expected, decisions to
triage are physician specific and personal, and
there is some leeway. Decisions could well be
guided by bed availability. This all may seem easy
in times of plenty, but it becomes definitively more
complicated when (barely) recovered patients in
the NICU may have to give way to new admissions. The economic pressure on physicians to
reduce the length of hospital stay is always a factor,
and this may also have an impact on ICU admission7 (Capsule 2.1). In some ICUs, fast-​track programs are in place. These postoperative programs
involve early extubation, reduced use of postoperative sedation, and pre-​authorized implementation of ICU transfer orders.6,7
Admission to the NICU must be free of bias
and requires excellent rapport among the physician, nurse manager, and charge nurse. Criteria for
NICU admission should be flexible.8 For instance,
sedation for marked agitation or monitoring of
airway patency alone may justify admission for
some patients. Also, although the suitability of
NICU admission may be questioned for patients

with an unsalvageable acute brain injury, transition to comfort care is rarely performed in the
emergency department, and these patients may
be admitted to the NICU to await the arrival of
patients’ families and to allow time for the families
to come to grips with the situation. Palliation may

also involve the activation of an organ procurement protocol, and these complex logistics are
better handled in the NICU.
Criteria can be developed to assist in the initial
assessment of NICU eligibility. These criteria can
involve signs and symptoms (Figure 2.1) or specifically refer to major neurologic or neurosurgical
disorders. The admission criteria for each of these
neurologic disorders (discussed in Part VII of this
book) are summarized in Table 2.1 for easy reference. Admission to the NICU after elective neuroendovascular procedures seems undisputed, but
others found that step-​down units may suffice in
patients with coiling of unruptured cerebral aneurysms. Recognition of sudden new complications
that may require intervention would need to be
guaranteed, and thus many opt for safety in the
NICU setting.10,15
While little disagreement exists regarding triage to an ICU, how much care—​beyond
appropriate support and initial management—​should be provided in the emergency
department before transfer is debatable. Most
physicians would want to see the patient in an
NICU promptly after initially resuscitated and
stabilized. Transfer documentation between the
emergency department and the NICU (known
in hospital jargon as “sign-​
outs” or “hand-​
offs”) best includes certain essential elements
about the patient’s condition (Table 2.2) and
is best communicated between the attending
emergency physicians and the attending neurointensivists and charge nurse. Information
about the patient’s neurologic condition should
include level of consciousness, focal findings,
seizure control (if any), and a summary of computed tomographic (CT) or magnetic resonance

CAPSULE 2.1    INTENSIVE CARE RESOURCES AND BED RATIONING
A survey in the United States found that only a small proportion of physicians believe that limitations
on the use of intensive care unit (ICU) resources exist; more often, physicians believe that excessive
care is given to patients.17 Resources in the ICU are often challenged, and critical care admissions may
be determined on the basis of selection bias and personal preference. Patient age may be a factor in
ICU admission, but it does not override severity of illness.14 Ageism may play a role, but a definitive
age criterion or threshold was not supported by 95% of ICU physicians when surveyed.14 A propensity
exists for ICU admission and later withdrawal, rather than refusal of admission for elderly patients.13
Case mix in the ICU may differ considerably among countries. As expected, transfers from other hospitals involve sicker patients and may impact negatively on quality measures.16 Fewer patients may
be admitted when ICU beds are scarce, but nursing workload is a major factor in the number of ICU
admissions.12
A position statement with broad general recommendations for all ICUs has been proposed.1 It
includes the following premises:
1. Access to ICU care requires sufficient medical or surgical need.
2. Patients should have equal access to the ICU, regardless of ability to pay.
3. Patients should receive all resources appropriate to their needs.
4. When ICU demand exceeds its capacity, patients should be admitted on a first-​
come,
first-​served basis.
5. Access to marginally beneficial ICU care may be restricted on the basis of limited benefit.

Deterioration in
neurologic deficit

Need for monitoring or
neurosurgical intervention

Ascending or rapid
worsening paralysis

Need for neurosurgical intervention
Need for respiratory support

Agitation

Need for repeated
IV sedation

Stupor
or coma

No

Intermediate
unit or ward

Need for respiratory support
Yes

Seizures

Need for 2° or 3° line AED

Neuromuscular
respiratory failure

Need for respiratory
monitoring or support

Cardiac arrhythmias
Abnormal troponin

Need for IV drugs or infusion

Acute
hypertension

Need for IV drugs or infusion

FIGURE  2.1:   Common

NICU or ICU

signs and symptoms associated with acute neurologic illness when triaging patients to an
intensive care unit or other wards.
AED, antiepileptic drug; ICU, intensive care unit; IV, intravenous; NICU, neurosciences intensive care unit.


TABLE 2.1.   COMMON REASONS FOR ADMISSION TO THE NEUROSCIENCES

INTENSIVE CARE UNIT
Aneurysmal subarachnoid hemorrhage
Drowsiness, stupor, or coma
Mechanical ventilation
Any neurologic deterioration
Seizures
Neurogenic pulmonary edema
Aspiration pneumonia
Cardiac arrhythmias

Abnormal electrocardiogram
S/​P coil placement
S/​P clipping of aneurysm
Ganglionic or lobar hemorrhage
Drowsiness, stupor, or coma
Mechanical ventilation
CT scan evidence of brain shift
Hypertensive surges
Recurrent seizures
Coagulopathy or warfarin use
S/​P ventriculostomy
S/​P craniotomy
Cerebellum or brainstem hemorrhage
Drowsiness, stupor, or coma
Mechanical ventilation
CT or clinical signs of brainstem compression
Cardiac arrhythmia
S/​P ventriculostomy
S/​P craniotomy
Major hemispheric ischemic stroke syndromes
Drowsiness, stupor, or coma
Mechanical ventilation
CT scan evidence of early swelling
or hemorrhagic conversion
Seizures
Cardiac failure or arrhythmias
S/​P craniotomy
S/​P endovascular intervention
Basilar artery occlusion
Drowsiness, stupor, or coma

Mechanical ventilation
S/​P thrombolysis
S/​P endovascular intervention
Cerebellar infarct
Drowsiness, stupor, or coma
Mechanical ventilation
CT scan or clinical evidence
of brainstem compression
Cardiac arrhythmias
S/​P ventriculostomy
S/​P craniotomy

Acute bacterial meningitis
Drowsiness, stupor, or coma
Mechanical ventilation
CT scan evidence of edema
Any neurologic deterioration despite antibiotic
therapy
Seizures
Shock
Pulmonary infiltrates
Brain abscess
Drowsiness, stupor, or coma
Mechanical ventilation
CT scan evidence of mass effect
Seizures
S/​P drainage
S/​P stereotactic puncture
Acute encephalitis
Drowsiness, stupor, or coma

Mechanical ventilation
CT scan evidence of swelling
Seizures
S/​P brain biopsy
Acute spinal cord disorders
Mechanical ventilation
Cervical lesion
Ascending paralysis
Associated traumatic brain injury
Pulmonary infiltrates
Dysautonomia or acute bladder distension
Anticipated surgical intervention
Acute white matter disorders
Drowsiness, stupor, or coma
Mechanical ventilation
Seizures
Need to monitor plasma exchange
Acute obstructive hydrocephalus
Drowsiness, stupor, or coma
Mechanical ventilation
Ventriculostomy
Malignant brain tumors
Drowsiness, stupor, or coma
Mechanical ventilation
CT scan evidence of cerebral edema
Recurrent seizures
Status epilepticus
Drowsiness, stupor, or coma
Mechanical ventilation
Need for more intravenous antiepileptic drugs

Need for video/​EEG monitoring

(continued)


12

Part I: General Principles
TABLE 2.1  (CONTINUED)

Cerebral venous thrombosis
Drowsiness, stupor, or coma
Mechanical ventilation
CT scan evidence of hemorrhagic infarct
Seizures
Suspected pulmonary embolus
S/​P endovascular intervention

Traumatic brain injury
Drowsiness, stupor, or coma
Mechanical ventilation
CT scan evidence of contusions or early brain swelling
Seizures
Evidence of multitrauma
S/​P craniotomy

Guillain-​Barré syndrome
VC < 20 mL/​kg, PImax< −30 cm H2O, PEmax < 40 cm
H2O or 30% decrease in any of these values
Mechanical ventilation

Pulmonary infiltrates
Rapid clinical progression
Dysautonomia
Pneumonia or sepsis

Myasthenia gravis
Myasthenic crisis with neuromuscular respiratory
failure (VC< 20 mL/​kg or 30% decrease)
Bulbar weakness
Mechanical ventilation

CT, computed tomography; EEG, electroencephalography; ICH, intracranial hemorrhage; PEmax, maximal expiratory pressure;
PImax, maximal inspiratory pressure; S/​P, status post; VC, vital capacity.

imaging (MRI) findings. Information about
medical conditions should include vital signs,
airway control (and mechanical ventilator settings), pharmaceutical support, procedures and
interventions used in the emergency department, and pending laboratory test results.
Triage out of the NICU is not an exact reversal
of the original indication and is more complex
to regulate.5 Inability to clear secretions, continuous agitation, lability of blood pressure
measurements, and occasional need for IV
hypertensive drugs are all reasons for return to

TABLE 2.2.   C ONSI DE R AT IONS

F OR T R A N SF E R OF T H E NE U ROLO G IC
PAT IE N T (E SSE N T IA LS OF PAT I E NT
HA N D OF F S )
Detailed neurologic examination and clinical course

FOUR score (EMBR 0–​16)*
Mechanical ventilator settings
Review of dose of vasopressors
Review of recent use of neuromusculzar blocking
agents and sedatives
Review of antiepileptic drugs
Review of neuroimaging
Consult with interventional neuroradiologist
Meeting with family members for their
understanding of patient’s condition and
assessment of level of care.
*For FOUR score description, see Chapter 12.

the ICU (“bounce-​back”).9 Medication reconciliation is of utmost importance before transfer. Bounce-​backs within 24 hours seem less
common but more often are scrutinized for
errors. It is unclear if mortality or morbidity
is significantly higher with patients who have
returned. Bounce-​backs and unplanned transfers can be substantial when closely surveyed.11
The frequency of these incidents can be targeted by administrators as a quality measure
(see Chapter 14).

CONCLUSIONS
• Triage to the NICU could be based
on certain criteria. Any patient with a
neurologic disorder and unstable vital signs
(pulse rate, blood pressure, respiratory
rate, core temperature) or a progressive
neurologic presentation should be admitted.
• Communication between the physician in
the emergency department and the NICU

attending physician requires special effort.
• Triage out the NICU requires assessment
of neurologic and respiratory stability and
no recent use of IV antihypertensives or IV
cardiac drugs.
REFERENCES

1.The Society of Critical Care Medicine Ethics
Committee. Attitudes of critical care medicine
professionals concerning distribution of intensive
care resources. Crit Care Med 1994;22:358–​362.


Chapter 2: Criteria of Triage
2. Bagshaw SM, Webb SA, Delaney A, et al. Very old
patients admitted to intensive care in Australia
and New Zealand: a multi-​centre cohort analysis.
Crit Care 2009;13:R45.
3.Cohen RI, Eichorn A, Motschwiller C, et  al.
Medical intensive care unit consults occurring
within 48 hours of admission:  a prospective
study. J Crit Care 2015;30:363–​368.
4. Cohen RI, Lisker GN, Eichorn A, Multz AS, Silver
A. The impact of do-​not-​resuscitate order on triage decisions to a medical intensive care unit. J
Crit Care 2009;24:311–​315.
5. Coon EA, Kramer NM, Fabris RR, et al. Structured
handoff checklists improve clinical measures in
patients discharged from the neurointensive care
unit. Neurol Clin Prac 2015;5:42–​49.
6. Daly K, Beale R, Chang RW. Reduction in mortality after inappropriate early discharge from

intensive care unit:  logistic regression triage
model. BMJ 2001;322:1274–​1276.
7. Einav S, Soudry E, Levin PD, Grunfeld GB, Sprung
CL. Intensive care physicians’ attitudes concerning distribution of intensive care resources: a comparison of Israeli, North American and European
cohorts. Intens Care Med 2004;30:1140–​1143.
8. Escher M, Perneger TV, Chevrolet JC. National
questionnaire survey on what influences doctors’
decisions about admission to intensive care. BMJ
2004;329:425.
9. Fakhry SM, Leon S, Derderian C, Al-​Harakeh H,
Ferguson PL. Intensive care unit bounce back in
trauma patients: an analysis of unplanned returns
to the intensive care unit. J Trauma Acute Care
Surg 2013;74:1528–​1533.

13

10.Gaughen J, Jr, Hawk H, Evans A, Dumont A,
Jensen M. The necessity of intensive care unit
monitoring following elective endovascular
treatment of unruptured intracranial aneurysms
J Neurointerv Surg 2009;1:75–​76.
11. Gold CA, Mayer SA, Lennihan L, Claassen J, Willey
JZ. Unplanned transfers from hospital wards to the
neurological intensive care unit. Neurocrit Care
2015;23:159–​165.
12. Hurst SA, Hull SC, DuVal G, Danis M. Physicians’
responses to resource constraints. Arch Intern
Med 2005;165:639–​644.
13. Manara AR, Pittman JA, Braddon FE. Reasons

for withdrawing treatment in patients receiving
intensive care. Anaesthesia 1998;53:523–​528.
14. Nuckton TJ, List ND. Age as a factor in critical care unit admissions. Arch Intern Med 1995;
155:1087–​1092.
15. Richards BF, Fleming JB, Shannon CN, Walters
BC, Harrigan MR. Safety and cost effectiveness of
step-​down unit admission following elective neurointerventional procedures. J Neurointerv Surg
2012;4:390–​392.
16. Rosenberg AL, Hofer TP, Strachan C, Watts CM,
Hayward RA. Accepting critically ill transfer
patients:  adverse effect on a referral center’s outcome and benchmark measures. Ann Intern Med
2003;138:882–​890.
17. Ward NS, Teno JM, Curtis JR, Rubenfeld GD,
Levy MM. Perceptions of cost constraints,
resource limitations, and rationing in United
States intensive care units:  results of a national
survey. Crit Care Med 2008;36:471–​476.