Neurological Emergencies
By S.D. Shorvon
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Neurological Emergencies - S.D. Shorvon
Cambridge
Preface
About 10% of all emergency medical admissions are due to neurological disease. Neurology has a reputation for being complex and esoteric, yet in emergency settings this is unjustified. A simple logical approach will allow rapid diagnosis and effective treatment in the great majority of cases. Nevertheless, neurological emergencies are frequently mishandled, and this is unfortunate, as delayed diagnosis or treatment may have grave consequences for prognosis.
In this book the initial assessment and early treatment of patients presenting with neurological emergencies are outlined. The emphasis is on those clinical features that assist rapid diagnosis, emergency investigations and early treatment, and those situations in which urgent neurological or neurosurgical referral is advisable. The commonest emergencies only have been covered, and this text is no substitute for the comprehensive textbooks of neurology and therapeutics; rather it is intended as an essentially practical guide.
The book is aimed principally at the non-specialists who first receive the patient — the general practitioner, casualty officer and general medical teams — and the neurologist or neurosurgeon in training. It is often these doctors who have the burden of responsiblity for correct early management, and whose actions may profoundly affect the outcome. It is hoped that the book will make their task easier, and their practice more proficient.
S.D. Shorvon
1
Coma
Publisher Summary
This chapter discusses coma that is one of the most common neurological emergencies in general hospital practice and one in which skillful management may be lifesaving. Four basic principles are involved—resuscitation, diagnosis, serial monitoring, and treatment. Resuscitation is directed primarily at ensuring adequate circulatory and respiratory function. Diagnosis may seem daunting, as almost any intrinsic or extrinsic malfunction of the upper brain stem or extensive bilateral cerebral disorder can lead to coma, and the causes are multitudinous. Diagnosis of coma proceeds in two stages. The site of the neurological lesion is identified, which includes focal supratentorial, focal subtentorial, diffuse or systemic, and then, the likely etiology is established. The chapter highlights possible causes of coma—namely, infarction, hemorrhage, tumor, abscess, aneurysm, demyelination, diffuse neurological disorders, systemic disturbance, drugs, and poisoning. The first priority is to safeguard cardiorespiratory function. In the absence of coexistent cardiovascular disease, this is threatened only in deep coma. Pulse, blood pressure, and respiratory rate should be measured, the airways protected, and the patient kept in the coma position. If there is any evidence of respiratory insufficiency, artificial respiration should be considered; it is better to institute this early rather than late in the development of respiratory failure. As a supratentorial mass lesion expands, it may cause increasing compression of brain-stem structures by downward movement of the cerebral hemispheres. This is known as transtentorial herniation or coning.
Coma is one of the most common neurological emergencies in general hospital practice, and one in which skilful management may be life-saving. Four basic principles are involved: resuscitation, diagnosis, serial monitoring and treatment.
Resuscitation is directed primarily at ensuring adequate circulatory and respiratory function. Diagnosis may seem daunting, as almost any intrinsic or extrinsic malfunction of the upper brain stem or extensive bilateral cerebral disorder can lead to coma, and the causes are multitudinous (Table 1.1). However, a history and careful clinical examination are usually sufficient, and these are often best carried out in the casualty or emergency room. Serial monitoring of coma is necessary to detect improvement or deterioration in clinical status, as subsequent treatment may depend as much on such changes as on the underlying pathology. Observations are best made using an objective clinical scale such as the well-tried Glasgow Coma Scale, which is based on assessment of three aspects of neurological function (Table 1.2). Emergency treatment includes both specific and non-specific therapy, which is often initiated before the precise cause of the coma has been established. Transtentorial herniation (coning) is a particular danger of supratentorial mass lesions, and the emergency physician should be aware of the signs of this serious development and its treatment.
Table 1.1
Possible causes of coma of unknown aetiology
Focal supratentorial lesions (30%)*
Infarction
arterial (embolic, thrombotic, occlusive)
venous
Haemorrhage
intracerebral (e.g. arteriovenous malformation, hypertensive, other)
subdural
extradural
secondary to subarachnoid haemorrhage
Tumour
primary
secondary
Abscess
intracerebral
extradural
subdural
Other (e.g. hydrocephalus)
Focal subtentorial lesions (10%)*
Infarction
cerebellar
brain-stem
Haemorrhage
cerebellar
brain-stem
extradural
subdural
Tumour
primary
secondary
Other brain-stem disorders (e.g. abscess, aneurysm,