Neurological emergenciesSarah RamsayDept of Anaesthesia and ICU

Are you in a coma or only sleeping??. Avoid secondary injury... Purpose of assessment• To document the level of consciousness and other brain functions so that the patient's progress can

Neurological emergencies

Sarah RamsayDept of Anaesthesia and ICU

Are you in a coma or only

sleeping??

Approach to the unconscious patient

Specific conditions

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

GLASGOW COMA SCALE

• Verbal

• Motor

• Eyes

GLASGOW COMA SCALE

• Verbal

• Motor

• Eyes

• Glucose, RFTs, LFTs, ABGs, CBC, coag

• ECG, baseline CXR

• CT +/- contrast

• Others: Infection screen, TFTS, blood

alcohol level, toxicology,

LP (rare)EEG, MRI

• Resuscitation = ABC (2o injury; c-spine)

• Emergency treatment (glucose; thiamine;

• 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

Subdural

Extradural

Infection

Toxins and drugs

• Status epilepticus

• Acute CVA

• Head injury

Status epilepticus

• Risk of brain damage: local & 2o injury

• “Recurrent seizures with failure to

recover from one seizure before next seizure begins”

• “continuous clinical or electrical seizure activity for >30 mins; regardless of

conscious level”

Known epileptic or de novo case

SE: Why so bad?

SE: Treatment

• ABC & oxygen & IV access

• Glucose if indicated or unsure

16000 new strokes in HK

Ischaemic stroke

• Most will not get ICU care

• Supportive therapy:

– oxygen, avoid aspiration

– maintain cerebral perfusion (HR & BP

control – labetolol)– Aspirin (& ? Warfarin)

• Stroke units

Ischaemic stroke

Thrombolytic therapy (rt-PA) :

lower mortality & 30% improved morbidity

 onset of <3 hour before start of t-PA

 moderate to severe neurological deficit in carotid

artery territory

 Haemorrhagic infarction

 Hypertension: systolic >185 diastolic > 100

 History of warfarin therapy or PT >15 seconds

 Platelet count <100,000

Ischaemic stroke

Decompressive craniectomy

• Large middle cerebral artery,pan

hemispheric & cerebellar infarctions

• Massive cerebral oedema associated

with early mortality

• Consider surgery if medical treatment

fails / rapid deterioration

• Improved mortality; still debilitated

• Supportive therapy

• Surgery

ICH: surgery

 Large clots in the frontal, temporal

or occipital regions with progressive

• 75% aneurysm rupture; 5% AVM; rest ?

• Outcome depends on grade at

presentation

• Grade 5 SAH, Age>75,

GCS < 5 without

hydrocephalus or intracerebral

haematoma unlikely to benefit

from aggressive treatment