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15 Assessment and management of neurological problems (2)
  1. C M Gavin,
  2. J T Gray
  1. Hope Hospital, Salford, UK
  1. Correspondence to:
 Dr C Gavin
 Consultant in Emergency Medicine, Hope Hospital, Salford, M6 8HD; carole.gavinsrht.nhs.uk

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Patients with neurological conditions present with a wide variety of symptoms and signs. These may sometimes be non-specific or vague and often present a diagnostic challenge to the practitioner. Therefore it is important that all patients are assessed using a robust system that will identify those who require urgent treatment or hospital referral. Box 1 describes the objectives of this article.

Box 1 Article objectives

This article will consider patients presenting with:

  • Collapse

  • Dizziness

  • Visual disturbance

  • Focal neurological deficit

  • Generalised weakness

THE PRIMARY SURVEY POSITIVE PATIENT

The patient should be assessed according to ABC principles (box 2).

Box 2 Primary survey

If any of the observations below are present treat immediately and transfer to hospital

  • Airway obstruction

  • Respiratory rate <10 or >29 per minute

  • Oxygen saturation <93%

  • Pulse <50 or >120 per minute

  • Systolic blood pressure <90 mm Hg

  • Glasgow Coma Scale score<12

The main categories of primary survey positive patients are covered in neurological problems (1),1 however, occasionally patients will be found to have an ABC problem not related to unconsciousness or fitting that will require immediate transfer to hospital.

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  • A airway obstruction/compromise—loss of protective airway reflexes or aspiration secondary to brainstem damage or dysfunction

  • B breathing inadequacy due to respiratory muscle involvement—for example, Guillain–Barré syndrome, myasthenia gravis, motor neurone disease

  • C circulatory compromise—hypotension due to arrhythmias may produce symptoms such as dizziness or collapse

The patient’s primary symptom should suggest the differential diagnosis. It is important that a thorough history is taken to elicit this further. A focused neurological examination will then enable the practitioner to decide if the patient can be managed at home or if referral is needed. An important clue to the possible aetiology is the speed of onset of symptoms (table 1).

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Table 1

 Speed of onset as a clue to possible aetiology

THE PATIENT PRESENTING WITH COLLAPSE/SYNCOPE

The management of the patient who …

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