Neurological and Psychiatric Emergencies
Core concepts
Know the stroke pathway: time of onset, glucose and CT first, thrombolysis window, and thrombectomy criteria. Understand the difference between ischaemic and haemorrhagic stroke and when to reverse anticoagulation. Cover status epilepticus management (benzodiazepine first-line, then second-line agent, then anaesthesia), and the recognition of raised intracranial pressure and herniation syndromes. Headache red flags (thunderclap, fever, focal deficit, age over 50) must be memorised. For psychiatric emergencies, focus on risk assessment, safe containment, serotonin syndrome, neuroleptic malignant syndrome, and acute agitation management.
Traps
Always check glucose before labelling a deficit as stroke. A thunderclap headache is subarachnoid haemorrhage until excluded - a normal CT early may need lumbar puncture. In status epilepticus, do not under-dose the benzodiazepine. Distinguish NMS (rigidity, hyperthermia, raised CK) from serotonin syndrome (clonus, hyperreflexia).
Rule of thumb
In any acute neurological presentation, the first three actions are airway protection, glucose check, and a non-contrast CT head. Time is brain: document the last-known-well time precisely.
Worked example
A 70-year-old on warfarin presents 2 hours after sudden right hemiparesis; INR is 3.5 and CT shows no blood: thrombolysis is contraindicated by the raised INR - arrange thrombectomy assessment and reverse anticoagulation.