Medical and Neurologic Emergencies in Transport
Time-critical disease, time-critical decisions
Medical and neurologic transfers usually exist to protect a narrow therapeutic window. For stroke: last-known-well time, glucose, a validated severity screen, blood pressure under 185/110 before thrombolysis, and a pre-arrival alert so imaging begins on arrival. For STEMI: an early 12-lead, transmitted ahead, aspirin and anticoagulation per protocol, and destination chosen by PCI capability rather than distance alone. For sepsis: lactate, cultures, broad-spectrum antibiotics within the first hour, 30 mL/kg crystalloid for hypotension or lactate of 4 or more, and norepinephrine for MAP under 65.
Neuro: recognize herniation signs - declining consciousness, pupil asymmetry, and the Cushing response of hypertension with bradycardia and irregular respirations. Keep the head midline, avoid hypoxia and hypotension, and reserve hyperventilation as a brief bridge only.
Seizures: protect the airway, check glucose, treat status epilepticus with a benzodiazepine followed by a second-line agent, and never restrain a seizing patient's limbs.
Trap: hypoglycemia and postictal states mimic stroke, so a glucose check is not optional. Another: labels like "intoxicated" or "drug-seeking" hide subdural hematomas - a focused neuro exam beats a story.
Worked example: aphasia and right-sided weakness, last known well 90 minutes ago, BP 190/105. Rule of thumb: do not lower the pressure aggressively; bring it just below 185/110 to preserve lytic eligibility and let the receiving stroke team manage the rest. Document last-known-well explicitly - it is the most frequently missing element in transfer records.