Neurological Emergencies
Core concepts
Neurological emergencies include stroke, traumatic brain injury, seizures and status epilepticus, altered mental status, and spinal cord injury. Prioritize airway, oxygenation, ventilation, and glucose. For suspected stroke, use a validated screen, establish last-known-well time, and transport to an appropriate stroke center. For TBI, prevent hypoxia and hypotension, maintain adequate cerebral perfusion, and avoid routine hyperventilation. Seizures require benzodiazepines per protocol and correction of reversible causes.
Traps
Questions often test permissive hypertension in ischemic stroke versus lowering blood pressure too aggressively. Pupillary changes are a late sign of herniation. Hypoglycemia can mimic stroke or seizure. Do not hyperventilate TBI patients unless there is evidence of herniation. Avoid hypoxia and hypotension, which worsen brain injury.
Rule of thumb
For TBI, aim to prevent hypoxia and hypotension; a common target is systolic blood pressure above 110 mm Hg in adults, following local protocol. Check glucose in every altered mental status.
Worked example
A patient with sudden right-sided weakness has a last-known-well time within the thrombolysis window. Check glucose, perform a stroke screen, avoid unnecessary blood pressure reduction, and transport to a stroke center. The trap is delaying transport for nonessential testing.