Neurologic Emergencies
Domain focus
The Neurologic Emergencies domain tests stroke reperfusion, seizure control, coma evaluation, and headache red flags. Expect time-based decisions and careful exclusion of mimics.
Core rules
- Acute ischemic stroke: check glucose, CT without contrast, NIHSS. IV thrombolysis within 4.5 h if no contraindication; door-to-needle ≤60 min. BP must be <185/110 before thrombolysis.
- Do not lower BP aggressively unless >220/120 or reperfusion is planned.
- Large-vessel occlusion: consider mechanical thrombectomy up to 24 h in selected patients.
- Status epilepticus: benzodiazepine first (lorazepam 0.1 mg/kg or midazolam), then levetiracetam, fosphenytoin, or valproate.
- Headache red flags: thunderclap, fever, neurologic deficit, age >50, pregnancy/postpartum.
- Coma: check glucose and naloxone, protect airway, consider tox and trauma.
Worked example
A 70-year-old has sudden aphasia and right hemiparesis, last known well 2 hours ago. Glucose is normal, CT shows no hemorrhage, BP is 172/94. Give alteplase 0.9 mg/kg (maximum 90 mg), 10% bolus, remainder over 60 minutes, after consent and contraindication check. Reasoning: within 4.5 h, no hemorrhage, BP below 185/110, and disabling deficit.
Traps
Giving thrombolysis without excluding hypoglycemia is a classic error. Do not treat a thunderclap headache as migraine before excluding subarachnoid hemorrhage. Underdosing benzodiazepines in status epilepticus and delaying CT are costly.