Common emergencies I see on the acute take- CNS and spine
I am going to share my experience of management of common emergencies I see on the acute take.
This is not an official guideline and is just my experience. Please refer to your local guidelines and always escalate if you are not sure.
Read the national NICE guidance here:
https://www.nice.org.uk/
Here is a list of communicable diseases you need to inform Public Health, England about:
https://www.gov.uk/health-and-social-care/health-protection
BRAIN
Headache? SAH
This is a common reason for admission.
There are some excellent guidelines here:
https://www.bash.org.uk/guidelines/ .
Usually these patients come with sudden onset headache , worst headache in their life, thunderclap in nature.
You have to rule out subarachanoid hemorrhage in such cases. The only way to do so is by performing a lumbar puncture.
I always ensure that their platelets, coagulation is normal and that they are not on any blood thinners. If they are, I always ask a consultant ( who usually asks me to talk to the haematology team).
Most patients have already had a CT head as well which confirms that they do not have raised intrancranial pressure secondary to a mass.
As a registrar, I tend to do a quick lumbar puncture if the history is very convincing, unless I am on nights or if the time of onset was less than 6 hours.
Please read my tips on doing lumbar punctures here:
https://omarsguidelines.blogspot.com/2020/02/procedures-sho-is-expected-to-do-in-nhs.html
If it is a day shift and not too busy, I try to get my SHOs and even FY1s to do lumbar punctures under my supervision and can get them signed off so that when there is a very busy shift ahead, the SHOs can do these independently and hence I, as a registrar can focus on seeing unwell patients. Also, the SHOs stay engaged this way and motivated to do on calls if they get to do procedures. Sometimes, I use the ambulatory clinic to do LPs ( Some trusts allow such procedures to be done in ambulatory clinic - it takes 10 minutes to prepare the trolley, 10 minutes to do the procedure and it takes 45 min to 2 hours to get the results - hence the patient can go home the same day).
Top tip:
?SAH patients can be discharged the same day if the LP results are normal.
What if the LP is not normal?
If the CSF analysis shows xanthochromia, usually we discuss this with the neurosurgery team and do a CT angio, re-discuss with neurosurgery who then take over the patient for surgery if appropriate.
Read the management here in more detail:
https://patient.info/doctor/subarachnoid-haemorrhage-pro
Meningitis
https://www.nice.org.uk/guidance/conditions-and-diseases/infections/meningitis-and-meningococcal-septicaemia
Unlike SAH, this warrants an urgent lumbar puncture. These patients tend to get unwell very quickly and have already received the first dose of IV antibiotics. I again make sure their clotting, platelets are normal. They usually have had a CT head however some trusts/radiologists state it is not required.
Remember that you may need to inform Public Health, England if it is a communicable disease ( which depends on the LP results).
I also send an extra sample for the lab to save as the microbiology team may need more samples to do further tests.
Top tips:
History is very important - they may just have frontal headache and the CT head shows sinusitis. This is unlikely to be meningitis UNLESS there are red flags.
Do not ignore the dark room - photophobia, fever, high CRP should not be ignored.
Take a detailed travel history and talk to the microbiology team if you are unsure about anything. Please do not delay antibiotics. Follow your local guidelines.
Please do a LP ASAP but DO NOT delay treatment.
Send an extra sample for saving as the micro team may want to do further tests.
Stop antibiotics if the LP is normal, ONLY if it was done after a single dose of antibiotics. Remember that the LP can be misleadingly normal if it was done after a few doses of antibiotics.
This is my experience of working as a core medical trainee year 2 in neurology:
https://omarsguidelines.blogspot.com/2019/06/my-experience-of-working-in-neurology.html
Stroke
http://omarsguidelines.blogspot.com/2018/02/teaching-session-stroke.html
Be aware of inpatient strokes. I remember how a HCA noticed subtle slurred speech and facial drooping of an inpatient. She informed the nurse in charge, me and the stroke nurse on call. We got the patients CT head done urgently and after discussion with the stroke consultant on call, the patient was thrombolysed ( the symptoms had gotten worse by then) - all within less than 30 minutes.
For hemorrhagic strokes when the patient is on warfarin/NOAC, ensure that this is reversed ASAP - refer to your local guidelines or call the hematologist on call.
Top tips:
Call the stroke nurse ASAP. They can organize CT heads urgently and coordinate with the stroke consultant on call if they need urgent thrombolysis
I/P strokes should not be missed and hence you should have a low threshold to consider this as a differential.
Be aware of stroke mimics.
Do not thrombolyze the patient without involving the appropriate teams - in my trust, it is the stroke consultant on call who makes this decision.
Brain metastasis/ solitary mass
This present in very strange ways.
I remember a patient who used to come in with CCF secondary to critical aortic stenosis all the time. On the 5th admission, she was mildly dizzy. On detailed examination, she had nystagmus, ataxia, positive rhombergs.
CT head shows a massive solitary mass, CT head with contrast confirmed this and she was then transferred to a tertiary center for further management.
Top tips:
Never take "dizziness" lightly - do a very thorough neurology examination and you will pick up more findings ( a medical registrar has given PACES and can do this in less than 4 minutes).
When in doubt, scan the head.
SPINE
Metastatic spinal cord compression
https://www.nice.org.uk/guidance/cg75
This is a potentially treatable condition. The patient usually has an underlying malignancy ( this may be un-diagnosed) and hence a detailed history and neuro exam is very important.
Each trust has its own guidelines for management of cauda equina.
Top tips:
Always do a PR - to check for anal tone and you can also appreciate saddle anesthesia.
Do a detailed neurological examination Print out your local guidelines for this and follow the pathway.
Always consider this in your differentials if you have the following info: Known cancer, leg weakness/ incontinence/ loss of sensation.
Performance status is an important factor the oncology team would like to know prior to deciding the best treatment option:
https://www.nice.org.uk/guidance/ta121/chapter/Appendix-C-WHO-performance-status-classification
Back pain
There are various differentials of this. The most important ones which we need to rule out are:
Metastatic spinal cord compression
Unstable vertebral fracture
Both can be ruled out after a detailed history and examination ( look for spinal tenderness, .
Always do a X ray of the spine to rule out an obvious fracture.
Most cases are elderly, had a fall. X ray NAD, bloods ( including bone profile, Vit D) normal, are seen by the physio team in ED and then discharged from ED if they are mobilizing well.
In some cases, they have severe pain on mobilizing and need further scans- ie MRI spine/ CT spine if MRI contraindicated
Top tips:
Do not discharge a patient if (s)he is unable to mobilize. Do not take pain lightly - especially if they need high dose opioids. X ray is not specific enough for minor fractures. Hence, when in doubt -admit.
Check the bone profile - calcium, phosphate, Vit D : supplementation can prevent further fractures.
EYES
Papilloedema
https://patient.info/doctor/optic-disc-swelling-including-papilloedema
Most trusts have a papilloedema pathway. It is important to follow it. As it varies so much, it is difficult to discuss the management here. Usually, they end up having a LP checking for opening pressures to confirm whether there is an element of benign intracranial hypertension ( females, high BMI ). They are jointly manged by the eye team and neurology team. On the acute take, this is what is important:
1. Doing a CT head to r/o mass/ lesion
2. Doing a LP at some point ( non urgent - day time, not out of hours) to check opening pressures - still send a sample for protein, glucose, WCC, C+S
Hypertensive crisis
https://patient.info/doctor/hypertensive-emergencies
Blurred vision, BP 220 mmHg systolic.
Usually, these patients have gone to the opticians with reduced vision - they then refer them to ophthalmology when they see features of retinopathy, who then check the BP and refer them to acute medicine for management of 'hypertensive crisis".
This is what we do:
1. Investigate the underlying cause -urine dip for protein, urine PCR is important along with other routine bloods.
2. Detailed history and examination is important.
3. Do not forget the commonly asked conditions in our MRCP exams - pheochromocytoma, MEN syndromes ( I have seen a few of them- but they are still rare)
4. Treatment according to local guidelines - labetolol may be indicated in some cases.
OTHER WEIRD AND WONDERFUL CONDITIONS:
We may be referred management of possible strange infections seen on an routine eye examination. I usually end up talking to the ophthamology consultant on call, microbiology team and radiologists on what to do next.
I have mentioned a few conditions here as well:
https://omarsguidelines.blogspot.com/2019/06/my-experience-of-working-in-neurology.html
Top tips:
Do not be afraid of talking to the specialist teams even if it is out of hours. A patient has been admitted on the acute take for a reason - for acute management. And I am not smart enough to decide what the best management is for such patients. Hence, I always talk to the relevant specialists.
This is not an official guideline and is just my experience. Please refer to your local guidelines and always escalate if you are not sure.
Read the national NICE guidance here:
https://www.nice.org.uk/
Here is a list of communicable diseases you need to inform Public Health, England about:
https://www.gov.uk/health-and-social-care/health-protection
BRAIN
Headache? SAH
This is a common reason for admission.
There are some excellent guidelines here:
https://www.bash.org.uk/guidelines/ .
Usually these patients come with sudden onset headache , worst headache in their life, thunderclap in nature.
You have to rule out subarachanoid hemorrhage in such cases. The only way to do so is by performing a lumbar puncture.
I always ensure that their platelets, coagulation is normal and that they are not on any blood thinners. If they are, I always ask a consultant ( who usually asks me to talk to the haematology team).
Most patients have already had a CT head as well which confirms that they do not have raised intrancranial pressure secondary to a mass.
As a registrar, I tend to do a quick lumbar puncture if the history is very convincing, unless I am on nights or if the time of onset was less than 6 hours.
Please read my tips on doing lumbar punctures here:
https://omarsguidelines.blogspot.com/2020/02/procedures-sho-is-expected-to-do-in-nhs.html
If it is a day shift and not too busy, I try to get my SHOs and even FY1s to do lumbar punctures under my supervision and can get them signed off so that when there is a very busy shift ahead, the SHOs can do these independently and hence I, as a registrar can focus on seeing unwell patients. Also, the SHOs stay engaged this way and motivated to do on calls if they get to do procedures. Sometimes, I use the ambulatory clinic to do LPs ( Some trusts allow such procedures to be done in ambulatory clinic - it takes 10 minutes to prepare the trolley, 10 minutes to do the procedure and it takes 45 min to 2 hours to get the results - hence the patient can go home the same day).
Top tip:
?SAH patients can be discharged the same day if the LP results are normal.
What if the LP is not normal?
If the CSF analysis shows xanthochromia, usually we discuss this with the neurosurgery team and do a CT angio, re-discuss with neurosurgery who then take over the patient for surgery if appropriate.
Read the management here in more detail:
https://patient.info/doctor/subarachnoid-haemorrhage-pro
Meningitis
https://www.nice.org.uk/guidance/conditions-and-diseases/infections/meningitis-and-meningococcal-septicaemia
Unlike SAH, this warrants an urgent lumbar puncture. These patients tend to get unwell very quickly and have already received the first dose of IV antibiotics. I again make sure their clotting, platelets are normal. They usually have had a CT head however some trusts/radiologists state it is not required.
Remember that you may need to inform Public Health, England if it is a communicable disease ( which depends on the LP results).
I also send an extra sample for the lab to save as the microbiology team may need more samples to do further tests.
Top tips:
History is very important - they may just have frontal headache and the CT head shows sinusitis. This is unlikely to be meningitis UNLESS there are red flags.
Do not ignore the dark room - photophobia, fever, high CRP should not be ignored.
Take a detailed travel history and talk to the microbiology team if you are unsure about anything. Please do not delay antibiotics. Follow your local guidelines.
Please do a LP ASAP but DO NOT delay treatment.
Send an extra sample for saving as the micro team may want to do further tests.
Stop antibiotics if the LP is normal, ONLY if it was done after a single dose of antibiotics. Remember that the LP can be misleadingly normal if it was done after a few doses of antibiotics.
This is my experience of working as a core medical trainee year 2 in neurology:
https://omarsguidelines.blogspot.com/2019/06/my-experience-of-working-in-neurology.html
Stroke
http://omarsguidelines.blogspot.com/2018/02/teaching-session-stroke.html
Be aware of inpatient strokes. I remember how a HCA noticed subtle slurred speech and facial drooping of an inpatient. She informed the nurse in charge, me and the stroke nurse on call. We got the patients CT head done urgently and after discussion with the stroke consultant on call, the patient was thrombolysed ( the symptoms had gotten worse by then) - all within less than 30 minutes.
For hemorrhagic strokes when the patient is on warfarin/NOAC, ensure that this is reversed ASAP - refer to your local guidelines or call the hematologist on call.
Top tips:
Call the stroke nurse ASAP. They can organize CT heads urgently and coordinate with the stroke consultant on call if they need urgent thrombolysis
I/P strokes should not be missed and hence you should have a low threshold to consider this as a differential.
Be aware of stroke mimics.
Do not thrombolyze the patient without involving the appropriate teams - in my trust, it is the stroke consultant on call who makes this decision.
Brain metastasis/ solitary mass
This present in very strange ways.
I remember a patient who used to come in with CCF secondary to critical aortic stenosis all the time. On the 5th admission, she was mildly dizzy. On detailed examination, she had nystagmus, ataxia, positive rhombergs.
CT head shows a massive solitary mass, CT head with contrast confirmed this and she was then transferred to a tertiary center for further management.
Top tips:
Never take "dizziness" lightly - do a very thorough neurology examination and you will pick up more findings ( a medical registrar has given PACES and can do this in less than 4 minutes).
When in doubt, scan the head.
SPINE
Metastatic spinal cord compression
https://www.nice.org.uk/guidance/cg75
This is a potentially treatable condition. The patient usually has an underlying malignancy ( this may be un-diagnosed) and hence a detailed history and neuro exam is very important.
Each trust has its own guidelines for management of cauda equina.
Top tips:
Always do a PR - to check for anal tone and you can also appreciate saddle anesthesia.
Do a detailed neurological examination Print out your local guidelines for this and follow the pathway.
Always consider this in your differentials if you have the following info: Known cancer, leg weakness/ incontinence/ loss of sensation.
Performance status is an important factor the oncology team would like to know prior to deciding the best treatment option:
https://www.nice.org.uk/guidance/ta121/chapter/Appendix-C-WHO-performance-status-classification
Back pain
There are various differentials of this. The most important ones which we need to rule out are:
Metastatic spinal cord compression
Unstable vertebral fracture
Both can be ruled out after a detailed history and examination ( look for spinal tenderness, .
Always do a X ray of the spine to rule out an obvious fracture.
Most cases are elderly, had a fall. X ray NAD, bloods ( including bone profile, Vit D) normal, are seen by the physio team in ED and then discharged from ED if they are mobilizing well.
In some cases, they have severe pain on mobilizing and need further scans- ie MRI spine/ CT spine if MRI contraindicated
Top tips:
Do not discharge a patient if (s)he is unable to mobilize. Do not take pain lightly - especially if they need high dose opioids. X ray is not specific enough for minor fractures. Hence, when in doubt -admit.
Check the bone profile - calcium, phosphate, Vit D : supplementation can prevent further fractures.
EYES
Papilloedema
https://patient.info/doctor/optic-disc-swelling-including-papilloedema
Most trusts have a papilloedema pathway. It is important to follow it. As it varies so much, it is difficult to discuss the management here. Usually, they end up having a LP checking for opening pressures to confirm whether there is an element of benign intracranial hypertension ( females, high BMI ). They are jointly manged by the eye team and neurology team. On the acute take, this is what is important:
1. Doing a CT head to r/o mass/ lesion
2. Doing a LP at some point ( non urgent - day time, not out of hours) to check opening pressures - still send a sample for protein, glucose, WCC, C+S
Hypertensive crisis
https://patient.info/doctor/hypertensive-emergencies
Blurred vision, BP 220 mmHg systolic.
Usually, these patients have gone to the opticians with reduced vision - they then refer them to ophthalmology when they see features of retinopathy, who then check the BP and refer them to acute medicine for management of 'hypertensive crisis".
This is what we do:
1. Investigate the underlying cause -urine dip for protein, urine PCR is important along with other routine bloods.
2. Detailed history and examination is important.
3. Do not forget the commonly asked conditions in our MRCP exams - pheochromocytoma, MEN syndromes ( I have seen a few of them- but they are still rare)
4. Treatment according to local guidelines - labetolol may be indicated in some cases.
OTHER WEIRD AND WONDERFUL CONDITIONS:
We may be referred management of possible strange infections seen on an routine eye examination. I usually end up talking to the ophthamology consultant on call, microbiology team and radiologists on what to do next.
I have mentioned a few conditions here as well:
https://omarsguidelines.blogspot.com/2019/06/my-experience-of-working-in-neurology.html
Top tips:
Do not be afraid of talking to the specialist teams even if it is out of hours. A patient has been admitted on the acute take for a reason - for acute management. And I am not smart enough to decide what the best management is for such patients. Hence, I always talk to the relevant specialists.
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