Urgent considerations

See Differentials for more details

Ischaemic stroke

Unilateral, complete, or partial loss of muscle strength in the face, arm, and/or leg is a typical presentation of stroke. Visual symptoms (e.g., partial or complete hemianopia, gaze palsies) may also feature. Suspected ischaemic stroke warrants immediate diagnostic and therapeutic intervention to reduce the deficit and reduce secondary injury.[6][7]

Immediate non-contrast computed tomography (CT) effectively excludes intracranial haemorrhage before administering thrombolytic agents and may detect signs of ischaemic stroke.[8][7]​​ Magnetic resonance imaging (MRI) is also effective for this purpose.​[6][7]​​[8]​​

Blood glucose must be measured and hypoglycaemia treated.[6]​ 

Thrombolysis should be administered within 4.5 hours of the onset of stroke symptoms.[7]​[9][10][11][12][13]​​​​​​​​​ Mechanical thrombectomy is recommended for select groups of patients up to 24 hours from stroke onset.[6]

Intracranial haemorrhage

Subdural haemorrhage may follow relatively minor trauma and may be suggested by nausea, vomiting, confusion, diminishing Glasgow Coma Scale score, localised weakness, loss of bowel function, and bladder weakness.

Subarachnoid haemorrhage (SAH) typically features a sudden, severe, 'worst ever' headache, with photophobia, loss of consciousness, and third cranial nerve palsy.

Any form of intracranial haemorrhage can be a life-threatening, progressive process, especially in the increasing number of patients being treated with antiplatelet or anticoagulant medications. Subarachnoid haemorrhage and intraventricular haemorrhage, in particular, are life threatening if they remain undiagnosed.

Urgent CT imaging is the standard diagnostic test for SAH.[7]​ Modern CT scanners will detect SAH in 93% of cases if performed in the first 24 hours after the bleed, and in 100% of cases when performed within 6 hours of onset of headache and interpreted by experienced neuroradiologists.[14][15][16][17] If a patient presents with a suspected SAH but a CT scan is normal, or if more than 24 hours have elapsed since the symptoms started, a lumbar puncture may be performed to test for xanthochromia (the presence of degraded haemoglobin in the cerebrospinal fluid). Urgent endovascular intervention or surgery may be indicated.

Spinal cord compression

This can arise from myriad aetiologies. Clinical features may include back pain, numbness, or paraesthesias, weakness or paralysis, bladder and/or bowel dysfunction, hyperreflexia, and loss of tone below the level of suspected injury. Saddle (perineal) anaesthesia, bladder retention, and leg weakness is typical of cauda equina syndrome.

Prompt MRI spine is the imaging study of choice for suspected spinal cord compression. Gadolinium contrast may be used when osteomyelitis or epidural abscess is suspected. CT myelography is generally reserved for people who have contraindications to MRI scanning. If there is a history of spinal trauma, CT can detect fractures, vertebral misalignment, and prevertebral soft tissue swelling, in addition to spinal cord compression. Imaging is essential to defining the extent and cause of the problem and will help define the best approach to decompression and definitive treatment.

Myasthenic crisis

This involves any exacerbation of myasthenia gravis (MG) requiring mechanical ventilation. MG crisis may be provoked by infections, aspiration, medications including high-dose corticosteroids, surgery, or trauma. If respiratory muscles become involved, patients require intubation, ventilatory support, and intensive care.[18]

Guillain-Barre syndrome

Guillain-Barre syndrome (GBS) typically follows a viral or bacterial illness, usually featuring ascending paraesthesia in the hands and feet, followed by lower limb weakness, leg and back pain, and areflexia or hyporeflexia.

Ultimately, this rapid-onset, ascending polyneuropathy often involves the respiratory muscles, necessitating intubation, ventilatory support, and intensive care. Death can occur due to adult respiratory distress syndrome, sepsis, pneumonia, pulmonary emboli, and cardiac arrest.

Compartment syndrome

Typically occurs after trauma or a crush injury, it is characterised by a tense muscle compartment, with a pale, pulseless distal limb, with reduction or loss of motor and sensory function. If this condition is suspected, it is important to undertake formal measurement of compartment pressures. If not treated (usually by surgical fasciotomy), neuromuscular injury can quickly ensue.

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