An Sist Sanit Navar
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An Sist Sanit Navar · Jan 2008
[Patients with alteration of consciousness in the emergency department].
A subject is conscious when he is awake and with an adequate awareness of him and the environment. The term alteration of consciousness requires specification as to whether it defines alteration of arousal--when the patient might be confused, in a stupor or in some degree of coma (light, deep)--or alteration of awareness--that is, confused (spatio-temporally disoriented, with difficulty in maintaining his attention), with or without delirious ideation. The coma, in the strict sense, originates from structural (neurological) or functional (metabolic) dysfunction of the ascending reticular activator system, but it is accepted that it can derive also from diffuse bi-hemispheric cortical-subcortical damage. ⋯ Neurological exploration will specify the respiratory, pupil and ocular patterns and motor responses. The depth of the coma is established through scales; a simplification of Jouvet's scale is proposed. The etiological diagnosis will on occasion require image tests and lumbar puncture.
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Intracerebral haemorrhage (ICH) results from the spontaneous rupture of an intracranial vessel. It comprises about 15% of all cerebrovascular diseases, and carries the highest risk of mortality and morbidity. ⋯ Ultra-early haemostatic agents such as recombinant factor VII (rfVII) may have a role in ICH management; although further clinical trials are required for it to be used in routine management. This article reviews its pathophysiology and natural history, and the evidence supporting recent advances in medical and chirurgical management for spontaneous ICH.
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Cerebral ischaemia is a dynamic process triggered when an intracranial artery is acutely occluded, normally due to an embolism from the heart or from arteriolosclerotic lesions of more proximal arteries. Urgent rerouting of these arteries and early reperfusion of the cerebral tissue, neuroprotector therapies that intervene in the ischaemic cascade and prevention of recurrence are the therapeutic aims in the acute phase of ischaemic stroke. Thrombolytic treatment pursues the lysis of the dot occluding the intracranial artery. ⋯ Establishment of this treatment involves a profound change in the health structures and the training of the personnel responsible. The small therapeutic window and the limitations of this medicine in daily practice have led to the urgent exploration of new strategies: we review the reconsideration of exclusion criteria (especially in the elderly and in minor neurological deficits or those of rapid improvement), the widening of the therapeutic window beyond 3 hours with the selection of patients by multimodal image, the possibility of thrombolysis combined with antithrombotic drugs or with enhancement through ultrasound. We also review the new thrombolytics that are appearing and the intra-arterial thrombolysis approach and therapies of endovascular mechanical reperfusion.
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Headache is among the most frequent neurological symptoms in the Emergency department. Although most of the patients suffer from primary headaches (migraine), an acute headache might be the only symptom of a serious disease, such as subarachnoid haemorrhage. ⋯ An accurate history will identify most of the patients with secondary headaches. Clinicians should suspect secondary causes in sudden onset headache, headache in patients aged over 50 years, and also in those patients with abnormalities on neurological examination.
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An Sist Sanit Navar · Jan 2008
[The problem of neurological emergencies and the need for specific neurology shifts].
In recent years different studies have highlighted a progressive increase in the demand for neurological care in emergency departments. To analyze the convenience of specific neurology shifts or the role that the neurologist should play in the emergency department, it is necessary to answer questions such as: What is the demand for emergency neurological care? What are the most frequent neurological emergencies? Who should attend to neurological emergencies and why? Are specific neurology shifts necessary? Neurological emergencies account for between 2.6% and 14% of medical emergencies. ⋯ On the basis of quality of care criteria and professional competence, the best care for patients with a neurological emergency is provided by a specialist in neurology. The implementation of specific neurology shifts, with a 24 hour physical presence, is associated with greater quality of care, better diagnostic and therapeutic orientation from the moment the patient arrives in emergency department, reduces unnecessary admissions, reduces costs and strengthens the neurology service.