6 Neurological Emergency Assessment and Prioritization

Start with immediate threats

Neurological emergencies require rapid recognition, repeated assessment, and stabilization of threats to life before detailed diagnosis. Begin with ABCDE, checking airway, breathing, circulation, level of consciousness, pupils, and limb movement. Measure glucose when it is available and appropriate, and immediately escalate sudden neurological changes.

Recognize and prioritize possible stroke

Sudden facial droop, slurred speech, difficulty speaking, or one-sided weakness may indicate an acute stroke. Activate emergency stroke care, record the last-known-well time, and arrange rapid transport. Do not wait to see whether symptoms resolve; treatment options depend on timely evaluation.

A promptly available glucose check can help identify hypoglycemia as a stroke mimic, but it must not stop or delay the time-sensitive stroke assessment. Keep the patient NPO until swallowing safety is assessed, and do not give food, water, or oral glucose when swallowing is unsafe. Do not give aspirin before clinicians have evaluated for bleeding.

When prioritizing several patients, assess a patient with a new facial droop and difficulty speaking before patients with a resolved headache and normal findings, a stable old tingling sensation, or a known seizure disorder after recovery to their usual state. Prioritize according to current threat and time sensitivity, not simply diagnosis history or symptom duration.

Respond to seizures

Protect a person having a convulsive seizure from nearby hazards, time the event, support airway and breathing, and activate emergency help when needed. A seizure lasting five minutes or longer, repeated seizures without recovery, or breathing problems require emergency help.

Do not restrain the person’s arms or legs, put an object in their mouth, or offer water while the event is ongoing or swallowing is unsafe.

Escalate worsening findings after head injury

After a head injury, worsening drowsiness or confusion, repeated vomiting, unequal pupils, seizure, or new weakness are danger signs that require urgent emergency care. Reassess and support airway, breathing, and circulation while escalating; do not allow a patient with worsening signs to simply sleep without further checks.

A declining level of consciousness or worsening neurological findings may indicate evolving intracranial pathology. Do not rely on a single earlier normal examination to rule out deterioration, and do not wait for the next scheduled check when the patient is worsening. Preventing secondary injury includes avoiding hypoxia and hypotension.

Worsening headache and confusion after head trauma require urgent evaluation, including when the patient is taking an anticoagulant. Anticoagulant use is important information for the emergency team, and the absence of an initial loss of consciousness does not rule out serious injury.

Protect the spine while resuscitating

Neck pain and tingling in the limbs after major trauma raise concern for spinal injury. Minimize spinal movement and maintain spinal alignment during assessment and care. Do not ask the person to sit up or walk to test strength, or rotate the neck to assess its range of motion.

Continue to prioritize airway, breathing, and circulation; do not delay airway support until imaging is completed. Record neurological findings and repeat the assessment.

Apply ongoing assessment and escalation

In suspected neurological emergencies, identify and treat immediate threats, escalate sudden or worsening changes, and repeat relevant assessments. Follow local emergency protocols and qualified clinical direction in actual care.

• prolonged seizure

• neurological deterioration