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The Practice of Emergency and Critical Care Neurology puts a more modern approach on the practice of emergency neurological care. This new edition concentrates on the management of neurologic conditions, recognition of deterioration of neurologic functions, neurosurgical procedures, and immediate interventions. Dr. Wijdicks condenses essential information into several sections comprising of the principles in recognizing critically ill neurologic patients in the emergency department, the evaluation of symptoms indicating critical emergency, general principles of managing critically ill patients, monitoring devices and diagnostic tests, complete management of specific disorders in the neurosciences intensive care unit, postoperative neurosurgical and neurointerventional complications, management of medical complications, and end of life care.

Purpose of Review This study aims to provide a concise delirium review for practicing emergency medicine providers using the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) framework. Recent Findings Delirium is a form of acute brain dysfunction that results in significant mortality and morbidity for older emergency department (ED) patients. Delirium is frequently missed by healthcare providers, but monitoring for this syndrome using brief delirium assessments may improve recognition. Once delirium is diagnosed, emergency medicine providers’ primary goal is to perform a comprehensive history and physical examination to uncover the underlying etiology for delirium. This includes obtaining history from a collateral historian and obtaining an accurate medication history. If posssible, emergency physicians (EPs) should treat the medical etiology that precipitated the delirium. If agitated, non-pharmacologic interventions such that minimize the use of tethers are preferred. Pharmacologic agents such as antipsychotic medications should be used as a last resort. Summary Delirium is a common geriatric emergency and requires the EP to assess, diagnose, evaluate, prevent, and treat. Delirium is a key geriatric syndrome that geriatric ED providers should routinely screen for. A strong emphasis is on the widespread use of delirium screening, followed by prevention and treatment efforts.

Purpose of Review This review summarizes the current knowledge and evidence behind the diagnosis and management of adult status epilepticus (SE) in the Emergency Department (ED). It incorporates the most recent evidence-based diagnostic and management strategies, while reflecting them back onto the foundational aspects of SE care. Recent Findings Recent studies have re-emphasized the importance of early and appropriately dosed benzodiazepines as first-line therapy for SE. Second-line therapy has evolved from phenytoin to alternative anti-epileptics (AEDs) like levetiracetam. Additionally, cerebral perfusion-computed tomography (PCT) and electroencephalogram (EEG) are critical in the diagnosis of non-convulsive SE (NCSE) in the ED. Summary Early and aggressive medical management is crucial to curb the morbidity and mortality of adult SE in the ED starting with benzodiazepines and progressing to AEDs. Patients who remain altered after treatment may still have NCSE. Due to the clinical subtleties associated with NCSE, it is essential to utilize tools such as alternative EEG monitoring and PCT.

Purpose of Review This review seeks to inform ED providers about best practices in the evaluation and treatment of new onset seizures in adults as well as those with established seizure diagnosis and breakthrough seizures. Recent Findings Current evidence suggests that early EEG has a higher rate of detecting epileptiform activity which is important as it can determine which patients need initiation of AED therapy. Early initiation of AEDs is important because although it does not have a mortality benefit or improve long-term remission it does improve quality of life and number of seizures. Summary Appropriate assessment and treatment of new onset and breakthrough seizures are crucial for this common presentation. Successfully ruling out other etiologies and ensuring timely follow-up and EEG/neuroimaging are key decisions ED providers must make in the care of these patients. Given the variability of neurology consultation and follow-up based on location, ED providers must understand and well utilize their available resources to advocate for best care for patients with seizures in their EDs.

Purpose of Review Emergency providers are well prepared for the rapid diagnosis and management of common etiologies of altered mental status. However, patients with persistently altered mental status of unclear etiology can present diagnostic and management challenges. Recent Findings Enhanced laboratory and imaging testing for patients in the emergency department has enabled the expanded workup and rapid diagnosis of life-threatening etiologies of altered mental status. Emergency physicians can improve patient care by reviewing updates in the current understanding of complex conditions causing altered mental status such as posterior reversible encephalopathy syndrome, vasculitis, and autoimmune disorders. Summary Herein, we provide a discussion of clinical cues and brief management pearls for some of the less common causes of altered mental status encountered in adults in the emergency department.

Purpose of Review Vertebral or carotid artery dissections, collectively called cervical artery dissections (CeADs), are uncommon, regularly missed vascular injuries. They are associated with major trauma, but also occur spontaneously or with relatively minor trauma. Diagnosis hinges on imaging identification. Previously, catheter angiogram was the gold standard, but currently, there is no consensus on the initial imaging study. Recent Findings Computer tomography angiography (CTA) is the most common initial study for CeAD, but can fail to identify some dissections. MRI/MRA provides better images and is preferred in the pediatric population, but misses some pathology. Newer MRI/MRA techniques are improving diagnostic accuracy for CeADs. Ultrasound is increasingly used for screening and monitoring. Treatment focuses on preventing thromboembolic events with antiplatelet or anticoagulation medications, though neither appears superior based on the CADISS trial. Summary No imaging study is the best initial CeAD study. MRI/MRA is preferred for pediatric patients. Ultrasound has good specificity for CeAD identification with caveats.

Purpose of Review This review describes the technologies and methods currently utilized to detect large vessel occlusion (LVO) ischemic stroke in the prehospital setting. A comparison of various LVO stroke scales, including their similarities and differences, is included. Emerging technology, novel stroke detection methods, and likely areas of future research are discussed. Recent Findings Many prehospital stroke detection scales have been described previously in the medical literature, characterized by varying degrees of efficacy. Despite their cost-effectiveness and ease of use, prehospital stroke scales do not reliably detect LVO. Current efforts in prehospital LVO stroke detection are aimed at improving upon the sensitivity and specificity of these scales, leveraging new screening technologies to streamline LVO triage and decrease time-to-intervention. Summary The prehospital stroke scales that we reviewed differ greatly in many respects, including their definition of LVO and the type and number of items tested. Despite the tremendous global effort made to rapidly triage and deliver LVO stroke patients to definitive treatment centers, no single scale has emerged with both a high positive predictive value (PPV) and negative predictive value (NPV). This has led to a lack of consensus, preventing widespread adoption of a single scale for prehospital LVO detection. Despite the ever-increasing number of stroke scales available to the prehospital clinician, LVO detection remains a challenge. Future advances in prehospital LVO stroke detection are expected to involve new and improved in-field diagnostic testing.

Purpose of Review This review seeks to provide clinicians with an approach to evaluation of individuals with presenting symptoms of upper extremity weakness, paresthesia, or pain. We will discuss advances made in the evaluation and treatment of upper extremity palsies, focusing on expected physical examination findings, initial evaluation, and management. Recent Findings While more common syndromes such as carpal tunnel syndrome and cubital tunnel syndrome have well-established diagnostic and treatment algorithms, the less common syndromes also have made advances in examination, electrodiagnostic testing, and both conservative and surgical treatment algorithms. Summary In the evaluation of individuals with signs of an upper extremity palsy, it is critical to be comfortable with the anatomy and physical examination of the upper extremity. Advances in electrodiagnostic testing show promising opportunities for prognostication, treatment, and further development of surgical techniques to hopefully improve patient outcomes with upper extremity palsies.

Purpose of Review To provide a summary of mobile stroke unit (MSU) utilization within Emergency Medicine stroke systems. Recent Findings MSUs have been deployed around the world into prehospital stroke systems demonstrating the ability to differentiate stroke subtypes and to initiate thrombolysis in eligible patients with shorter symptom onset to treatment times than conventional systems. MSU technology may enable the administration of other standard interventions or future experimental agents in the hyperacute time window. It is conceivable that MSU technology may be extended to other disease states in resource-limited areas without immediate access to an emergency department. Summary MSUs can identify key stroke subtypes and offer promising reductions in treatment times for the time-sensitive condition of acute ischemic stroke. Further research is necessary to guide optimal utilization within stroke systems.

Purpose of review This review summarizes how a concussion is defined and diagnosed. We seek to give physicians and other providers a better understanding of the tools available to help diagnose and manage concussion in the Emergency Department. Recent findings There is a paucity of research on how to diagnose and manage concussion in the Emergency Department. What has been done has demonstrated that there are patients with concussion who are not being diagnosed correctly or given proper discharge instructions on their condition. Most of the existing research focuses on sports-specific concussion. Summary Emergency Department physicians have an opportunity to correctly diagnose concussions and ensure patients have a plan for follow-up care and for gradual return to activity.