The ABC of community emergency care 15 ASSESSMENT AND MANAGEMENT OF NEUROLOGICAL PROBLEMS (2) Box 1 Article objectives

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1 564 The ABC of ommunity emergeny are 15 ASSESSMENT AND MANAGEMENT OF NEUROLOGICAL PROBLEMS (2) THE P CMGavin,JTGray Emerg Med J 2005; 22: doi: /emj atients with neurologial onditions present with a wide variety of symptoms and signs. These may sometimes be non-speifi or vague and often present a diagnosti hallenge to the pratitioner. Therefore it is important that all patients are assessed using a robust system that will identify those who require urgent treatment or hospital referral. Box 1 desribes the objetives of this artile. Box 1 Artile objetives This artile will onsider patients presenting with: Collapse Dizziness Visual disturbane Foal neurologial defiit Generalised weakness PRIMARY SURVEY POSITIVE PATIENT The patient should be assessed aording to ABC priniples (box 2). Box 2 Primary survey If any of the observations below are present treat immediately and transfer to hospital Airway obstrution Respiratory rate,10 or.29 per minute Oxygen saturation,93% Pulse,50 or.120 per minute Systoli blood pressure,90 mm Hg Glasgow Coma Sale sore,12 Emerg Med J: first published as /emj on 26 July Downloaded from See end of artile for authors affiliations Correspondene to: Dr C Gavin, Consultant in Emergeny Mediine, Hope Hospital, Salford, M6 8HD; arole.gavin@srht.nhs.uk The main ategories of primary survey positive patients are overed in neurologial problems (1), 1 however, oasionally patients will be found to have an ABC problem not related to unonsiousness or fitting that will require immediate transfer to hospital. Tip A airway obstrution/ompromise loss of protetive airway reflexes or aspiration seondary to brainstem damage or dysfuntion B breathing inadequay due to respiratory musle involvement for example, Guillain Barré syndrome, myasthenia gravis, motor neurone disease C irulatory ompromise hypotension due to arrhythmias may produe symptoms suh as dizziness or ollapse The patient s primary symptom should suggest the differential diagnosis. It is important that a thorough history is taken to eliit this further. A foused neurologial examination will then enable the pratitioner to deide if the patient an be managed at home or if referral is needed. An important lue to the possible aetiology is the speed of onset of symptoms (table 1). on 17 September 2018 by guest. Proteted by opyright.

2 Table 1 Speed of onset Sudden Hours to days Days to weeks Weeks to months.months Speed of onset as a lue to possible aetiology Possible aetiology Stroke, hypoglyaemia Infetion, Guillain Barré syndrome, botulism Infetion, inflammation for example, temporal arteritis, polymyalgia Cerebral tumours primary or seondary Degenerative onditions, motor neurone disease THE PATIENT PRESENTING WITH COLLAPSE/ SYNCOPE The management of the patient who is unonsious has been disussed in a previous artile. 1 They should be transported to hospital immediately by ambulane following treatment of any ABC problem and after exluding hypoglyaemia. A more ommon problem is the patient who has had an episode of ollapse with or without a period of unonsiousness, but who is fully alert when help arrives. Synope is the abrupt and transient loss of onsiousness assoiated with absene of postural tone, followed by a rapid and usually omplete reovery. This symptom is alarming for the individual, witnesses, family, and liniians. Although synope an be a harbinger of a multitude of disease proesses and an mimi the appearane of a ardia arrest, it is most often benign and self-limiting. There are many auses of synope and ollapse. However, despite the multiple aetiologies the ause may remain unknown. One prospetive study was unable to establish the ause in 18% of patients with synope. 3 The pratitioner will need to rely on a areful Table 2 Causes of ollapse 2 Differential diagnosis Hypoxia, hypoglyaemia Epilepsy* Affetive (psyhologial) Dysfuntion of brain stem for example, vertebrobasilar transient ishaemi attak, basilar migraine Heart for example, ishaemi heart disease Emboli pulmonary embolism Aorti obstrution for example, stenosis, hypertrophi obstrutive ardiomyopathy (HOCM)À Rhythm disorders for example, sik sinus syndrome, omplete heart blok Tahydysrhythmias for example, SVT, VT, long QT syndrome Vasovagal* ENT for example, Ménière s disease, aute labyrinthitis, benign paroxysmal positional vertigo Situational for example, fright, miturition, deglutition, defaeation Sensitive arotid sinus Etopi pregnany** Low vasular tone Sublavian steal** DRUGS for example, antihypertensives, sympatheti blokers ausing postural hypotension* *Common auses ÀRare auses history and examination to establish the most likely ause for eah individual patient. Subjetive assessment history Some types of synope are more sinister. Sudden and omplete loss of onsiousness, often ausing the patient to fall and injure themselves, may indiate a potentially serious ause, as does synope that ours with exertion. It is helpful to get a witness aount that may verify the loss of onsiousness, any assoiated limb movements, and the presene or absene of pallor or sweating. Information regarding the presene or absene of a pulse and the pulse rate during the episode is also of diagnosti signifiane. Clinial lues Tip A mnemoni that an help remember all the possible differential diagnoses is: HEAD, HEART, VESSELS, DRUGS (see table 2) 2 Tip Establish the number of episodes that have ourred. In general, benign auses of synope are usually assoiated with a single synopal episode or with multiple episodes over many years. The patient with multiple episodes ourring over a short period of time is more likely to have a serious underlying disorder. Should be piked up in primary survey Do not forget the gluose Previous history, postital period History of anxiety or pani disorder, hyperventilation Cerebellar signs on neurologial examination Reent hest pain, history of myoardial infartion Pleuriti hest pain, dyspnoea, alf pain, or swelling Preipitated by exertion, ardia murmur on ausultation May be piked up on primary survey if heart rate,50, history of ishaemi heart disease History of palpitations, may be piked up on primary survey if heart rate.100,,5 s prodromal period Prodrome of nausea, dizziness, yawning, sweaty History of vertigo, deafness, tinnitis. nystagmus on neurologial examination May be apparent from history Preipitated by head movement History of abdominal pain, amenorrhoea, PV bleeding, positive pregnany test Preipitated by upper arm exertion Elderly patient on multiple drugs Postural fall in blood pressure 565 Emerg Med J: first published as /emj on 26 July Downloaded from on 17 September 2018 by guest. Proteted by opyright.

3 566 Table 3 Conditions ausing dizziness Type Definition Causes Vertigo Sensation that the individual or environment is rotating In some ases it may be diffiult to distinguish between seizures and synope. Seizures are the probable ause of 5 15% of apparent synopal episodes. 4 They an mimi synope when the seizure is atypial and not assoiated with toni loni movements, the seizure is not observed, or a omplete history annot be obtained. In addition, some patients with synope present with abnormal movements that are suggestive of a seizure but are atually due to erebral hypoxia. One distinguishing feature is that patients with seizures rarely have an abrupt and omplete reovery. Instead, the postital state is haraterised by slow and omplete reovery. Another important lue, if present, is evidene of soft tissue injury at multiple sites due to toni loni movements during the seizure. Objetive information Perform a good general examination inluding lying and standing blood pressure, ardiovasular and neurologial examinations. Other examinations inluding abdomen may be indiated. Chek blood sugar (BM) and if possible take an eletroardiogram (ECG). Analysis and plan After taking a thorough history and performing a thorough examination the pratitioner will need to make the deision whether the patient an be safely managed at home or if they need referral for a medial assessment. Certain features may indiate that the patient is at higher risk of ompliations (box 3). 5 Box 3 Worrying features in the history of a patient who had ollapsed Symptoms and signs of heart disease or arrhythmia Abnormal ECG Multiple episodes Neurologial defiit Age over 70 Sudden loss of onsiousness with injury, marked tahyardia or exertional synope Moderate to severe postural hypotension Benign paroxysmal positional vertigo Aute labyrinthitis Vestibular neuronitis Ménière s disease Brainstem or erebellar disorder Drug toxiity Presynope Sensation that one is about to blak out Postural hypotension Dysrhythmia Cardia outflow obstrution Other auses of synope (see table 2) Hypoglyaemia Diabetes mellitus Alohol Insulin sereting tumours Dysequilibrium Drug effets Psyho-physiologial Imbalane when standing or walking without the sensation of movement or impending loss of onsiousness Non-speifi symptom may be from many different auses. Usually in proprioeptive or vestibular systems Saliylates, tranquillisers, aminoglyosides, antionvulsants, antihypertensives, antimalarials, alohol Pani attaks Anxiety Phobias If none of these features are present then the patient is at low risk of serious problems. If the history suggests the possibility of a ardia ause, or if the patient has abnormal examination findings, they should be referred immediately to hospital for further investigation. Those patients who have a single episode with a history suggestive of benign ause for example, vasovagal synope in a young, otherwise fit person may be left at home if they have fully reovered. They should be advised to seek medial attention if the episode reurs or if they develop any new symptoms. If the patient has had multiple episodes over a relatively short period of time, but the history is unhelpful and there are no abnormal findings, they should be referred to their general pratitioner (GP) for assessment and further referral as neessary. THE PATIENT PRESENTING WITH DIZZINESS The term dizziness is used to desribe a variety of vague symptoms inluding floating, swimming, light headedness, and giddiness. Vertigo on the other hand is the speifi sensation that the environment or individual is rotating or undergoing angle motion. Equilibrium and spatial orientation depends upon the interation between the visual system (eye and eye musles), proprioeptive system (posterior olumns, musles, joints and tendons), and the vestibular system (ear, eighth ranial nerve, brainstem and erebellum). Disturbane of any part, or the interation between them, may lead to the symptom of dizziness. Vertigo is usually due to defets in the vestibular system alone. The various onditions that may be desribed as dizziness by the patient are summarised in table 3. The history and neurologial examination ould suggest the possible ause of the symptoms. Partiular attention should be paid to the presene of nystagmus, erebellar signs, and ataxia. Patients who have a history of sudden onset of symptoms and who have signs of brainstem or erebellar dysfuntion may have had a posterior irulation stroke and should be referred to hospital for assessment. If a vestibular ause is suspeted then referral to the GP or ENT lini may be appropriate. Vertigo is overed in more detail in the ABC artile on the assessment and are of ENT problems. 6 Care Emerg Med J: first published as /emj on 26 July Downloaded from on 17 September 2018 by guest. Proteted by opyright.

4 Figure 1 Third nerve palsy right eye: ptosis, eye deviated down and out in primary position, dilated pupil. Courtesy of Medial-on-Line/ Medisan. should be taken in elderly people in whom the symptom of dizziness may be due to a ombination of disorders and may be ompounded by poor general mobility. THE PATIENT PRESENTING WITH VISUAL DISTURBANCE The pratitioner may be alled to see a patient whose main symptom is altered vision. To form a differential diagnosis and management plan it is important to establish the preise nature of this inluding the mode of onset (sudden or gradual), duration, and any assoiated symptoms for example, pain. The examination should inlude inspetion of the eye, visual auity, pupil reation, visual fields, and eye movements. The ommonest types of visual disturbane the pratitioner will enounter are blurred or double vision (diplopia), visual loss, and migrainous aura (table 4). Diplopia or blurred vision It is important to establish whether the patient has true diplopia or blurred vision. Ask speifi questions suh as Do you see two of everything or are objets blurred around the edges?. Try to determine whether it is present with the eyes in a resting position or only in ertain diretions of gaze. Establish whether the onset was sudden or gradual. Gradual onset of blurred vision may be due to refratory problems or diabetes. If there are no other abnormal findings on examination and the blood sugar is normal these patients may be managed at home with Table 4 Common visual symptoms Main visual symptom Causes Clinial lues advie to see their optometrist or GP. In ontrast, sudden onset of blurred vision or diplopia should always be taken seriously as it may be a symptom of an oular or neurologial ondition requiring urgent investigation and/or treatment. Diplopia may be due to a defet at any level of the brainstem, ranial nerves, neuromusular juntion, oular musles, or orbit. The ommonest auses of diplopia are ranial nerve palsies (third, fourth, sixth ranial nerves) (figs 1 and 2), and onditions ausing weakness of the oular musles. Third ranial nerve palsy Weakness of eye movement whereby the eye is deviated down and out in the resting position is only one feature of a third nerve palsy whih may also ause ptosis and dilatation of the pupil (see fig 1). Causes inlude posterior ommuniating artery aneurysm (whih is usually painful), and pathology in the avernous sinus, superior orbital fissure, or orbit. Fourth ranial nerve palsy This auses inomplete depression of the eye in the adduted position. The patient may try to ompensate by tilting their head towards the opposite shoulder. It is unommon but may be aused by trauma affeting the orbit. Double vision (diplopia) Cranial nerve palsy Abnormal eye movements Weakness of oular musles for example, multiple slerosis, myasthenia gravis, Often assoiated with other neurologial symptoms and signs Guillain Barré syndrome Sudden visual loss Complete Central retinal vein olusion Abnormal fundusopy Retinal artery olusion Retinal detahment Flashing lights Opti neuritis Assoiated with pain Partial Stroke Assoiated with other neurologial signs Multiple slerosis May be other neurologial symptoms/signs Glauoma Painful red eye, vomiting Transient Migrainous aura Transient ishaemi attak, amaurosis fugax Our in approximately 80% of people with migraine Figure 2 Fourth nerve palsy right eye: failure of abdution. Courtesy of Dr P Marazzi/SPL model released. Risk fators for erebrovasular disease. May be other neurologial symptoms Usually preede onset of headahe Typially flikering zigzag lines starting in entre of vision and gradually proeeding towards the periphery of one visual field often leaving a sotoma. Usually resolves in less than an hour 567 Emerg Med J: first published as /emj on 26 July Downloaded from on 17 September 2018 by guest. Proteted by opyright.

5 568 Sixth ranial nerve palsy This may ause some in-turning of the eye and double vision in the primary position (fig 2). The patient may try to ompensate by turning their head to the side of the eye affeted to obtain single vision by looking forward. Causes inlude multiple slerosis and raised intraranial pressure. Conditions ausing weakness of the oular musles inlude myasthenia gravis, multiple slerosis and the Guillain Barré syndrome. Onset may be aute or gradual. Usually these onditions will be assoiated with other neurologial symptoms and signs not onfined to the eyes. In general, any ranial nerve palsy or sudden onset of diplopia requires a neurologial assessment, and these patients should be assessed in hospital. Sudden visual loss Aute loss of vision always merits urgent hospital assessment. Tip Key points in the history that will aid in making the diagnosis are the presene of pain, whether the loss of vision is in one eye or both, and whether it is partial, omplete, or transient. Aute painless loss of vision in one eye is most ommonly due to retinal arterial or venous olusion or temporal arteritis. Central retinal artery or vein olusion auses omplete loss of vision in one eye whereas branh olusions may result in partial visual field loss. Patients should be asked about vasular risk fators and previous history of stroke or myoardial infartion. Symptoms suh as headahe, malaise, myalgia, and weight loss in a patient aged over 50 years should raise the suspiion of temporal arteritis. Little an be done in the prehospital setting to affet outome, however, these onditions should be treated as medial emergenies for two reasons. In the ase of entral retinal artery olusion the prognosis for visual reovery is diretly related to the promptness of treatment, and urgent referral to ophthalmology is indiated. If a branh olusion has ourred, or if the visual loss is a result of temporal arteritis, the rest of the retina or the other eye is at risk. If the underlying onditions are not treated the patient may go on to develop omplete blindness. Other auses of painless loss of vision requiring urgent assessment inlude retinal detahment and vitreous haemorrhage. Retinal detahment is usually assoiated with floaters or flashing lights at the onset, and the patient may desribe the loss of vision like a urtain falling. It is more ommon in shortsighted people. Vitreous haemorrhage may our with entral retinal vein olusion or retinal detahment and may also our spontaneously in patients with proliferative diabeti retinopathy. Transient painless loss of vision with or without other neurologial symptoms is most likely to be a transient ishaemi attak (TIA). Patients should be referred for investigation as disussed later in this artile. The ommonest ause of a painful loss of vision is opti neuritis. The onset may be subaute with visual blurring gradually getting worse over a few days until the patient an see very little. The pain is typially worse on eye movement. A ommon underlying ondition is multiple slerosis and this diagnosis should be suspeted in young patients, partiularly if they have a previous history of other neurologial symptoms. Redution in visual auity assoiated with pain, headahe and vomiting may be due to glauoma (see Assessment and management of neurologial problems (1) 1 ). If there is any suggestion of this the patient must be referred immediately for an ophthalmologial assessment. THE PATIENT WITH FOCAL NEUROLOGICAL DEFICIT It is not unommon for the ommunity pratitioner to enounter a patient who has developed a foal neurologial defiit. The spetrum of severity is wide, ranging from the patient with dense unilateral signs (for example, stroke, hemiplegi migraine, Todd s paresis) to the patient with isolated symptoms in one musle or dermatome (for example, peripheral nerve palsy or mononeuropathy). The ause will usually be apparent from the history and examination and the pratitioner must formulate a management plan based on the underlying ondition. Box4WorldHealthOrganizationdefinitionof stroke 7 Clinial syndrome haraterised by rapidly developed linial signs of foal (or global) disturbane of erebral funtion, lasting more than 24 hours or leading to death, with no apparent ause other than of vasular origin. Stroke and TIA Stroke is the ommonest ause of a unilateral motor and/or sensory defiit. A TIA by definition will resolve ompletely within 24 hours of onset, although it is often not possible to make this distintion if the patient is seen shortly after the onset of symptoms. Approximately 80% of strokes are due to erebral ishaemia, with the remainder being due to haemorrhage (15%) or unknown ause (5%). However, in pratie it is impossible to make the distintion between an ishaemi stroke and a haemorrhagi stroke based on the history and examination alone. The neurologial examination will usually indiate whih vasular territory is affeted. For ishaemi strokes a ommonly used lassifiation is the Oxford Community Stroke Projet (Bamford et al) lassifiation (table 5), whih gives an indiation of stroke severity and prognosis. 8 Stroke is a medial emergeny. With ative management in the initial hours after stroke, vulnerable areas of the brain around the infart may be saved from infartion and morbidity and mortality may be improved. The Royal College of Physiians has issued omprehensive guidelines on the aute management of stroke and TIA. 9 Some patients with stroke will be primary survey positive for example, redued onsious level, fast atrial fibrillation and should be managed aording to ABC priniples. All other patients with persistent symptoms that may be due to stroke should be referred urgently to hospital for speialist assessment and brain imaging. Some units may be offering thrombolysis for Emerg Med J: first published as /emj on 26 July Downloaded from on 17 September 2018 by guest. Proteted by opyright.

6 Table 5 Oxford Community Stroke Projet lassifiation of stroke 8 Stroke subtype Total anterior irulation syndrome (TACS) Partial anterior irulation syndrome (PACS) Posterior irulation syndrome (POCS) Launar syndromes (LACS) Pure motor stroke (PMS) Pure sensory stroke (PSS) Ataxi hemiparesis (AH) Sensory motor stroke (SMS) Box 5 Investigation and management of TIA 9 Clinial features Patients first seen in the ommunity should be assessed and investigated in a speialist servie for example, neurovasular lini as soon as possible within seven days of the inident Patients likely to have a diagnosis of TIA should be presribed an alternative antiplatelet regimen immediately Patients with more than one TIA in a week should be investigated in hospital immediately Risk fators for erebrovasular disease suh as severe hypertension should be treated appropriately or the patient referred for speialist management eligible patients presenting within three hours of stroke onset in whih ase time is of the essene. Patients who have had symptoms of stroke that have ompletely resolved by the time they are seen by the pratitioner that is, have a possible diagnosis of TIA should be treated with the same urgeny as stroke, as the risk of developing a stroke after a TIA an be as high as 20% in the first month, with the greatest risk being in the first 72 hours. When making a diagnosis of TIA it is important to establish that the symptoms were foal, ame on suddenly and were maximal at onset. Vague symptoms of dizziness not assoiated with foal neurologial defiit and symptoms assoiated with loss of onsiousness are rarely due to TIA and other auses should be onsidered (see tables 2 and 3). Whether patients thought to have had a TIA are referred immediately to hospital or to a diret aess lini will depend on loal protools, however the National Clinial Guidelines 9 should be followed (box 5). If there are no ontraindiations the patient should be started on aspirin or an alternative antiplatelet agent for example, dipyridamole. Patients who Unilateral motor and/or sensory defiit of at least two areas of the fae, arm, and leg Homonymous hemianopia Higher erebral dysfuntion for example, aphasia, neglet Any two of: unilateral motor and/or sensory defiit ipsilateral hemianopia higher erebral dysfuntion Any of: ipsilateral ranial nerve palsy with ontralateral motor and/or sensory defiit bilateral motor and/or sensory defiit disorder of onjugate eye movement erebellar dysfuntion without ipsilateral long trat defiit (that is, ataxi hemiparesis) isolated homonymous visual field defet Unilateral pure motor defiit learly involving two of three areas fae, arm, and leg with the whole of any limb being involved Unilateral purely sensory symptoms signs involving at least two of the three areas with the whole of any limb being involved Ipsilateral erebellar and ortiospinal trat signs with or without dysarthria in the absene of higher erebral dysfuntion or visual field defiit PMS and PSS ombined that is, unilateral motor and sensory signs in the absene of higher erebral dysfuntion or visual field defiit Box 6 International Headahe Soiety lassifiation of prolonged auras Migraine with prolonged aura if the aura lasts more than one hour but less than one week with normal brain imaging Persistent aura without infartion if the aura lasts more than one week with no evidene of infartion Migrainous infartion (if the defiit lasts more than one hour and the neuroimaging shows an infartion) have had a TIA and are in atrial fibrillation should be referred to hospital as antioagulation may help to prevent a stroke. Hemiplegi migraine Migraine may be assoiated with sensory, motor, or aphasi aura. Hemiplegi migraine is haraterised by unilateral sensory and/or motor signs. One population study found that 37% of patients with migraine had sensory aura and 6% had motor aura, usually affeting the hand and arm. 10 In general the motor aura tended to be most prolonged, lasting more than an hour in 67% of ases. In 93% of ases the aura preeded the onset of headahe. If the patient has a history of hemiplegi migraine and the foal symptoms resolve in less than an hour the patient may be managed at home. Patients in whom the aura has lasted for longer than an hour should be referred for hospital assessment as they may be developing ompliated migraine (box 6) and will need neuroimaging to exlude migrainous infartion. Caution must be exerised in diagnosing migraine, espeially if it is assoiated with neurologial signs, when the patient has no previous history of migraine, or if the history differs from their usual migraine symptoms. In suh ases alternative diagnoses for example, subarahnoid haemorrhage must be exluded Emerg Med J: first published as /emj on 26 July Downloaded from on 17 September 2018 by guest. Proteted by opyright.

7 570 Table 6 Conditions that may present with generalised weakness Condition Guillain Barré syndrome Botulism Wound botulism Food borne botulism Spinal ord disease Motor neurone disease Vasuliti neuropathy Myasthenia gravis Viral myositis Drug indued myopathy Metaboli disorders Hypokalaemia Hypomagnesaemia Hypophosphataemia Polymyalgia rheumatia Clinial lues Rapidly progressive asending weakness May involve respiratory musles Loss of reflexes May have severe bak pain Respiratory or gastrointestinal illness two to four weeks prior to onset Symmetri desending weakness Cranial nerve weakness for example, diplopia No sensory symptoms Prodromal nausea, vomiting, diarrhoea Suspet in intravenous drug users Bak pain Sensory level Sphinter disturbane Progressive weakness over months Fasiulation of musles Exaggerated reflexes May have bulbar involvement Painful Multiple peripheral nerves affeted (mononeuritis multiplex) Raised inflammatory markers May be assoiated with rash, arthropathy, renal disease Bulbar, oular, and respiratory musles affeted Ptosis Fatigability Painful musles Raised reatine kinase Progressive proximal weakness over weeks Myalgia Drugs history for example, statins Aloholism Anorexia Drugs for example, laxatives, diuretis Elderly patient Proximal pain and weakness Malaise May be assoiated with weight loss, headahe, Raised ESR Todd s paralysis Todd s paralysis (also alled postital paresis), is a transient neurologial defiit following an epilepti seizure. As the name implies, the lassi defiit is weakness of a hand, arm, or leg that appears following foal motor seizure ativity involving one limb or side of the body. The diagnosis may be apparent from the history and should be onsidered in a patient with a history of epilepsy. One study of patients with intratable foal epilepsy found the inidene of Todd s paralysis to be 13.4%. 11 The signs were always unilateral and ranged in duration from 11 seonds to 22 minutes. If the patient has a history of epilepsy and the neurologial symptoms have ompletely resolved then they may be safely managed at home. The pratitioner must be aware however that aute stroke may be assoiated with fitting, therefore if the patient has any persistent neurologial signs or does not have a history of epilepsy, they should be referred to hospital for further investigation. Mononeuropathy Making the diagnosis of a mononeuropathy an be diffiult. It depends on reognising that the neurologial defiit is onfined to the distribution of a single nerve, and it requires good knowledge of peripheral nerve anatomy and of the motor and sensory territories of eah nerve. A good history may give a lue to the underlying ause. Common auses inlude trauma, external ompression (for example, after a period of unonsiousness or sleep), internal ompression (for example, median nerve entrapment in the arpal tunnel), or intrinsi lesions of the nerve (for example, arising as a foal manifestation of a more generalised proess suh as vasulitis). A full neurologial examination should be performed to determine the extent of the defiit. A general examination should also be done to exlude any underlying ondition. Patients with diabetes have an inreased risk of nerve injury therefore blood sugar should be heked. If the signs are onfined to the distribution of a single nerve and the patient is otherwise well then they an be managed at home, however, arrangements will need to be made for further investigation that may inlude nerve ondution studies. THE PATIENT WITH GENERALISED WEAKNESS Patients may present with less speifi symptoms of generalised weakness. This an present partiular diagnosti diffiulty as it may be due to a wide range of onditions affeting the spinal ord, nerves or musles, some of whih may be serious and require urgent investigation and treatment. One again a thorough history and examination are the key to determining the likely differential diagnosis. The patient should be asked speifially about the speed of onset and about any assoiated symptoms suh as diffiulty with speeh or swallowing (bulbar symptoms), breathing diffiulties, visual disturbane, pain, and twithing of the musles. Conditions to onsider are listed in table 6. Any patient with bulbar symptoms or shortness of breath should be referred to hospital immediately. All patients will require some investigation either as an inpatient or as an urgent outpatient to determine the ause. SUMMARY The ommunity pratitioner may be asked to see patients with a wide range of neurologial symptoms that an be diffiult to diagnose with ertainty in the ommunity. A strutured history and examination is vital in formulating a differential diagnosis and in deiding whih patients should be referred for urgent investigation and treatment. In general symptoms of aute onset require immediate referral whereas those of subaute (over days to weeks) or hroni onset may be more appropriately investigated in an outpatient setting if the patient is otherwise well.... Authors affiliations C M Gavin, J T Gray, Hope Hospital, Salford, UK REFERENCES 1 Gray JT, Gavin CM. The ABC of ommunity emergeny are. Assessment and management of neurologial problems. Emerg Med J 2005;22: Young W. Synope. In: Markovik V, Pons P, eds. Emergeny Mediine Serets, 3rd edn. Philadelphia: Hanley and Belfus In, 2003:67. 3 Alboni P, Brignole M, Menozzi C, et al. Diagnosti value of history in patients with synope with or without heart disease. J Am Coll Cardiol 2001;37: Sheldon R, Rose S, Rithie D, et al. Historial riteria that distinguish synope from seizures. J Am Coll Cardiol 2002;40: Crane SD. Risk stratifiation of patients with synope in an aident and emergeny department. Emerg Med J 2002;19: Carter S, Laird C. The ABC of ommunity emergeny are: Assessment and are of ENT problems. Emerg Med J 2005;22: Hatano S. Experiene from a multientre stroke register: a preliminary report. Bull World Health Organ 1976;54: Emerg Med J: first published as /emj on 26 July Downloaded from on 17 September 2018 by guest. Proteted by opyright.

8 8 Bamford J, Sanderok P, Dennis M, et al. Classifiation and natural history of linially identifiable subtypes of erebral infartion. Lanet 1991;337: Interollegiate Stroke Working Party. National Clinial Guidelines for stroke, 2nd edition London: Royal College of Physiians of London. Available at Clinial Evidene Call for ontributors 10 Russell MB, Olesen J. A nosographi analysis of the migraine aura in a general population. Brain 1996;119(Pt 2): Gallmetzer P, Leutmezer F, Serles W, et al. Postital paresis in foal epilepsies inidene, duration, and auses: a video-eeg monitoring study. Neurology 2004;22: Clinial Evidene is a regularly updated evidene-based journal available worldwide both as a paper version and on the internet. Clinial Evidene needs to reruit a number of new ontributors. Contributors are healthare professionals or epidemiologists with experiene in evidene-based mediine and the ability to write in a onise and strutured way. Areas for whih we are urrently seeking authors: N Child health: noturnal enuresis N Eye disorders: baterial onjuntivitis N Male health: prostate aner (metastati) N Women s health: pre-menstrual syndrome; pyelonephritis in non-pregnant women However, we are always looking for others, so do not let this list disourage you. Being a ontributor involves: N Seleting from a validated, sreened searh (performed by in-house Information Speialists) epidemiologially sound studies for inlusion. N Doumenting your deisions about whih studies to inlude on an inlusion and exlusion form, whih we keep on file. N Writing the text to a highly strutured template (about words), using evidene from the final studies hosen, within 8 10 weeks of reeiving the literature searh. N Working with Clinial Evidene editors to ensure that the final text meets epidemiologial and style standards. N Updating the text every six months using any new, sound evidene that beomes available. The Clinial Evidene in-house team will ondut the searhes for ontributors; your task is simply to filter out high quality studies and inorporate them in the existing text. N To expand the topi to inlude a new question about one every months. If you would like to beome a ontributor for Clinial Evidene or require more information about what this involves please send your ontat details and a opy of your CV, learly stating the linial area you are interested in, to Klara Brunnhuber (kbrunnhuber@ bmjgroup.om). Call for peer reviewers Clinial Evidene also needs to reruit a number of new peer reviewers speifially with an interest in the linial areas stated above, and also others related to general pratie. Peer reviewers are healthare professionals or epidemiologists with experiene in evidene-based mediine. As a peer reviewer you would be asked for your views on the linial relevane, validity, and aessibility of speifi topis within the journal, and their usefulness to the intended audiene (international generalists and healthare professionals, possibly with limited statistial knowledge). Topis are usually words in length and we would ask you to review between 2 5 topis per year. The peer review proess takes plae throughout the year, and our turnaround time for eah review is ideally days. If you are interested in beoming a peer reviewer for Clinial Evidene, please omplete the peer review questionnaire at or ontat Klara Brunnhuber (kbrunnhuber@bmjgroup.om). 571 Emerg Med J: first published as /emj on 26 July Downloaded from on 17 September 2018 by guest. Proteted by opyright.