Principles and practice of emergency neurology: handbook for emergency physicians

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In the United States, nearly 1 in 10 patients present to an emergency department (ED) for a neurologically related complaint. Over the past 10 years, it is fortunate that the evolving subspecialty of emergency neurology has grown and several quality references authored specifically for the practicing emergency physician now exist.

In 1999, the editorial team of Shah and Kelly published the comprehensive text Emergency Neurology: Principles and Practice. It has become a standard resource for practicing emergency physicians and residents in training. In the preface for the new abbreviated handbook version, the authors' stated interest is in “extending our initial goal of disseminating the principles of emergency neurology to emergency physicians and providing a ready resource in caring for patients with neurological emergencies.”

In this handbook, there are 66 contributors who are mostly emergency physicians and neurologists. The handbook is divided into 8 sections and 38 chapters, most authored by an emergency physician–neurologist team. The editors make efficient use of illustrations, algorithms, tables, and figures. In addition, each chapter ends with a “Pearls and Pitfalls” section summarizing the author's key points.

The first section covers the neurologic examination and testing. It is rarely necessary to perform a detailed neurologic examination in the ED, but information on the complete neurologic examination, including neurologic function and anatomic localization, is outlined. The neuroradiology chapter, although useful in the text version, is not practical in this abbreviated handbook format. Finally, chapters on lumbar puncture and electroencephalogram are presented but are readily available elsewhere, such as in Roberts and Hedges' Clinical Procedures in Emergency Medicine.¹

The second section identifies 6 common neurologic triage presentations. The chapter on dizziness nicely overviews this complex condition and makes efficient use of figures and tables, but the discussion of seizure falls short in that it only briefly mentions the ubiquitous psychogenic seizure disorder. Subsequent chapters cover weakness, headache, altered mental status, and gait disturbances and do so capably.

Seventeen specific neurologic conditions are covered in the third section. Broad, common topics such as movement disorders and central nervous system infections are presented. Uncommon conditions such as myasthenia gravis, normal pressure hydrocephalus, and idiopathic intracranial hypertension are thoroughly discussed. Chapters on cerebrovascular disease, neuro-opthalmologic emergencies, and nontraumatic spinal cord emergencies could serve as excellent stand-alone references.

The fourth section, on neurologic trauma, contains several chapters, such as a review of spinal cord injury and management, while providing an up-to-date discussion of the National Acute Spinal Cord Injury Studies (NASCIS) III trial and the controversy surrounding high-dose steroids. A thorough discussion of traumatic brain injury is limited to patients with severe head injury (Glasgow Coma Scale score <9) and does not address the largest segment of patients with traumatic brain injury (everyone else) who sustain a head injury.

Pediatric neurologic emergencies and pregnancy-related emergencies sections follow. The chapters on hydrocephalus and shunts in children, seizures, and central nervous system infections are practical and useful. The neurotoxicology section covers a multitude of topics, such as general neurotoxicology, envenomations, and other environmentally related emergencies, presenting information in several well-organized tables. Finally, the text ends with a brief discussion of conducting a brain death examination, which is informative but impractical for myriad reasons in the ED.

Compared with Henry and Jagoda's handbook on Neurologic Emergencies: A Symptom-Oriented Approach,² this handbook contains more information and disease-specific chapters, making it easier to reference. With the publication of Shah and Kelly's handbook, we are now fortunate to have two high-quality portable neurologic emergency references. This handbook is concise, practical, and up-to-date; I plan on adding it to my personal reference library. I highly recommend it to anyone managing patients with acute neurologic emergencies.

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References 

1. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th ed.. Philadelphia, PA: WB Saunders; 2003;
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2. Henry GL, Jagoda A, Little N, et al. Neurologic Emergencies: A Symptom-Oriented Approach. 2nd ed.. New York, NY: McGraw-Hill Publishing; 2003;
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