Acute Focal Deficit

Recognizing an acute change in clinical status is critical in patients with neurologic injury. Priority should be given to the patient’s airway, breathing, and circulation, and subsequent localization of focal deficits which will guide stabilization and management decisions. Close attention should be paid to the recognition of hemodynamic and respiratory changes that may suggest an acute intracranial process or neurologic emergency. In the case of a clinical emergency, such as brain herniation, stabilization and initial management is often followed by urgent radiographic imaging. Multimodal monitoring may be considered when there is a concern for elevated intracranial pressure (ICP), or alterations in cerebral hemodynamics and metabolism. In the absence of a new identifiable lesion, seizures should be on the differential diagnosis and surface or depth EEG (electroencephalogram) may be considered. Alternative diagnoses such as metabolic disturbances, infections, or toxins may need to be considered in the absence of a primary neurologic cause. In the case of blood pressure variations, various shock classifications should be investigated and treated appropriately.