5.2 Core Workflows and Decision Points

5.2 Core Workflows and Decision Points

Neurologic emergencies test sequence and timing more than any other medical area. Three workflows dominate: seizure/status epilepticus, acute stroke, and altered mental status (AMS).

Seizures and status epilepticus

Most seizures are self-limiting and stop within 1-2 minutes; your job is to protect the airway, position the patient, give oxygen, and check a blood glucose (hypoglycemia is a reversible cause). Status epilepticus is defined as a continuous seizure lasting 5 minutes or longer, or two or more seizures without return to baseline between them — it is the trigger to give a benzodiazepine.

The first-line agents and their benzodiazepine doses, supported by the RAMPART trial and the American Epilepsy Society, are:

The key exam point from RAMPART: IM midazolam stops seizures at least as fast as IV lorazepam because the medication reaches the patient sooner — do not delay treatment to start an IV in an actively seizing patient. Underdosing (giving 2-5 mg of midazolam) is a documented real-world error; the adult IM dose is 10 mg.

Worked scenario

A 40-year-old has been seizing for 7 minutes. No IV. Glucose 92 mg/dL. The correct next step is midazolam 10 mg IM now, then reassess, support ventilation, and prepare a second benzodiazepine dose if the seizure continues. Choosing "establish IV first" wastes the most time-critical minutes. After two benzodiazepine doses fail, the seizure is refractory and definitive care (second-line antiepileptics, airway management) lies in the hospital, so rapid transport with airway support becomes the priority.

Always look for and treat reversible triggers in parallel: hypoglycemia, hypoxia, eclampsia in a pregnant patient (treat with magnesium, not just a benzodiazepine), hyperthermia, toxic ingestions, and head trauma. Document seizure onset time, duration, and the doses you gave, because that timeline drives in-hospital management.

Acute Stroke

For suspected stroke, the prehospital workflow is built around time and routing. Establish the last-known-well (LKW) time precisely — it, not symptom-discovery time, defines the treatment window (IV thrombolytics generally within 4.5 hours; mechanical thrombectomy for large-vessel occlusion out to 24 hours in selected patients). Check glucose immediately, because hypoglycemia is the great stroke mimic.

Use a two-step screening approach:

• Cincinnati Prehospital Stroke Scale (CPSS) / FAST — facial droop, arm drift, speech, time. Any single abnormality is a positive screen.
• LVO scale such as FAST-ED, RACE, or LAMS — these screen for a large-vessel occlusion that may need a thrombectomy-capable (comprehensive) stroke center.

Routing decision: a FAST-positive patient with a negative LVO screen can go to the nearest primary stroke center; a positive LVO screen within the thrombectomy window should bypass to a comprehensive (thrombectomy-capable) stroke center if reachable in a reasonable time. Do not aggressively lower blood pressure in the field; for ischemic stroke, permissive hypertension is preserved unless BP is extremely high, and aspirin is withheld until hemorrhage is excluded by CT. Pre-notify the receiving stroke team — "time is brain."

Altered mental status (AMS)

AMS is a presentation, not a diagnosis. Use the AEIOU-TIPS mnemonic to drive a systematic differential while you simultaneously treat reversible causes:

• A – Alcohol / Acidosis
• E – Epilepsy / Electrolytes / Encephalopathy
• I – Insulin (hypo/hyperglycemia)
• O – Overdose / Oxygen (hypoxia)
• U – Uremia
• T – Trauma / Temperature
• I – Infection (sepsis, meningitis)
• P – Psychiatric / Poisoning
• S – Stroke / Shock / Space-occupying lesion

Every AMS workup includes the "coma cocktail" thinking: oxygen for hypoxia, glucose check and dextrose for hypoglycemia, and naloxone if the opioid toxidrome is present. A subarachnoid hemorrhage classically presents as a sudden "thunderclap" / worst-headache-of-life with photophobia and nuchal rigidity (meningismus), and it is a neurosurgical emergency distinct from the gradual-onset migraine or bilateral pressure of a tension headache.

Decision-point discipline

Neurologic stems punish out-of-order thinking. For the seizing patient the order is protect-position-oxygenate-glucose-benzodiazepine; for the stroke patient it is LKW-glucose-FAST-LVO-route-prenotify; for AMS it is airway-breathing-circulation-glucose-naloxone-then-differential. When a stem offers a tempting "definitive" answer (CT, thrombolytics, a second-line drug) that is outside the field or out of sequence, treat it as a distractor. The right answer is the next correct field action, performed in the right order, that buys the patient time and a clean handoff.

Worked stroke scenario

Dispatched for "weakness," you find a 68-year-old with left-sided facial droop and left arm drift; the family says she was normal at breakfast 90 minutes ago. You confirm a positive Cincinnati screen, run FAST-ED and score it high (suggesting a large-vessel occlusion), check a glucose of 110 mg/dL to exclude the hypoglycemic mimic, and recognize that within the window a thrombectomy-capable center is the better destination if reachable promptly.

You pre-notify, keep her supine-to-slightly-elevated, give oxygen only if hypoxic, avoid lowering her blood pressure, and document the exact last-known-well time. Notice how each step is a decision point with a governing rule behind it — that is exactly how the exam frames neurologic items, and rehearsing the workflow aloud cements the order so you do not skip the glucose check or mis-time the window.