What is the appropriate emergency department evaluation and management of a patient presenting with altered sensation?

Emergency Department Approach to Altered Sensation

A patient presenting with altered sensation to the emergency department requires immediate ABCDE assessment (airway, breathing, circulation, disability, exposure) to identify life-threatening conditions, followed by rapid neurological examination and urgent non-contrast head CT within 25 minutes to differentiate stroke from other causes, with particular attention to focal deficits suggesting acute cerebral infarction. 1, 2

Immediate Assessment and Stabilization (First 10 Minutes)

Primary Survey

• Perform rapid airway-breathing-circulation assessment to identify airway obstruction, respiratory compromise, or hemodynamic instability, as these are the most sensitive indicators of patient deterioration 2, 3
• Continuously monitor oxygen saturation and administer supplemental oxygen at 2–3 L/min only when saturation falls below 92%, as routine oxygen may worsen outcomes 1
• Establish intravenous access and place patient on continuous cardiac monitoring with ECG capability 4
• Assess vital signs including heart rate, blood pressure, temperature, and respiratory rate 1

Neurological Disability Assessment

• Conduct standardized neurological examination using the NIH Stroke Scale (NIHSS) to quantify focal deficits and stroke severity 1
• Document Glasgow Coma Scale score and assess for altered sensorium, confusion, or decreased responsiveness 5
• Evaluate for focal neurological signs including hemiplegia, facial droop, speech abnormalities, visual field defects, and sensory loss 1
• Check pupillary response, motor function in all extremities, and coordination 5

Urgent Diagnostic Workup

Neuroimaging (Priority #1)

• Obtain non-contrast head CT within 25 minutes of arrival to differentiate ischemic stroke from hemorrhagic stroke or other structural lesions 1
• Perform CT angiography from aortic arch to vertex concurrently with initial CT to identify large-vessel occlusions amenable to thrombectomy 1
• Complete imaging interpretation by an experienced neuroradiologist within 45 minutes of acquisition 1

Laboratory Studies

• Draw acute bloodwork (electrolytes, glucose, CBC with platelets, INR/aPTT, creatinine/eGFR, troponin) without delaying imaging or treatment 1
• Obtain toxicology screens in younger patients or those with substance abuse history 5
• Check blood glucose immediately, as hypoglycemia can mimic stroke 1

Cardiac Evaluation

• Obtain 12-lead ECG after the thrombolysis decision (if hemodynamically stable) to detect atrial fibrillation or acute coronary syndrome 1
• Initiate continuous cardiac monitoring for 24–72 hours to capture paroxysmal atrial fibrillation 1

Differential Diagnosis Framework

Stroke/TIA (Most Critical)

• Acute focal neurological deficits with sudden onset suggest cerebral infarction requiring reperfusion therapy within 4.5 hours 1
• Intravenous alteplase 0.9 mg/kg (max 90 mg) is indicated within 4.5 hours of symptom onset for eligible patients 1
• Mechanical thrombectomy for large-vessel occlusions presenting ≤6 hours (or up to 24 hours in selected patients) 1

Metabolic Causes

• Patients with moderate diabetic ketoacidosis (blood glucose >500 mg/dL or pH <7.2) require continuous insulin infusion and may present with altered sensorium 5
• Hyponatremia and hypernatremia with alterations in clinical status (seizures or altered mental status) require cardiac monitoring and therapeutic intervention 5
• Hypoglycemia or severe hyperglycemia can cause sensory changes 5

Seizure-Related

• Patients with seizures who are responsive to therapy but require continuous cardiorespiratory monitoring may have altered sensorium in the post-ictal period 5
• Do not use prophylactic anticonvulsants in acute stroke, as they may impair neural recovery and worsen outcomes 1

Toxic/Infectious

• Head injury or alcohol intoxication are commonly associated with inadequate airway or diminished respiratory function 3
• Acute inflammation or infections of the central nervous system without neurologic deficiency require monitoring 5

Blood Pressure Management

For Thrombolysis Candidates

• Lower systolic BP to <185 mmHg and diastolic BP to <110 mmHg using labetalol, nitro-paste, or nicardipine before tPA administration 1

For Non-Thrombolysis Patients

• Intervene on BP only when systolic >220 mmHg or diastolic >120 mmHg, as aggressive reduction may worsen cerebral ischemia 1

Airway Management Considerations

Indications for Intubation

• Patients with altered sensorium in whom neurologic deterioration or depression is likely require airway protection 5
• Glasgow Coma Scale <9 indicates need for endotracheal intubation 6
• Position head flat (0°) when no risk of hypoxia or aspiration to maximize cerebral perfusion; elevate to 25–30° if aspiration risk or increased intracranial pressure present 1
• Keep patient NPO until formal swallowing assessment completed, as dysphagia is common after stroke 1

Neurological Monitoring Protocol

Post-Thrombolysis

• Perform neurological examinations and vital-sign checks every 15 minutes for the first 2 hours, then every 30 minutes for the next 6 hours, and hourly thereafter up to 24 hours 1

Without Thrombolysis

• Conduct at least hourly neurological checks in an ICU setting (or every 4 hours on a non-ICU ward) 1
• Obtain repeat head CT at 24 hours post-thrombolysis to screen for hemorrhagic transformation 1

Disposition and Admission Criteria

Intermediate Care Admission

• Patients with altered sensorium in whom neurologic deterioration or depression is unlikely but who require neurologic assessment (not more often than every 2 hours) may be admitted to intermediate care 5

Stroke Unit Admission

• All stroke patients should be admitted to a dedicated stroke unit within 24 hours of hospital arrival, as this significantly reduces mortality (OR 0.76) and death or dependency (OR 0.80) 1

Critical Pitfalls to Avoid

• Do not discharge from the emergency department until diagnostic evaluation is complete, functional status assessed, and secondary-prevention therapy initiated 1
• Do not delay imaging or acute treatment while awaiting laboratory results unless specific clinical indication (e.g., suspected coagulopathy) exists 1
• Do not administer IV rtPA to patients with frank hypodensity involving >1/3 of the middle cerebral artery territory due to heightened hemorrhage risk 1
• Do not assume altered sensation is benign—one-third of MI patients present without chest discomfort, and elderly individuals, women, and diabetics in this group have 2.2-fold higher mortality 4