Thanks to Giulia Giovannetti for developing this.
Nitrous Oxide has been used clinically and recreationally since its discovery in 1772. Since then Nitrous Oxide induced neurotoxicity have been reported, and has been shown to be dose depaendant. With infrequent users unlikely to be at risk of neurotoxicity, while heavier and habitual used at risk of serious neurological conserquences.
With the increase in recreation use of “Whippits” we need to remember to take a detailed recreation drug history when seeing patients presenting to ED with neurological symptoms. As Nitrous Oxide induced neurotoxicity is treatable.
Nitrous Oxide induced neurotoxicity can present as either spinal cord demyelination , peripheral neuropathy or a a combination of the two.
Nitrous Oxide usage can render vitamin B12 inactive, which in-turn disrupts myelination, causing the demyelination of nerves.
Start before Tests are back (i.e. on clinical suspicion)
The prevalence of diseases transmitted by tick bite have increased in recent years, within the UK. And it is now recognised that there are 3 main infections
Neurological Observations MUST include the following:
Head injury is witnessed, reported, suspected, or cannot be excluded.
Post fall Neurological Observations must be completed for at least 12 hours and at the above intervals as a minimum:
During this time If there is any deterioration in the patient’s condition including level of consciousness, pupil reaction, limb power, cardiovascular observation you must revert to ½ hourly neurological observation and seek URGENT medical review.
Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.
Under no circumstances should Neurological observations be omitted because the patient is asleep
Admitted with Head Injury
During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must revert to ½ hourly neurological observations and seek URGENT medical review. Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.
Under no circumstances should Neurological observations be omitted because the patient is asleep.
During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must seek URGENT medical review and revert to ½ hourly neurological observations as a minimum, or ¼ hourly, if still within the first 2 hours post thrombolysis.
Under no circumstances should Neurological observations be omitted because the patient is asleep.
AFP/AFM is rare rare but serious neurological condition, which is associated with POLIO infection but has also been linked with other infections (and in the USA they have spikes every 2 yrs last 2020). AFP leads to weakness and paralysis affecting face and limbs but also the respiratory muscles and may lead to respiratory failure.
An elderly patient attends the ED with difficulty mobilising, Nursing staff tell you that the patient needs a CT head for STROKE? – “They are really unsteady if they try to stand and they can’t lift their arms up”. Read more
Cervical artery dissection is a rare but significant cause of stroke and headache/neckache, which is easy to overlook. Leading to a typically delay in diagnosis of 7 days. Unfortunately imaging the cervical arteries is not simple, with MRA being the method of choice. Hence these patients must be referred to the “Stroke Consultant”.
Vertigo is not always labyrinthitis!! There are some potentially serious conditions to think about. Your main question should be is it peripheral [good] or central [bad]?
