2. Discuss
Neurology is a difficult subject with many critical diseases
for most of physicians. It is also a blind spot and difficult area in
medical diagnosis and treatment. Therefore, urgent consultation in
neurology department is very common in the tertiary hospital center. In
this analysis, there are two main findings listed. First, neurological
diseases account for 77.8% of total cases in the urgent consultation
diseases, which is different from the disease spectrum of inpatients
applying for emergency consultation in neurology department reported
recently [1]. 57.5% of diseases in the urgent consultation were in
line with the urgent consultation criteria. . Second, the most common
reasons of urgent consultation were disturbance of consciousness,
tic/stiffness, limb weakness and mental disorders. Common neurological
disorders were acute cerebrovascular disease (33.6%), epilepsy/status
epilepticus, and encephalitis, metabolic or infective toxic
encephalopathy.
In 1437 cases of urgent consultation, the actual number of cases was
decreased year by year from 573 cases in 2014 to 257 cases in 2017,
which may be attributed to the improvement of the clinical skills of
non-neurologists in our hospital and the rational and effective
management from the hospital medical services section. In this urgent
consultation indications assessment, only 57.5% of consultations were
in line with the urgent consultation criteria. Therefore,
non-neurological practitioners should strengthen the learning of neural
diseases; strictly make a judgment on the urgent neurological
consultation. And medical manage office should put forward the
appropriate management measures to enhance the effective urgent
consultaionn.
In urgent consultation, acute cerebrovascular diseases account for
33.6%, including cerebral infarction, cerebral hemorrhage and transient
ischemic attack, which was similar with foreign reports [8]. In our
hospital, the average age of patients with urgent consultation was 60.3
years old. This older age may be related to the highly incidence of
stroke onset increasing with age [6]. Most of the consultations are
in line with the guidelines of urgent consultation. However, the urgent
consultation cases were decreased. There are several reasons for that.
First, the management office has strengthen the importance of basic
medical knowledge and basic skills. There are lots of training held
during the continuing medical education. Second, the physicians are more
skilled in making a diagnosis and treatment the acute cerebrovascular
diseases. Third, there is a standardized clinical pathway for the
physician to reference on several neurological diseases. There were 177
cases of epileptic/epileptic persistent state, which was different from
the common urgent consultation diseases reported in domestic emergency
consultation reports. The main reason may be that there is an epileptic
center in our department, which is one of the famous epileptic centers
in China. There are several experts on epilepsy and a large number of
regular follow-up patients, which come from neighbor area with the poor
treatment managed by non-specialist physicians before. The metabolic or
infective toxic encephalopathy and encephalitis were the third largest
group of urgent neurological consultation in our hospital. There are
many patients with encephalopathy and encephalitis, who were treated for
a longer time. In the hospital, there is a Chongqing Key Laboratory of
Neurology, which is operated by full-time personnel. They can detect
acid-fast bacillus with more than 80% positive results and abscissile
cells. They also can detect more than ten antibodies related to
autoimmune encephalitis, which are highly specific and sensitive. The
neurological physicians could practice better management in making a
diagnosis and treatment of encephalitis.
Some of departments had frequently applied for urgent neurological
consultation including intensive care unit (ICU), respiratory medicine,
cardiovascular medicine, hematology and nephrology. At present, it is
estimated that there are about 10% of patients presented with some
neurological manifestations [10-12]. It had been reported that the
neurological consultation in ICU was often urgent consultation, which
also suggested that the patients had server disease to be managed. At
the same time, there are some of ICU doctors lacked relevant knowledge
of neurologic critical illness. It advised that resident on internal
medicine should be trained in neurological specialty at least 6 months
with the 3 years of standardized resident training in China. In
addition, physicians in the ICU should take part in more lectures on
emergency neurology in our hospital. Most of the patients have a common
occurrence of cerebrovascular disease in the department of
cardiovascular medicine and nephrology, who have the risk factors of
vascular sclerosis. Patients with renal failure are consulted by
neurology because of the impaired consciousness or convulsive in
dialysis, which are due to the internal environment dysfunction, renal
encephalopathy and dialysis encephalopathy. The common reasons for the
application for consultation in the department of respiratory medicine
include convulsions, disturbance of consciousness, and the etiology is
mostly pulmonary encephalopathy, ischemic and hypoxic encephalopathy.
First of all, it is very important for them to control the primary
disease. If the patients with lung tuberculosis presented with headache,
disturbance of consciousness, convulsion, hyponatremia, the tuberculosis
meningitis should be considered. And then the patients should be
prescribed routine with the lumber puncture for cerebrospinal fluid
analysis, dynamic electroencephalogram and brain enhanced MRI
examination. Once the patients have been made a diagnosis of
tuberculosis meningitis, physicians should prescribe with
anti-tuberculosis drugs in combination at enough doses as soon as
possible. The main reasons for applying for urgent consultation in
surgical department are impaired consciousness. The uncontrollable
postoperative epilepsy is one of the special reasons for the
neurosurgery department. However, the preoperative evaluation and
secondary prevention of cerebrovascular disease are often met in the
surgical department, which should be consulted at regular time rather
than an urgent consultation.
To take the accuracy case history and the neurologic examination may
help the physician in the differential neurological diseases with
others. There were 150 cases of non-neurological diseases including
restlessness, mental disorder, disturbance of consciousness and
headache, which were considered to be related to internal environmental
disorders, primary diseases, hypertension, anxiety state and vagal
reflex syncope. Some physicians confuse with the aphasia and unclear
utterance in mental disturbance. Therefore, in order to reduce
unnecessary urgent neurological consultation, physicians should rule out
the above diseases before application for an urgent enological
consultation. Acute encephalopathy often is secondary to infection after
cardiopulmonary resuscitation or metabolic diseases. To control the
primary causes is the main measures. Before applying for consultation,
it is suggested for the physicians to complete blood gas analysis,
electroencephalogram, blood glucose and electrolyte,
computer tomography of the skull, and to take the detail history of drug
use including sedatives and antidepressants. In the case of urgent
consciousness disorder and cognitive impairment after surgery, drugs
adverse effects should be considered first. Therefore the physicians
should be familiar to the adverse effects of anesthetic drugs. For the
tetanus/convulsion, as one of the common reason for urgent consultation,
the physician should be familiar with the possible cause of the
convulsion including the diseases of respiratory medicine, cardiology
and other internal medicine. Only parts of them are diagnosed as
epilepsy, which should apply for neurological consultation. Limb
weakness is the same with them. Non-neurological diseases accounted for
10.4%. Both internal medicine and surgical departments account for half
of them, such as respiratory, cardiology, orthopedics, obstetrics and
gynecology, and digestive departments. Non-neurologic diseases usually
presented with irritability and delirium with no focal nervous system
signs, which may be regarded as the differential criteria with the
neurological diseases. Most of the consultation patients with
non-neurologic diseases have no new structural damage in the central
nervous system [13], and the treatment is mainly to maintain the
stability of the internal environment for the treatment of primary
diseases. Pain is a common cause of consultation in previous reports
[14]. Some of them should be consulted with neurosurgical physician
rather than neurologic physician such as cerebral contusion and
laceration, skull base fracture, diffuse axonal injury, intracranial
tumor, hydrocephalus, subdural hematoma, etc. The physicians should know
more about neurosurgical knowledge.
Some of the consultations should be ordinary consultation rather than
urgent consultation. For example, a patient with Parkinson’s disease
applied for emergency consultation in neurology department because asked
for the intravenous treatment of ganglioside. There are 169 cases that
could not be diagnosed in the study because of severe diseases failure
to complete relevant examinations and physicians’ poor recording in the
cases. Medical staff in non-neurologic departments should strengthen the
learning of common urgent and critical diseases related in clinics,
while the neurologists provide more lectures to the junior physicians in
the hospital.