📋 Key Information Summary
- Suspected acute stroke with symptom onset within 4.5 hours requires an immediate Triple Zero (000) call — do NOT drive the patient yourself; paramedics can pre-notify the stroke team and initiate pre-hospital thrombolysis pathways.
- Use the FAST screen (Face, Arms, Speech, Time) and note exact last-known-well time; this determines eligibility for IV alteplase (tenecteplase increasingly used in some Australian centres) and endovascular thrombectomy up to 24 hours in select cases.
- Status epilepticus is defined as seizure lasting ≥5 minutes or ≥2 seizures without return to baseline — administer IM midazolam 10 mg (>40 kg) or rectal/buccal diazepam as first-line benzodiazepine before ambulance arrival.
- Acute paraplegia or rapidly progressive ascending weakness (suspected Guillain–Barré syndrome or spinal cord compression) is a time-critical emergency requiring same-day hospital assessment and transfer.
- Suspected bacterial meningitis or meningococcal sepsis: administer IM benzylpenicillin 2.4 g (adults) or ceftriaxone 2 g IV/IM immediately if available, then call 000 — do not delay transfer for lumbar puncture in primary care.
- In the pre-transfer stabilization period, use the ABCDE approach: secure airway (recovery position if GCS <9), high-flow oxygen if SpO₂ <94%, IV access with 0.9% NaCl, BSL check, and continuous vital-sign monitoring.
- Document all findings, medications given, and exact times on the Australian Ambulance clinical handover form or ISBAR framework to ensure seamless transition of care.
- Hypoglycaemia (BSL <4.0 mmol/L) is the most common stroke mimic — always check and correct glucose before assuming a neurologic emergency is present.
- Blood pressure management in suspected stroke: do NOT lower BP acutely in primary care unless hypertensive emergency (systolic >220 mmHg) — permissive hypertension maintains cerebral perfusion.
- Aboriginal and Torres Strait Islander peoples experience stroke incidence 1.5–3 times higher than non-Indigenous Australians, with younger age of onset and higher mortality — culturally safe communication and community-based awareness programs are essential.
- Patients on anticoagulants (warfarin, DOACs) with suspected stroke require specific documentation of INR, last dose, and agent name — this directly influences thrombolysis eligibility.
- For recurrent seizure activity after benzodiazepine administration, position patient in recovery position, protect from injury, time the seizure, and communicate duration to paramedics — do NOT insert objects into the mouth.
Introduction & Australian Epidemiology
Neurologic emergencies represent some of the most time-critical presentations encountered in Australian primary care. General practitioners and practice nurses are frequently the first clinicians to assess patients with acute neurologic deterioration, and the actions taken in the first 10–30 minutes can profoundly influence long-term outcomes including mortality, functional independence, and quality of life.
This guideline provides a practical framework for Australian primary care clinicians to: (1) recognise neurologic emergencies that mandate immediate ambulance transfer, (2) initiate evidence-based stabilisation measures, and (3) communicate effectively with receiving emergency departments and specialist teams.
Australian Epidemiology
- Stroke: Approximately 38,000 Australians experience a new or recurrent stroke annually (Stroke Foundation, 2023). Stroke is the third leading cause of death and the leading cause of acquired disability. The Australian Stroke Clinical Registry (AuSCR) reports that only ~40% of ischaemic stroke patients arrive at hospital within the 4.5-hour window for IV thrombolysis, highlighting the critical role of primary care recognition and rapid transfer.
- Epilepsy and seizures: Approximately 250,000 Australians live with epilepsy (Epilepsy Action Australia). Status epilepticus has an in-hospital mortality of 15–20% and community-onset cases often present first to primary care.
- Meningitis: Bacterial meningitis incidence in Australia is approximately 2–3 per 100,000 per year. Meningococcal disease notifications averaged 700–900 per year pre-COVID; serogroup B and W are now predominant (National Notifiable Diseases Surveillance System).
- Guillain–Barré syndrome (GBS): Incidence 1–2 per 100,000 per year, with significant morbidity requiring ICU admission in up to 30% of cases. Early recognition in primary care is essential as respiratory failure can develop within hours.
- Spinal cord emergencies: Traumatic spinal cord injury affects ~2,000 Australians annually (AIHW). Non-traumatic cord compression from metastatic disease or epidural abscess is an increasingly common presentation in primary care, particularly in patients with known malignancy.
- Aboriginal and Torres Strait Islander populations: First Nations Australians experience stroke at 1.5–3 times the rate of non-Indigenous Australians, at a significantly younger age, and with higher case-fatality rates (AIHW, 2022). Access to stroke units and thrombolysis-capable hospitals remains limited in rural and remote communities.
Time is brain: In ischaemic stroke, approximately 1.9 million neurons are lost per minute of untreated arterial occlusion. Every minute of delay in recognition and transfer reduces the probability of a good functional outcome. Primary care clinicians must act with urgency.
When to Call an Ambulance
The following clinical scenarios represent neurologic emergencies requiring immediate activation of Triple Zero (000) ambulance services. In each case, the primary care clinician should call 000 personally rather than instructing a patient or carer to do so, to ensure accurate clinical handover to the dispatch centre and responding paramedics.
Critical rule: If a patient presents with any acute focal neurologic deficit, new seizure, severe headache with neck stiffness, or rapidly progressive weakness — call 000 first, investigate second. Do not delay transfer for imaging or blood tests that can be performed at the receiving hospital.
1. Suspected Acute Stroke
Stroke is the prototypical "time-critical" neurologic emergency. Both ischaemic stroke (eligible for IV thrombolysis within 4.5 hours and endovascular thrombectomy within 24 hours in select cases) and haemorrhagic stroke (requiring urgent neurosurgical assessment) demand rapid hospital transfer.
Recognition — FAST and BE-FAST
The FAST mnemonic remains the standard community screening tool endorsed by the Australian Stroke Foundation. The expanded BE-FAST adds Balance and Eyes to improve sensitivity for posterior circulation strokes, which account for approximately 20% of presentations:
| Letter | Feature | Assessment |
|---|---|---|
| B | Balance | Sudden loss of balance or coordination, ataxia, vertigo |
| E | Eyes | Sudden visual loss, double vision, visual field defect |
| F | Face | Facial droop — ask patient to smile or show teeth |
| A | Arms | Arm drift — ask patient to hold both arms out for 10 seconds |
| S | Speech | Slurred speech or inability to repeat a simple sentence |
| T | Time | Note exact last-known-well time — ask patient, family, bystanders |
Additional Stroke Red Flags Requiring 000 Call
- Sudden severe headache ("thunderclap headache") with focal deficits — consider subarachnoid haemorrhage
- Sudden isolated vertigo with nystagmus and ataxia — posterior circulation stroke
- Sudden confusion, agitation, or reduced consciousness in a patient with new neurologic signs
- Known atrial fibrillation or mechanical heart valve with new neurologic deficit
- Patient on anticoagulants with suspected stroke (document agent, last dose, INR if available)
Stroke mimics to consider but do NOT delay transfer: Hypoglycaemia (check BSL immediately and correct — this is the most important reversible mimic), Todd's paresis (post-ictal focal weakness, usually resolves within 24 hours), hemiplegic migraine, and conversion disorder. If any doubt exists, treat as stroke and transfer.
2. Status Epilepticus
Status epilepticus is defined by the International League Against Epilepsy (ILAE) as a seizure lasting ≥5 minutes OR two or more seizures without recovery of consciousness between them. It is a medical emergency with significant morbidity and mortality if not treated promptly.
Classification
| Type | Definition | Clinical Features | Urgency |
|---|---|---|---|
| Generalised convulsive status epilepticus (GCSE) | Generalised tonic-clonic seizure ≥5 min | Rhythmic limb jerking, cyanosis, incontinence, tongue biting | Immediate 000 |
| Focal status epilepticus | Continuous focal seizure ≥5 min | Rhythmic jerking of one limb or facial muscles, preserved consciousness initially | Immediate 000 |
| Non-convulsive status epilepticus (NCSE) | Prolonged altered consciousness without overt motor activity | Confusion, staring, subtle eye blinking — often misdiagnosed | Urgent 000 if persistent |
When to Call 000
- Any seizure lasting ≥5 minutes in a known epilepsy patient
- First-ever seizure — always requires emergency assessment (exclude structural cause, meningitis, metabolic derangement)
- Seizure in a patient who has not responded to their usual rescue medication (e.g., buccal midazolam)
- Recurrent seizures without return to consciousness between episodes
- Seizure in a pregnant patient (exclude eclampsia — administer IV magnesium sulfate 4 g over 15–20 min if available)
- Seizure associated with head trauma, fever, signs of meningitis, or known immunocompromise
- Post-ictal period lasting >30 minutes without neurological recovery
3. Acute Paraplegia / Spinal Cord Emergency
Acute onset of bilateral lower limb weakness, sensory level, or sphincter dysfunction constitutes a spinal cord emergency. The most common causes encountered in primary care include:
- Spinal cord compression — from metastatic disease (breast, lung, prostate, kidney, thyroid), epidural abscess, or severe disc herniation
- Spinal cord infarction — anterior spinal artery syndrome with acute paraplegia, loss of pain/temperature sensation below the level, and preserved posterior column function
- Transverse myelitis — bilateral motor and sensory deficits with a sensory level, often post-infectious or associated with multiple sclerosis, NMOSD, or MOG-antibody disease
- Cauda equina syndrome — saddle anaesthesia, bilateral sciatica, urinary retention, reduced anal tone
Critical: Spinal cord compression from metastatic disease is an oncologic emergency. If motor deficits are present for <24–48 hours, emergency surgical decompression or radiotherapy may restore function. Every hour of delay reduces the probability of ambulatory recovery. Call 000 immediately — do not wait for MRI in primary care.
Red Flags in Acute Paraplegia
- Known malignancy with new back pain and bilateral leg weakness
- Sensory level (use pin-prick testing to identify dermatomal level)
- New urinary retention or incontinence with lower limb weakness
- Bilateral positive Babinski sign (upgoing plantars)
- Fever with back pain and progressive weakness (suspect epidural abscess)
- Anticoagulant use with sudden onset back pain and paraplegia (suspect spinal epidural haematoma)
4. Suspected Meningitis / Meningococcal Sepsis
Bacterial meningitis and meningococcal sepsis are rapidly progressive, life-threatening infections. Primary care clinicians may encounter patients in the early stages where the classic triad of fever, neck stiffness, and altered mental status is not yet fully developed.
Clinical Features — High-Suspicion Presentation
- Classic triad (present in ~45% of bacterial meningitis cases): Fever + neck stiffness + altered consciousness
- Early/meningococcal features: Fever with petechial or purpuric rash (non-blanching), leg pain, cold hands and feet, rapid deterioration
- Neonates and infants: Fever, irritability, poor feeding, bulging fontanelle, high-pitched cry, lethargy
- Immunocompromised patients: May present atypically without fever or meningism — maintain high index of suspicion
- Photophobia, severe headache, nausea/vomiting, Kernig's sign, Brudzinski's sign
Meningococcal sepsis — act before the rash: In early meningococcal disease, the characteristic non-blanching petechial rash may be absent or limited to a few spots. A child or young adult presenting with fever, malaise, leg pain, and cold peripheries should be treated as possible meningococcal sepsis. Administer IM benzylpenicillin and call 000. Do NOT wait for a rash to appear.
Pre-Hospital Antibiotic Administration
If bacterial meningitis or meningococcal sepsis is suspected and hospital transfer will take >30 minutes, administer pre-hospital antibiotics in primary care. Do not delay transfer for antibiotic administration if the ambulance is imminently arriving.
Benzylpenicillin (Penicillin G)
Crystapen® · IV/IM · Penicillin antibiotic
Adult dose
2.4 g IV or IM (single pre-hospital dose)
Paediatric dose
300 mg (infants <1 year), 600 mg (children ≥1 year) IM or IV
Route
IV (preferred) or IM
Renal adjustment
Not required for single pre-hospital dose
PBS status
✔ PBS General Benefit
Ceftriaxone
Rocephin® · IV/IM · Third-generation cephalosporin
Adult dose
2 g IV or IM (single pre-hospital dose if available)
Paediatric dose
50–100 mg/kg IV or IM (max 2 g, single dose)
Route
IV (preferred) or IM (diluted with 1% lidocaine if IM)
Renal adjustment
Not required for single pre-hospital dose
PBS status
✔ PBS General Benefit
5. Rapidly Progressive Weakness — Guillain–Barré Syndrome and Acute Neuromuscular Emergencies
Rapidly progressive weakness — ascending, descending, or generalised — may indicate Guillain–Barré syndrome (GBS), myasthenic crisis, or acute inflammatory myopathy. These conditions can progress to respiratory failure within hours to days.
Guillain–Barré Syndrome (GBS)
- Typically presents 1–4 weeks after a preceding infection (most commonly Campylobacter jejuni gastroenteritis, respiratory tract infection, or Zika virus)
- Symmetrical ascending weakness starting in the legs, with areflexia
- May have paraesthesia, back pain, and autonomic dysfunction (tachycardia, hypertension, urinary retention)
- Respiratory involvement: monitor vital capacity — bedside forced vital capacity (FVC) <20 mL/kg or rapid decline is an indication for ICU transfer
- Facial weakness (bilateral), bulbar weakness (dysphagia, dysarthria), and ophthalmoplegia may occur
Respiratory monitoring in GBS: Bedside peak flow or FVC measurement is essential in primary care if GBS is suspected. FVC <20 mL/kg, declining FVC trend, or the patient unable to count to 20 on a single breath indicate imminent respiratory failure — call 000 for ICU-level transfer.
Myasthenic Crisis
- Exacerbation of myasthenia gravis with respiratory failure or need for intubation
- Often precipitated by infection, medication changes (aminoglycosides, beta-blockers, magnesium), surgery, or non-adherence
- Progressive bulbar weakness (difficulty swallowing, choking), ptosis, diplopia, and proximal limb weakness
- Any myasthenia patient with new dyspnoea, difficulty managing secretions, or inability to swallow medications warrants 000 transfer
When to Call 000 for Progressive Weakness
- Bilateral leg weakness developing over hours to days, especially with areflexia
- Difficulty breathing, unable to speak in full sentences, shallow breathing, or using accessory muscles
- Inability to swallow, choking on saliva or fluids
- Rapidly worsening weakness in a patient with known myasthenia gravis
- New bilateral weakness with bladder or bowel dysfunction
- Suspected botulism (descending paralysis, bulbar palsy, blurred vision after ingestion of home-canned food)
Stabilisation Prior to Transfer
Once a neurologic emergency has been recognised and 000 activated, the primary care clinician must initiate stabilisation measures using the structured ABCDE approach. The goal is to prevent secondary brain or spinal cord injury and maintain organ perfusion until paramedics arrive and during transfer.
ISBAR Communication Framework: Use ISBAR (Identification, Situation, Background, Assessment, Recommendation) when communicating with the receiving emergency department, neurologist, or stroke team. This structured handover has been adopted across Australian hospitals under the NSQHS Clinical Communication Standard.
A — Airway
- Assess: Is the patient speaking? Are there gurgling sounds, snoring, or stridor? Is there pooling of secretions?
- GCS <9: The patient cannot protect their own airway — place in the recovery position (lateral decubitus), head tilted slightly down to allow secretions to drain
- Seizure patients: Maintain airway by jaw thrust; place in recovery position once convulsions cease; do NOT insert any object into the mouth
- Bulbar weakness (GBS, myasthenic crisis): Sit upright if able; if unable to manage secretions, position to prevent aspiration; suction if available
- Cervical spine precautions: If trauma suspected (particularly in seizures with fall, or acute paraplegia with trauma), maintain manual in-line stabilisation until paramedics apply a collar
1
Head-tilt chin-lift
Open the airway using head-tilt chin-lift (or jaw thrust if cervical injury suspected)
2
Recovery position
If GCS <9 and breathing, place in left lateral decubitus with head dependent
3
Suction / clear
Clear secretions, vomit, or blood from the oropharynx if suction equipment available
B — Breathing
- Assess respiratory rate, depth, pattern, and SpO₂: Target SpO₂ ≥94% (or ≥88–92% in known COPD with chronic hypercapnia)
- Supplemental oxygen: Apply high-flow oxygen (15 L/min via non-rebreather mask) if SpO₂ <94% or signs of respiratory distress. In suspected stroke, avoid hyperoxia — titrate to SpO₂ 94–98% once established
- Respiratory pattern assessment:
| Pattern | Significance | Action |
|---|---|---|
| Cheyne–Stokes (crescendo–decrescendo with apnoeic pauses) | Bilateral cerebral hemispheric or diencephalic dysfunction; heart failure | Elevate head of bed 30°; document and communicate |
| Central neurogenic hyperventilation | Brainstem lesion | Urgent — anticipate intubation |
| Ataxic / Biot's breathing (irregular with prolonged pauses) | Medullary compression — pre-terminal sign | Immediate 000 if not already en route; prepare for bag-valve-mask |
| Paradoxical breathing (abdomen moves in on inspiration) | Diaphragmatic weakness — GBS, high cervical cord lesion, myasthenic crisis | ICU-level transfer required |
C — Circulation
- Establish IV access: Insert a large-bore (18G or 16G) peripheral IV cannula. Obtain bloods simultaneously (FBC, UEC, LFTs, coagulation, BSL, VBG or ABG, lactate, troponin if cardiac cause considered)
- IV fluid: Commence 0.9% sodium chloride at a keep-vein-open rate (e.g., 80–100 mL/hr) unless signs of fluid overload. Avoid hypotonic solutions (risk of cerebral oedema)
- Blood pressure management — disease-specific:
| Scenario | BP Target | Notes |
|---|---|---|
| Ischaemic stroke (pre-thrombolysis) | <185/110 mmHg for alteplase eligibility | Managed by receiving stroke team — do NOT lower in GP |
| Ischaemic stroke (no thrombolysis planned) | Permissive hypertension; treat if >220/120 mmHg | Permissive hypertension maintains penumbral perfusion |
| Intracerebral haemorrhage | <140 mmHg systolic (INTERACT2/ATACH-2 targets) | Managed at hospital — but avoid excessive BP in primary care |
| Subarachnoid haemorrhage | <160 mmHg systolic | Urgent neurosurgical transfer |
| Spinal cord compression | MAP ≥85 mmHg | Maintain perfusion to the injured cord; IV fluids ± vasopressors at hospital |
| Meningococcal sepsis | Support with IV fluids; fluid bolus 20 mL/kg NS for children | Vasopressors initiated by paramedics / ED |
Do NOT acutely lower blood pressure in suspected stroke in primary care. Permissive hypertension maintains cerebral perfusion to the ischaemic penumbra. The only exception is hypertensive emergency with end-organ damage (systolic >220 mmHg), and even this should be managed by paramedics or the receiving team. Avoid sublingual nifedipine — it causes unpredictable drops in BP.
D — Disability (Neurologic Assessment)
Perform a focused neurologic assessment and document findings for handover. This assessment serves as the baseline against which deterioration or improvement is measured.
Glasgow Coma Scale (GCS)
| Component | Response | Score |
|---|---|---|
| Eye opening (E) | Spontaneous | 4 |
| To voice | 3 | |
| To pain | 2 | |
| None | 1 | |
| Verbal (V) | Oriented | 5 |
| Confused | 4 | |
| Inappropriate words | 3 | |
| Incomprehensible sounds | 2 | |
| None | 1 | |
| Motor (M) | Obeys commands | 6 |
| Localises pain | 5 | |
| Withdrawal (flexion) | 4 | |
| Abnormal flexion (decorticate) | 3 | |
| Extension (decerebrate) | 2 | |
| None | 1 |
Focused Neurologic Examination Prior to Transfer
- Pupils: Size, symmetry, reactivity to light — unequal or fixed pupils suggest herniation
- Limb strength: Medical Research Council (MRC) grading 0–5 in all four limbs; document any asymmetry
- Reflexes: Present, absent, or exaggerated; Babinski sign (upgoing plantars = upper motor neuron)
- Sensation: Light touch, pin-prick — identify any sensory level in suspected cord pathology
- Cerebellar signs: Finger–nose test, heel–shin test, rapid alternating movements
- Cranial nerves: Brief assessment of II–XII (visual fields, eye movements, facial symmetry, tongue protrusion, palatal movement, shoulder shrug)
Blood Glucose Level (BSL) — Critical Step
Always check BSL first. Hypoglycaemia (BSL <4.0 mmol/L) is the most common and treatable stroke/seizure mimic. Hyperglycaemia (BSL >15 mmol/L) can also cause focal neurologic signs. Correct hypoglycaemia immediately: oral glucose if conscious and able to swallow, or IM/IV glucagon 1 mg, or IV 50% dextrose 50 mL (25 g) if IV access established.
Glucose 50% (IV dextrose)
Various · IV · Monosaccharide
Adult dose
50 mL (25 g) IV bolus via large vein; may repeat once
Paediatric dose
2–5 mL/kg of 10% dextrose (0.2–0.5 g/kg) IV
Caution
Extravasation causes tissue necrosis — ensure IV patency
PBS status
✔ PBS General Benefit
Glucagon
GlucaGen® HypoKit · IM/SC · Pancreatic hormone
Adult dose
1 mg IM or SC; may repeat in 10–15 min
Paediatric dose
<25 kg: 0.5 mg IM/SC; ≥25 kg: 1 mg IM/SC
Onset
IM: 10–15 min; less effective in malnourished/depleted glycogen stores
PBS status
⚠ PBS Authority Required
E — Exposure and Environment
- Fully expose the patient (within privacy and dignity) to identify rash (petechiae in meningococcal sepsis), injuries from falls during seizures, or skin changes
- Maintain normothermia — use blankets to prevent hypothermia; hyperthermia >38.5°C in status epilepticus may indicate superimposed infection and should prompt consideration of meningitis
- Check for medical alert bracelet, identification necklace, or phone ICE (In Case of Emergency) contacts
- Document weight estimation (for drug dosing) if possible
Seizure-Specific Stabilisation — Benzodiazepine Administration
If a patient is actively seizing in the primary care setting, first-line benzodiazepines should be administered before ambulance arrival. The route depends on availability and clinical setting:
Midazolam
Hypnovel® · Buccal/IM/IV · Benzodiazepine
Adult dose (>40 kg)
Buccal: 10 mg (2 × 5 mg syringes) between lower lip and gum; IM: 10 mg in deltoid; IV: 5 mg over 2 min
Paediatric dose
Buccal: 10–25 kg: 5 mg; >25 kg: 10 mg; IM: 0.2 mg/kg (max 10 mg); IV: 0.1–0.2 mg/kg (max 5 mg)
Duration
Single dose; may repeat once after 5–10 min if seizure continues
Renal adjustment
Use lower end of dose range; enhanced sensitivity in renal impairment
PBS status
✔ PBS General Benefit
Diazepam
Diazemuls® · Rectal/IV · Benzodiazepine
Adult dose
Rectal: 10–20 mg; IV: 5–10 mg over 2–3 min
Paediatric dose
Rectal: 1–2 years: 5 mg; 2–12 years: 5–10 mg; >12 years: 10–20 mg; IV: 0.1–0.3 mg/kg (max 10 mg)
Duration
Single dose; may repeat once after 5–10 min
Renal adjustment
No specific adjustment; use lower dose in elderly
PBS status
✔ PBS General Benefit
Communication with the Receiving Team
Effective communication between primary care and the receiving emergency department or specialist team is critical for timely and appropriate management. Use the ISBAR framework (endorsed by the Australian Commission on Safety and Quality in Health Care):
I
Identification
Your name, role, practice location; patient name, age, gender, weight
S
Situation
Chief complaint: "I am calling about a 68-year-old male with suspected acute ischaemic stroke presenting with right hemiparesis and expressive dysphasia"
B
Background
Relevant history: AF, warfarin (INR unknown/2.5 last week), hypertension, last known well time, medications, allergies
A
Assessment
Vital signs, GCS, NIHSS elements, BSL, pupils, treatments given (with times)
R
Recommendation
"I recommend stroke team activation and CT angiography on arrival. ETA of ambulance is approximately 12 minutes."
Essential Information to Document and Communicate
- Exact last-known-well time (stroke) or seizure onset time
- All vital signs with times (HR, BP, RR, SpO₂, temperature, GCS, BSL)
- Medications given (drug, dose, route, time)
- Current medications — especially anticoagulants (agent, dose, last dose taken, INR if known), anticonvulsants, antihypertensives, and insulin
- Allergies
- Relevant medical history (AF, prosthetic heart valve, malignancy, epilepsy, myasthenia gravis, recent surgery)
- Trend of neurologic observations (improving, stable, or deteriorating)
- Contact details for next of kin or substitute decision-maker
Stroke thrombolysis eligibility — key information for the receiving team: Document the exact last-known-well time, current and recent anticoagulant use (including DOACs — note last dose within 48 hours may preclude thrombolysis), recent surgery or trauma, recent stroke, and bleeding history. If the patient is on warfarin, provide the most recent INR. If no INR is available, communicate this — the receiving team will obtain urgent bloods.
Specific Stabilisation Measures by Emergency Type
| Emergency | Specific GP Measures | Do NOT Do |
|---|---|---|
| Ischaemic stroke | NBM (nil by mouth); position head at 30°; record last-known-well time; note anticoagulant use | Do NOT give aspirin pre-hospital; do NOT lower BP acutely; do NOT give IV fluids rapidly (risk of cerebral oedema) |
| Intracerebral haemorrhage | Elevate head 30°; NBM; correct coagulopathy information for receiving team | Do NOT administer antiplatelet agents or anticoagulants; do NOT lower BP aggressively in GP |
| Status epilepticus | Buccal midazolam or IM midazolam; recovery position; BSL; oxygen if SpO₂ <94% | Do NOT insert objects in mouth; do NOT restrain forcefully; do NOT give oral medications during seizure |
| Meningitis | IM benzylpenicillin 2.4 g (adult) or ceftriaxone 2 g; IV access; fluid resuscitation | Do NOT delay transfer for LP; do NOT use corticosteroids in primary care |
| Spinal cord compression | IV access; maintain MAP ≥85 mmHg with fluids; document sensory level and motor grade | Do NOT allow patient to mobilise; do NOT delay for MRI in GP |
| GBS / Myasthenic crisis | Sit upright; bedside FVC if possible; NBM if bulbar weakness; IV access | Do NOT administer aminoglycosides or magnesium if myasthenia suspected; do NOT leave patient unattended if respiratory compromise |
Investigations in Primary Care (Pre-Transfer)
Investigations in the primary care setting should be limited to those that are immediately available and will directly influence pre-hospital management or ambulance destination. Do NOT delay transfer for investigations that can be performed at the receiving hospital. The primary role of primary care is recognition, stabilisation, and initiation of time-critical treatments.
Essential
Blood Glucose Level (BSL)
Bedside glucometer — perform IMMEDIATELY on any patient with altered consciousness, seizure, or focal neurologic deficit. Correct if <4.0 mmol/L. Document result and time.
Essential
Vital Signs (HR, BP, RR, SpO₂, Temperature, GCS)
Document at presentation and repeat every 5–10 minutes until ambulance arrival. Use for ISBAR handover.
Essential
12-Lead ECG (if available)
Identify atrial fibrillation (stroke aetiology), ST changes, prolonged QTc (relevant for future anti-epileptic choice), Brugada pattern. Can be performed in GP without delaying transfer.
Available
Blood Pathology (FBC, UEC, Coagulation, LFTs)
Collect if IV access established and time permits — label, send with patient. INR critical if patient on warfarin with suspected stroke. MBS items: 65070 (FBC), 66500 (coagulation), 66503 (UEC). Results will be available at receiving hospital if sent electronically (if connected to hospital pathology provider).
Available
Urine Dipstick / Urinalysis
Exclude UTI as precipitant of confusion/seizure; detect myoglobinuria in suspected rhabdomyolysis from prolonged seizure.
Referred
CT Brain (Non-Contrast)
NOT available in most Australian GP practices. Critical for distinguishing ischaemic from haemorrhagic stroke — performed at receiving hospital. Primary care should NOT delay transfer to arrange GP-initiated CT.
Specialist
MRI Brain / Spine
Performed at hospital — critical for stroke (DWI-MRI), spinal cord compression, and GBS (nerve root enhancement). Arrange via receiving team.
Specialist
Lumbar Puncture
Should NOT be performed in primary care. Contraindicated if raised ICP suspected (CT first at hospital). If meningitis suspected, administer antibiotics first and transfer.
Specialist
CT Angiography (CTA) / CT Perfusion
Performed at stroke-capable hospital — identifies large vessel occlusion for endovascular thrombectomy candidacy.
Risk Stratification & Transport Destination
In metropolitan areas, paramedics will generally transport to the nearest stroke-capable or major tertiary hospital. However, in regional and rural Australia, the primary care clinician may need to advise on transport destination. The following stratification guides decision-making:
Time-Critical
Thrombolysis-Eligible Stroke
Ischaemic stroke symptoms within 4.5 hours of last known well, no contraindications to alteplase
Transport to: Nearest thrombolysis-capable stroke centre (Primary Stroke Centre or Comprehensive Stroke Centre). In rural areas: activate Retrieval Services (e.g., RFDS, state retrieval service) for aeromedical transfer if road transport >60 min.
Time-Critical
Large Vessel Occlusion Stroke
Severe hemiparesis (NIHSS ≥6), gaze deviation, aphasia — may benefit from thrombectomy up to 24 hours
Transport to: Nearest Comprehensive Stroke Centre (with interventional neuroradiology). May require secondary transfer.
Time-Critical
Status Epilepticus — Unresponsive to Initial BZD
Seizure continuing after first-line benzodiazepine dose; recurrent seizures without recovery
Transport to: Nearest ED with ICU access. Second-line anticonvulsants (levetiracetam, phenytoin, sodium valproate) administered by paramedics or at ED.
Urgent
Meningitis / Meningococcal Sepsis
Suspected bacterial meningitis or meningococcal disease — antibiotics already given
Transport to: Nearest ED with infectious disease and ICU capability. Public health notification required (notifiable disease in all states/territories).
Urgent
Spinal Cord Compression / Acute Paraplegia
Progressive motor deficit with sensory level; suspected cord compression
Transport to: Nearest neurosurgical centre or tertiary hospital with MRI and neurosurgical/oncology pathways. May require retrieval.
Urgent
GBS / Myasthenic Crisis / Progressive Weakness
Ascending weakness with areflexia; bulbar weakness; respiratory compromise
Transport to: Hospital with ICU and neurology services. Bedside FVC monitoring en route. May require retrieval from regional areas.
Retrieval services in Australia: In regional and remote areas, activate state or territory retrieval services for aeromedical transfer: Royal Flying Doctor Service (RFDS — 1800 625 800), CareFlight, QGAP (QLD), NETS (NSW), MedSTAR (SA), RFDS (WA/NT/TAS). Activation should occur as soon as a time-critical neurologic emergency is identified — do not wait for ambulance arrival.
Monitoring During Pre-Transfer Period
Continuous monitoring from the time of recognition until handover to paramedics is essential. Document all observations with times to enable trending and informed decision-making by the receiving team.
Immediate (0 min)
BSL, GCS, vital signs (HR, BP, RR, SpO₂, temperature), pupil assessment, establish IV access, administer emergency treatments (benzodiazepines, pre-hospital antibiotics as indicated)
5 minutes
Repeat vital signs; reassess GCS; document seizure duration if applicable; confirm 000 called
10 minutes
Trend vital signs (any deterioration?); reassess respiratory status; second benzodiazepine dose if seizure continues; begin ISBAR handover to receiving hospital
Every 10–15 minutes
Continue vital sign monitoring; reassess GCS; check BSL if altered consciousness; document any changes in neurologic status
At ambulance arrival
Complete ISBAR handover to paramedics; provide written documentation of all observations, treatments given, and relevant history; hand over collected blood specimens
Key Monitoring Parameters
| Parameter | Frequency | Deterioration Triggers |
|---|---|---|
| GCS | Every 5–15 min | Drop of ≥2 points; new unilateral pupil dilation |
| Respiratory rate and SpO₂ | Continuous / every 5 min | RR <10 or >30; SpO₂ <92%; paradoxical breathing |
| Blood pressure | Every 5–10 min | Systolic <90 mmHg (hypoperfusion); SBP >220 (hypertensive emergency) |
| Heart rate | Continuous (ECG if available) | New AF; HR <50 or >150; new arrhythmia |
| BSL | At presentation; repeat if GCS drops | BSL <4.0 or >15 mmol/L |
| Temperature | At presentation; repeat every 15 min | Temperature >38.5°C (consider meningitis); hyperthermia in status epilepticus |
| Pupils | Every 10 min | New anisocoria; fixed dilated pupil (herniation) |
| Motor response | Every 10 min | New weakness; posturing (decorticate/decerebrate) |
| Seizure duration | Continuous timing | Seizure >5 min (→ give benzodiazepine); continuous after 2nd dose (→ 000 priority escalation) |
Special Populations
Pregnancy
Eclampsia: Seizures in pregnancy (usually >20 weeks) or postpartum should be treated as eclampsia until proven otherwise. Administer magnesium sulfate 4 g IV over 15–20 min (loading dose) followed by 1 g/hr maintenance — available as eclampsia pack in many Australian maternity units. Call 000 and the obstetric team simultaneously.
Stroke in pregnancy: Ischaemic and haemorrhagic stroke risk is elevated 2–3 fold in pregnancy and postpartum. IV alteplase may be considered but requires specialist discussion (teratogenicity data limited). Document gestational age.
Venous sinus thrombosis: Consider in pregnant/postpartum patients with headache, seizures, focal deficits, and papilloedema.
Positioning: Left lateral tilt (15–30°) to avoid aortocaval compression if >20 weeks gestation.
Paediatrics
Febrile seizures: Simple febrile seizures (<15 min, generalised, age 6 months–5 years) do not typically require 000 if the child recovers fully. Complex febrile seizures (>15 min, focal features, recurrent within 24 hours) require emergency assessment.
Meningitis in children: Higher index of suspicion — non-specific presentations in neonates and infants (fever, irritability, poor feeding, bulging fontanelle). Pre-hospital antibiotics: benzylpenicillin 300 mg IM (<1 year) or 600 mg IM (≥1 year), or ceftriaxone 50–100 mg/kg IM/IV.
Drug doses: Use weight-based dosing; refer to APLS (Advanced Paediatric Life Support) guidelines or the Australian Medicines Handbook – Children. Buccal midazolam: 10–25 kg: 5 mg; >25 kg: 10 mg.
Stroke in children: Rare but under-recognised. Sickle cell disease, cardiac disease, moyamoya, and prothrombotic states are risk factors. Call 000 if focal deficits or seizures occur in children with these conditions.
Non-accidental injury: Consider in children with unexplained seizures, subdural haematomas, or retinal haemorrhages — mandatory reporting obligations apply in all Australian states/territories.
Elderly
Atypical presentations: Elderly patients may present with stroke or meningitis without classic features — confusion, falls, new incontinence, or subtle behavioural changes may be the only signs.
Polypharmacy risks: Review medication list for drug interactions precipitating seizures (tramadol + SSRI, clozapine, theophylline, high-dose penicillin). Anticholinergic burden may worsen confusion.
Anticoagulant use: High prevalence of anticoagulant use (warfarin, apixaban, rivaroxaban, dabigatran) — document carefully for stroke team. Falls with head trauma on anticoagulants → urgent CT to exclude intracranial haemorrhage.
Delirium vs. stroke: Acute confusional state in the elderly may represent delirium (infection, metabolic, medication) rather than stroke — but assume stroke until proven otherwise if focal signs present.
End-of-life considerations: Some elderly patients have advance care directives limiting escalation of care. Check My Health Record, advance care plan documentation, or speak with family/carers before initiating full resuscitation measures.
Renal Impairment
Uraemic encephalopathy: Severe CKD/ESKD may present with confusion, myoclonus, or seizures — BSL alone will not differentiate from stroke. Document renal history and last dialysis date.
Drug dosing: Benzodiazepines: use lower doses in severe renal impairment (enhanced sensitivity). Pre-hospital antibiotics: benzylpenicillin dose adjustment not required for single dose; ceftriaxone no adjustment needed.
Dialysis patients: New neurologic deficits during or after haemodialysis may represent dialysis disequilibrium syndrome, intracranial haemorrhage (anticoagulation during dialysis), or stroke — always treat as stroke.
Hyperkalaemia: Severe hyperkalaemia (K⁺ >6.0 mmol/L) can cause muscle weakness mimicking stroke or GBS — obtain urgent ECG if this is a possibility.
Hepatic Impairment
Hepatic encephalopathy: Altered consciousness, confusion, asterixis, and focal signs may mimic stroke in patients with chronic liver disease. Document INR, Child-Pugh status, and history of portal hypertension.
Coagulopathy: Liver disease causes coagulopathy — relevant for any neurologic emergency. Communicate INR and platelet count to receiving team. May affect thrombolysis eligibility in stroke.
Drug metabolism: Midazolam and diazepam have prolonged half-lives in hepatic impairment — use lower doses and monitor closely for respiratory depression.
Immunocompromised
Expanded differential: Immunocompromised patients (HIV, transplant recipients, chemotherapy, biologics, high-dose corticosteroids) are at risk for opportunistic CNS infections: cryptococcal meningitis, cerebral toxoplasmosis, progressive multifocal leukoencephalopathy (PML), listeria meningitis, cerebral abscess.
Atypical presentations: Meningitis may present without fever or meningism; seizure may be the only feature of a CNS mass lesion.
Pre-hospital antibiotics: Include coverage for Listeria monocytogenes in immunocompromised patients with suspected meningitis — add IV amoxicillin 2 g (or discuss with receiving team). Ceftriaxone does not cover Listeria.
Drug interactions: Check for interactions with immunosuppressive agents (calcineurin inhibitors) before administering new medications.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
📚 References
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