Emergency Neurological Life Support (ENLS)

Emergency Neurological Life Support (ENLS) is here!

I’ve been waiting to see this come to fruition for some time now, having helped work on the Acute Non-Traumatic Weakness protocol with Oli Flower (@oliflower), who co-chaired this section. Overall, the project was headed by Wade Smith MD, PhD and — that man again — Scott Weingart, MD RDMS (@emcrit). ENLS is designed to ensure you know what  to do in the first critical hour of a neurological emergency.

It is a collection of protocols for the management of common neurological emergencies within the first hour of onset.  It was created by neurointensivists from the  Neurocritical Care Society and emergency physicians on a volunteer basis and improved by feedback from medical providers worldwide.

Use of ENLS is intended for all medical professionals and the protocols are provided free on-line (that’s right, it is FOAM!).

The goals of ENLS include:

  • Improving the care of patients with neurological emergencies
  • Providing protocols that list important steps in managing a patient with a potential neurological emergency
  • Attempting to standardize emergency neurological care by consensus of healthcare providers
  • Providing education to anyone dealing with neurological emergencies
  • Identifying areas where research is needed to improve the care of our patients.

The online ENLS Protocols are are works of art in my opinion. I was fortunate to have access to them while they were being developed and found them exceptionally useful when preparing for the ACEM Fellowship examination. The topics include: Ischemic Stroke, Intracerebral Hemorrhage, Status Epilepticus, Subarachnoid Hemorrhage, Meningitis and Encephalitis, Airway Management including intubating a patient with high intracranial pressure, Traumatic Brain Injury, Traumatic Spine injury and Spinal Cord Compression and – of course – acute non-traumatic weakness.

As well as the protocols there is the training site that gives the background for each protocol step-by-step, includes the original manuscripts on ENLS published in the journal Neurocritical Care, provides examination of each protocol in a multiple choice format, and produces a certificate of Certification in ENLS (Edit: unfortunately this CME component is not free). Additional videos of presentations on ENLS and FAQs are included to provide additional depth of understanding. This site is designed to train any medical professional who is part of the chain of survival for patients with emergency neurological conditions. This includes Emergency Physician and Nurses, ICU physicians and nurses, and neuroscience house staff. CME credit is also offered for the course (see here for info on CME).

See what the online course looks like here.

To start with, I recommend visiting the ENLS Protocols and marveling at the beauty of complex emergency medicine reduced to it’s practical state-of-the-art essence. Enjoy!

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  1. says

    Another great example of FOAM in action. The breakdown and structure, algorithms, quizzes, all make it useful even to the inexperienced medical practitioner/student.

    Also liked that they put Moodle (open-source educational platform) to good use.

    Well done to Wade Smith, Scott Weingart and others for putting together a valuable resource.

  2. Duncan says

    Thrombolysis in acute stroke?

    I know that this remains controversial, and I know that there are occasional surprising dramatically good anecdotal outcomes (which can also occur with no treatment…) but the fact that:
    -- no consistent benefit can be found (or there wouldn’t be debate)
    -- far more trials have shown harm than benefit
    -- pharmaceutical company sponsored trials have shown benefit, non-pharmaceutical company sponsored trials have shown harm
    make this whole thing a bit of a no-brainer for me.

    At the very least, I think a significant message about the controversy should make it onto there. My opinion is that thrombolysis in stroke will turn out to be the early 21st century’s autism with vaccinations. Fundamentally a nasty lie with some well-meaning but misled advocates.

    • rm says

      Essentially all IV thrombolytic trials where drug is given in less than 4.5 hours show a clear morbidity benefit. But don’t take my word for it. Here’s the results from 2009 Chochrane review on the topic (more positive trials exist since then):

      We included 26 trials involving 7152 patients. Not all trials contributed data to each outcome. The trials tested urokinase, streptokinase, recombinant tissue plasminogen activator, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke; three trials started treatment up to nine hours and one small trial up to 24 hours after stroke. About 55% of the data (patients and trials) come from trials testing intravenous tissue plasminogen activator. Very few of the patients (0.5%) were aged over 80 years. Many trials had some imbalances in key prognostic variables. Several trials did not have complete blinding of outcome assessment. Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of patients who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.81, 95% confidence interval (CI) 0.73 to 0.90). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.49, 95% CI 2.81 to 4.33) and death by three to six months after stroke (OR 1.31, 95% CI 1.14 to 1.50). Treatment within three hours of stroke appeared more effective in reducing death or dependency (OR 0.71, 95% CI 0.52 to 0.96) with no statistically significant adverse effect on death (OR 1.13, 95% CI 0.86 to 1.48). There was heterogeneity between the trials in part attributable to concomitant antithrombotic drug use (P = 0.02), stroke severity and time to treatment. Antithrombotic drugs given soon after thrombolysis may increase the risk of death.

  3. says


    Probably. Just cannot view them on an iPad cos use flash.

    Bugger. Will have to resprt to printing them out and laminating, to stick in ED…where no doubt will get lost/re-filed elsewhere

    Is there a PDF version?

  4. says

    Great review Chris -- thanks. Chris, as with most of the internet nowadays, was heavily involved with the initial development of ENLS.

    I’m excited about this kind of teaching initiative, that anyone with the internet can do and be qualified in, and can share with their colleagues anywhere.

    Viva la #FOAMed indeed!