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I Have the Worst Headache of My Life!
Abstract & Commentary
By John Shufeldt, MD, JD, MBA, FACEP, Chief Executive Officer, NextCare, Inc.; Attending Physician/Vice Chair, Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Mesa, AZ, is Editor for Urgent Care Alert.
Synopsis: An overview of the etiology, evaluation and treatment of subarachnoid hemorrhage.
Source: Tofteland ND, Salyers WJ. Subarachnoid hemorrhage. Hospital Physician. 2007;43:31-39.
Subarachnoid Hemorrhage SAH is an acute neurological emergency which affects more than 20,000 patients in the United States each year. The 30-day mortality approaches 50%, and survivors are often left with profound neurological deficits. Cerebral aneurysms and AVMs account for 70-80% of SAH. The incidence of saccular aneurysms in the United States is between 1-6%, respectively. The risk of rupture depends on size, location, and wall thickness.
The classic history is a sudden onset of the worst headache of the patient's life. The onset often occurs during physical activity, sexual activity, or even at rest. Associated signs are nausea, photophobia, vomiting, altered mental status, and focal or generalized neuro-symptoms. Approximately 33% of patients who present with SAH give a history of a severe headache during the preceding week. This is thought to be caused by a minor leaking of blood into the Subarachnoid space.
The physical examination of patients with SAH often reveals nuchal rigidity, cranial nerve palsies, alerted mental status, and vomiting. In patients without these findings, who present with a severe or different headache, or if the headache is accompanied by syncope or focal neurological deficit, the diagnosis of SAH must be entertained.
Non-contrast, thin-cut CT is the diagnostic modality of choice. Sensitivity approaches 100% for scans within the first 12 hours after symptom onset. False negatives can occur in patients who are anemic when CT scans cut wider than 3 mm, or with CT scans limited to artifact or patient movement. In patients whose CT scans are negative for SAH, lumbar puncture should be performed to look for bloody or xanthochromic cerebral spinous fluid.
Once diagnosed, early neurosurgical and neurological consultation must be obtained. The general management of these patients addresses 2 major objectives: identification of the bleeding site for possible intravascular or surgical intervention and treatment of the complications. The 2 most common complications are vasospasm and re-bleeding. Prior to the onset of vasospasm, all patients should receive prophylaxis with nimodipine within the first 12 hours. The typical dose is 60 mg PO or via NG tube for 21 days.
SAH is a devastating disease process which must be diagnosed early and accurately to help prevent some of the associated long-term morbidity and mortality. Up to 33% of patients diagnosed with SAH give a history of a severe headache within the preceding week. Often, these patients present for care during their "sentinel" leak, but unfortunately, the diagnosis was not ascertained.
Headache is a frequent presenting complaint in urgent care centers. Most of these patients have a non-life- threatening cause for their symptoms, and are appropriately treated with analgesics and antiemetics. A small subset of these patients is having a "sentinel" leak, or present at the onset of their SAH. It is in these urgent care patients, where the rapid evaluation and subsequent transfer can save a patient's life.
As in the previous article, the ability to recognize the high-risk, low-incidence urgent care conditions will save your patient's lives and lower your overall risk in what is otherwise a potentially high-risk practice.