Transcript File

SDMH EMC 2015
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Key assessment features to ascertain in acute headache –
differential causes
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When to consider neuroimaging
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Become familiar with subarachnoid haemorrhage (SAH) workup
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Understand the features of infective headaches
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Features that may suggest uncommon but important diagnoses
HISTORY
EXAM
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Acuity of onset
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ABCD – primarily GCS
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Prodromal features – fever, ‘flu’,
nausea, visual problems
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BP and T
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Syncope, meningism, eye pain,
focal neurology, facial pain,
seizures
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Neck rigidity/photophobia
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Detailed neurological exam
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Facial sinuses
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Eyes
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Headache pattern
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Family history – Migraine, SAH
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Medications –
immunosuppressant's, recent
antibiotics
Temporal artery tenderness
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Pathology – largely unhelpful.
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Serum Na, BSL and ESR/CRP may assist with some
differentials
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Imaging – CT head test of choice if indicated
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Invasive – Lumbar puncture if SAH, meningitis, encephalitis
or Idiopathic intracranial hypertension considered
HISTORICAL
EXAM
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Classic – unilateral, throbbing,
nauseating.
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Common – generalized
headache, deteriorating with time
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Headache preceded by aura
and/or nausea
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Family history. Onset in
adolescence or young adulthood
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Stereotypical – patient can
recognise it.
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Migraine sufferers can also suffer
other neuropathology eg SAH
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1st line - NSAID – PO/PR and Paracetamol
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2nd line –
Metoclopromide 10mg IM/IV OR
Prochlorperazine 12.5mg IM/IV OR
Droperidol
1-5 IM/IV
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3rd line – Chlorpromazine 12.5 mg IV in IV fluids.
Repeat x 1 if ineffective
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Rehydrate – fluids often helpful
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If failing to settle, consider alternate diagnosis, senior input
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Triptans – expensive, frequently ineffective in ED population
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Ergotamine unavailable
44 yr old female
Smoker
Sudden onset severe R sided headache whilst sitting
reading a book 3 hrs earlier
 Associated nausea, vomited x 2
 Otherwise well
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BUT….
 4 x sisters with ‘bleeds into brain’ – 2 deceased from
aneurysms in NZ
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80% due to aneurysm
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Median age 50
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Smoking 4-5 x risk
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Typically ‘worst ever’ headache
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Reaching maximal severity immediately
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Nausea/vomiting/syncope/seizure raise
suspicion
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May only have headache
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Headache may dissipate within hoursdays
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Causes 12-25% of thunderclap headaches
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Exam – often normal
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Photophobia/nuchal rigidity
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Decreasing level of
consciousness , worse
outcome
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Thus need to avoid missing
the ‘sentinel bleed’
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Re-bleed - 1 day to 1 month
later
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CT head
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First line test – non contrast
CT head
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Positive result on CT  CT
angiography
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Will help to determine
neurosurgical plan
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CT sensitivity traditionally quoted as
~ 90% at 4-12hrs after headache,
falling with time
CSF testing for RBC breakdown
(xanthochromia) - gold standard
‘Standard practice’ – if CT negative
do LP 12 hrs from onset headache
Perry et al 2011 – 100% CT sensitivity
< 6hrs headache  no LP needed if
presenting under 6 hrs
LP may find alternate pathology
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Definitive treatment - interventional
neuroradiology or neurosurgeon –
transfer
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Analgesia
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Antiemetic
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Avoid hypertension and hypotension
(?140>BP>100)
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?Seizure prophylaxis
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Nimodipine PO within 96 hrs
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Headache +fever +meningism
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Frequently following URTI
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May deteriorate quickly, or have
persistent headache for days
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Altered LoC significant feature –
drowsiness
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Vomiting common.
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Seizure 25% patients
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Rash in meningococcemia; may not be
present in isolated meningitis
Meningitis considered likely THEN
Dexamethasone 10mg IV then
Ceftriaxone 2g IV AND
Penicillin 2.4g IV IF
immunocompromised, age >50,
alcoholic, pregnant or debilitated
 Steroid BEFORE antibiotics.
 Avoid antibiotic delay
 10% all-comer mortality (20%
pneumococcus)
 25% neurological morbidity
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Theoretical concerns about cerebral
herniation
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Considered contraindicated in high
ICP (e.g. low GCS)
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If signs ICP  CT head
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Ideally LP within 2 hrs of antibiotic
administration
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PCR still possible after this
CT SIGNS OF HIGH ICP
Ventricle size
Slit-like or none
Basilar cistern size
Mildly effaced or effaced
Sulci size
Effaced or none visible
Transfalcine herniation
(midline shift)
Loss of gray-white matter
differentiation
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Typical meningitis symptoms
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May have viral syndrome OR
thunderclap onset
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NO altered LoC, seizures or focal
neurology
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Often appear ‘well’ (but miserable!)
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Stable symptom course
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85% enterovirus
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Treatment supportive
LP confirms diagnosis
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Viral infection of brain parenchyma
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Headache and fever common, but not
reliably present.
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Meningism mild or absent
 Focal neurology signs – higher functions
Due to grey matter inflammation – aphasia, behavior
change, lethargy, movement disorder, ‘psychiatric’
phenomenon, memory loss
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Seizures/confusion
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Varying viral aetiologies
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HSV potentially most damaging – 20%
mortality 25-40% neurological morbidity
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Diagnosis made by CSF PCR
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CTB required before LP
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MRI/EEG supportive
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LP findings similar to viral meningitis
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Treatment: institute early –
Aciclovir 10mg/kg IV tds
Vasculitis of medium-large arteries
 Classic symptoms of headache and
temporal artery tenderness. Jaw
claudication common.
 May only have weakness, lethargy,
headaches , +/- fever +/- anaemia
 Strongly associated with PMR
 Occurs age >50
 Only useful investigation ESR > 50
 Need to prevent visual loss
 If suspected – treat
Prednisone 50mg daily AND
Aspirin 100mg daily
 Refer for biopsy and rheumatology f/u
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Fear of brain tumour far outweighs
actual brain tumours in ED
presentations
Classic early morning headaches,
with positional change not common
Non-specific headache 70% pts
Often few other findings
Suspect with hx of
Vomiting
Neurological changes (often subtle)
Personality changes
New onset seizure (esp. focal)
Background hx Ca.
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Pseudotumor cerebri, Benign intracranial hypertension
Uncommon –younger, overweight, women age 15-50
Persistent headaches, consistent with high ICP
Due to abnormal CSF production/excretion
Papilloedema characteristic feature
Risk of visual field loss
Diagnosed by LP CSF pressure >25 cm
LP therapeutic !
Treat with acetazolamide 250mg bd
Refer for follow up Opthalmology/Neurology review
Take a good headache history ; ensure to check eyes,
temporal arteries on exam
 Not everyone needs a scan (but many will get one!) and
bloods not usually helpful
 Migraine stereotypical; don’t diagnose 1st ever migraine if
age>30
 CT +/- LP for sudden onset headaches
 Don’t delay antimicrobials if meningitis/encephalitis
considered likely
 Temporal arteritis only occurs age > 50
 LP both diagnostic and therapeutic if IIH considered
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