Emergency medicine: Headache Flashcards
What is the criteria for C-spine immobilisation?
GCS< 15, neck pain or tenderness, focal neurological deficit, distal paraesthesia of extremities, suspicion of C-spine injury
At what point would you order a CT within 1 hr in an adult patient with head injury?
Any one of the following:
- GCS <13 at presentation
- GCS < 15 2hr post-injury
- Focal neurological deficit
- Post-seizure
- Open or decompressive skull fracture
- Evidence of basal skull fracture (raccoon eyes, battle sign)
- > 1 episode of vomiting
At what point would you order a CT within 8 hr in an adult patient with head injury?
WARMB
Warfarin Age > 65yo Retrograde amnesia of >30mins before injury severe Mechanism of injury Bleeds or clotting risk
What is the criteria for CT in children?
Any one of the following:
- GCS < 13 adm, <15 if <1yo, <15 if 2hr post
- Non-accidental injury
- Laceration, bruise or swelling > 5cm on head
- Evidence of fracture or tense fontanelle
- Focal deficit
- Post-traumatic epilepsy
Or if > 1 of:
- Amnesia or LoC > 5mins, drowsy, >3 eps of vomiting, dangerous mechanism of injury
At which point would you consider intubation?
NB: Think general RRAPID
GCS < 8
What are the symptoms of Hyperosmolar Hyperglycaemic state?
Asymptomatic or
- Insidious onset polyuria + polydipsia
- Signs of dehydration
- Confusion (based on osmolar state if >440 = coma)
What are the investigations and results of hyperosmolar hyperglycaemic state? Why must one be cautious when looking at sodium?
- Plasma osmolality > 350 mosm/kg (key)
- Blood glucose (very high) > 30, usually > 50
- U+E - ^++Urea ^Creatinine, ^Na+ (may be masked*)
- FBC - leukocytosis (^WCC), polycythaemia (^RBC)
- Blood and Urine MSC - infective cause
- Urine may show ^Ketones (if so consider DKA)
- ABG
*^Na+ may be masked by hyperglycaemic state, as high levels of glucose draw H20 out of cells and reduce Na+, however these levels quickly rise after tx)
What is the management for hyperosmolar hyperglycaemic state?
- Fluids
- 1L 0.9% saline over 30 mins
- 1L 0.9% saline + K+ every 2hrs for 4hrs
- 1L 0.9% saline + K+ every 6hrs until rehydrated
- if Na+ > 140 (high) consider 0.45% saline - Insulin - 2-4U/hr
- if glucose falls below 15 - stop insulin, start 5% dextrose
- consider sliding scale - Treat cause - infection, MI, CVA
- Thromboprophylaxis - LMWH* or UFH
Who does hyperosmolar hyperglycaemic state typically affect
elderly t2 diabetics
define hyperosmolar hyperglycaemic state?
severe hyperglycaemic state in the presence of residual insulin production causing dehydration but NOT KETOACIDOSIS
What are the symptoms of SAH?
- Thunderclap headache - sudden + severe, radiating to occiput,
- Neck stiffness - nuchal rigidity
- Nausea + vomiting
- Impaired consciousness
- Focal deficit e.g. CNIII palsy
- Herald/Sentinel bleed - soft headache occurs days/weeks of attack due to mini bleed
What is the screening tool of SAH?
Hunt and Hess - determines risk of mortality
What investigations are required for SAH?
- Thorough history and exam
- Urgent CT - detects 90-95%
- LP > 12hr post-attack if CT normal but suggestive or bleed continues > 6hr –> turns xanthochromic (yellow) due to haemolysis
What is the treatment of SAH?
- O2 15L/min via NRBM
- Analgesia - morphine or codeine
- A/E - metoclopramide
- Urgent neurosurgery referral
- Hypotension –> Colloid or inotropes
- HTN - ensure BP is kept below 130 syst, use Nimodipine 60mg QDS PO
What is the criteria for C-spine CT?
- GCS < 13
- X-ray inconclusive, abnormal or unclear
- Emergency i.e. before surgery
- Suspicion of injury and any one of:
- -> 65yo
- -> dangerous mechanism of injury
- -> paraesthesia of limbs
- -> focal neuro deficit
What are the features of basal skull fracture? what is the action?
- Panda eyes (orbital bruising)
- Battle’s signs (bruising at back of ear)
- Subconjnuctival haemorrhage
- CSF ottorrhea or rhinorrhea
- Haemotympanum or bleeding from auditory meatus
Suspicion of basal skull fracture meets NICE criteria for CT within 1 hr
Which vessels are affected in subdural and extradural haematoma?
subdural - bridging veins between brain and dura (subdural space)
Extradural (epidural) - middle meningeal artery (anterior) typically due to temporal lob fracture
What are the features of a space occupying lesion?
- Raised ICP e.g. headache worse when lying down, coughing, bending forward, straining, low GCS
- New seizure
- Focal neurology (localising signs) e.g. CNVI palsy or Horners
- Visual disturbances
- Behavioural change
What are the localising symptoms for frontal lobe space occupying lesion
- Behaviour change - disinhibited, facetious,
- Hemiparesis C/L
- Brocas Dysphasia
- U/L anosmia
What are the localising symptoms for parietal lobe space occupying lesion
- C/L hemisensory loss
- Wernickes dysphasia
- Sensory inattention
- Astreogenesis
What are the localising symptoms for occipital lobe space occupying lesion
- Visual defect - C/L visual field loss
What are the localising symptoms for temporal lobe space occupying lesion
- Temporal lobe epilepsy - aura, hallucinations of smell, sight, touch, sound
- Dysphasia
- Amnesia
- C/L hemianopia or upper quandrantanopia
What are the localising symptoms for cerebellar space occupying lesion
D - dysdiadicokinesis A - ataxia S - slurred speech H - hypotonia I - intention tremore N - nystagmus G - gait abn
What are the treatment options for cerebellar oedema for a space occupying lesion?
Dexamethasone 4mg/8h
What are the clinical features of temporal arteritis?
- Diffuse headache (temporal)
- Localised superficial scalp pain
- Distended throbbing temporal artery
- Jaw claudication
- Acute transient visual loss
- Nausea, vomiting, fever, weight loss, night sweats
- PMR
What is the management for temporal arteritis?
- Steroids (immediate) - hydrocortisone (200mg IV) or prednisolone (40mg PO)
- Urgent referral to ophthalmology
What are the symptoms of venous sinus thrombosis?
Headache - gradual or sudden Seizure - U/L Visual impairment Drowsy, reduced LoC or GCS Signs of raised ICP - Signs of stroke - weakness + dysphasia
What are the investigations for venous sinus thrombosis?
CT/MRI head - determine location and nature
What are the treatments for venous sinus thrombosis?
- UFH or LMWH
- Warfarin if low bleeds risk
Not resolved after few days? - Thrombolysis
What are the causes of venous sinus thrombosis?
COCP, pregnancy, chemotherapy, nephrotic synd, thrombophilia, inflammatory disorders (IBD, meningitis)
What is the Canadian C-spine rule?
1. High risk factors Age > 65yo Dangerous mechanism of injury Paraesthesia of extremities - any of the above = radiograph
2. Low risk factors Delayed neck pain Slow rear MCV Sitting down Ambulatory No midline c-spine pain - none of the above = radiograph
- Neck movement
Able to move neck 45 degrees left and right?
- Yes = no radiograph needed
- No = radiograph needed
What are the key causes of SoL?
Tumour, aneurysm, abscess, haematoma
What is the difference between primary and secondary head injury?
Primary = head injury at the time of trauma
- axonal sheering or haemorrhage
- local or diffuse
Secondary = head injury later due to preventable and reversible factors
- hypoxia, hypotension, low cerebral perfusion, ^ICP, haematoma
What assessment should you do of a suspected head injury patient? (i.e. before considering C-spine immobilisation and CT head)
- ABCDE
- Vital signs - HR, RR, temp, CRT, BP
- GCS - <15 impaired; <8 intubate
- Glucose monitoring
- Alcohol assessment
- Pupil signs - fixed? dilated? papilloedema
- CNS - focal neurological deficit, cerebellar abnormalities
- PNS - tone, posture, reflexes, sensation
What are the bacterial causes of meningitis in (a) infant < 3 months (b) child > 3 months
a. group B strep
b. N.Meningitides
what are the viral causes of meningitis?
Enterovirus
HSV1
What are the clinical features of meningitis in (a) infants (b) older children (c) severe cases?
a. Infant - toddler: Irritable High pitched cry Poor feeding Fever > 37.0 + convulsions (seizures) Vomiting Signs of raised ICP - bulging fontanelle; U/L dilated fixed eye; papilloedema, confused, low GCS
b. Older child
Meningism - neck stiff (kernig + brudzinski), photphobia, headache
c. Severe
Opisthotonos
Non-blanching purpuric rash - meningococcal septicaemia (DIC)
Reduced GCS
What are the key investigations for suspected meningitis?
Septic screen:
- Lumbar puncture
- Blood culture
- Urine dip and MSC
- Stool culture + CXR if warranted
- FBC, CRP, glucose
Other tests
- Nasopharyngeal swab - bacteriology + virology
- Rapid antigen screen
What is the treatment ladder for meningitis?
ABCDE
- A =
- intubate if GCS <8 - B =
- ventilate if unable to or intubated
- oxygen - 15L/min via NRBM - escalate if - required - C =
- IV access
- bloods
- fluids - saline 0.9% or Hartmann’s 500ml
- Abx - if < 3 months IV cefotaxime, ampicillin, amoxicillin; if > 3 months IV ceftriaxone
Meningococcal septicaemia?
- manage with fluids to stabilise BP - 500ml saline 0.9% or Hartmann’s –> repeat
- Adrenaline if not effective
NB: Provide ciprofloxacin and rifampicin to all close contacts
What are the CI for LP?
Meningococcal septicaemia Signs of raised ICP Infection at site of LP Cardiorespiatory instability Focal neurological deficit Coagulopathy Thrombocytopoenia
How can you differentiate meningitis caused by (a) viral (b) bacterial (c) TB
A. Bacterial
- Cloudy, turbid
- High protein > 1g/L
- Glucose < 1/2 plasma
- Neutrophil polymorphs
B. Viral
- Clear
- Normal or slightly raised protein
- Glucose 60-80% plasma
- Lymphocytes
C. TB
- Cloudy with fibrin web
- Protein high > 1g/L
- Glucose < 1/2 plasma
- Lymphocytes
