Headaches in the ED Lecture Powerpoint

Question 1

High risk history for serious headache etiology when evaluating in the ED (5)

Answer 1

• sudden onset
• no history of similar headaches
• infection
• altered mental status/seizure
• age 50 or older

Question 2

Red flags of headache (7)

Answer 2

• fixed neurological deficits
• extremely abrupt onset
• papilledema
• new onset in patients <5 or >50
• signs of infection
• altered level of consciousness
• new headache in cancer or immunocompromised patient

Question 3

Primary vs secondary headaches

Answer 3

Primary is caused by benign intrinsic causes (migraine, tension, cluster) vs secondary caused by underlying causes (lesion, infection, etc)

Question 4

Kernigs sign

Answer 4

Test for meningitis by seeing severe stiffness in hamstrings causing inability to straighten leg when hip is flexed to 90 degrees

Question 5

Brudzinski’s sign

Answer 5

Test for meningitis that if positive sees patients hips and knees flex when the neck is flexed manually by the provider

Question 6

2 most helpful studies in identifying intracranial lesion or bleed

Answer 6

• Neuroimaging CT without contrast

- MRI

Question 7

Most helpful study in identifying CNS infection

Answer 7

Lumbar puncture (perform a CT prior to exclude any intracranial mass or bleed that could cause pressure issue and herniation of brain)

Question 8

Rule of RBCs in the CSF tubes for determining a brain bleed while performing a lumbar puncture

Answer 8

Should normally see the number of RBCs decrease over time when drawing tubes from an LP, if consistent amount then can indicate a brain bleed presence

Question 9

Decreased glucose in CSF analysis following LP is predictive of…

Answer 9

…infectious meningitis

Question 10

Classic triad of meningitis

Answer 10

• fever
• nuchal rigidity (inability to flex due to rigidity of neck muscles, if flexion is painful but full range of motion present then nuchal rigidity is absent)
• altered mental status

Question 11

2 types of meningitis

Answer 11

• Bacterial (deadly, N meningitis, pneumococcus, listeria)

- Viral (aseptic, nondeadly)

Question 12

Subarachnoid bleed characteristics and diagnostic studies (3) and treatment options (4)

Answer 12

Most are aneurysmal with sudden onset severe thunderclap headache that may be associated with brief loss of consciousness or seizures

• noncontrast CT and if nondiagnostic then lumbar puncture with elevated RBC that does not diminish in tubes 1-4, digital subtraction angiography highest resolution to detect suspected aneurysm is gold standard diagnosis
• IV fluids, antiepileptic therapy, ET tube, potential neurovascular surgery

Question 13

Subdural bleed characteristics, diagnostic study (1), prognosis (1), and treatment (1)

Answer 13

• bleed in potential space between dura and arachnoid membranes, most are from tearing bridging veins that drain from the surface of brain to the dural sinuses, head trauma most often cause***
• CT of head most widely used diagnostic tool
• overall mortality is up to 50%
• neurosurgery immediately

Question 14

Migraine cocktail components for migraine in emergency setting that has failed to respond to normal treatment (4)

Answer 14

• Antiemetic such as metaclopraide
• diphenhydramine
• Ketorlac (toradol)
• IV fluids

Question 15

What drug classes (2) should NOT be given to treat migraine?

Answer 15

Opioids or barbituates