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Emergency Medicine > The Approach to HA in the ER > Flashcards

The Approach to HA in the ER Flashcards

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1
Q

what ages are red flags while obtaining HX of a HA?

A

< 5 or > 50 y/o with new or worsening HA

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2
Q

what onset are red flags when obtaining a HX of a HA

A
  1. Sudden onset “thunderclap” - cerebral aneurysm rupture (seconds)
  2. Sudden onset with exertion
    - SAH
    - arterial dissection of the carotid or vertebrobasilar circulation
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3
Q

Sudden onset with valsalva would indicate what?

A

intracranial abnormality

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4
Q

how to assess character of HA pain?

A
  1. location, pattern, frequency, quality, severity
  2. same as previous HA’s?
    - different quality requires work up as a new-onset HA (red flag)
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5
Q

what associated sx is a red flag when obtaining the HA hx?

A

Fever
* onset in relation to HA onset
* severity
* suspicion for CNS infection

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6
Q

what ill contacts are possible when obtaining HA hx?

A
  • infectious etiology
  • CO poisoning
  • toxin exposure
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7
Q

how can rebound HA occur?

A

Frequency of use of OTC medication
analgesic overuse > 10x a month = risk of rebound HA

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8
Q

what medications are red flags when obtaining HA hx

A
  1. Anticoagulants, antiplatelet agents - increased risk of hemorrhage
  2. Abx - recent use may result in a less severe clinical presentation d/t partial tx
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9
Q

what medication can increase the risk of infection due to immunocompromised state

A

Chronic steroids, immunomodulatory agents

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10
Q

what social hx components should you consider while taking HA hx?

A
  1. Substance abuse - cocaine, amphetamine, methamphetamine
    - increase risk of hemorrhage, reversible cerebral vasoconstriction syndrome
  2. Alcohol use
    - increase risk of hemorrhage due to falls, violence, coagulation disorders associated with chronic ETOH abuse
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11
Q

what FHx components should you consider when obtaining HA hx?

A
  1. FMHx of aneurysm or sudden death in 1st degree relative
    - increases risk of aneurysm 3-5 x if family hx is (+)
  2. FMHx of migraine
    - 2-4 x more likely to develop migraines
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12
Q

a persistent HA despite an adequately controlled fever is a red flag for?

A

CNS infection

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13
Q

HA + fever + neck stiffness + AMS = high likelihood of what dx?

A

meningitis

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14
Q

with Elevated BP + AMS + neurologic dysfunction, what conditions should you consider?

A

HTN emergency, preeclampsia/eclampsia

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15
Q

tenderness along temporal artery is indicative of?

A

temporal arteritis

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16
Q

what eye PE finding is a red flag?

A

Optic disk: papilledema = increased ICP

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17
Q

What ears, neck, sinus PE findings should you find and r/o?

A
  • Ears - look for signs of OM
  • Sinus - look for signs of sinusitis
  • Neck - meningismus - indicative of infection or hemorrhage
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18
Q

What PE components should you do for a HA complaint?

A
  1. scalp
  2. eye
  3. ears
  4. neck
  5. sinus
  6. neurologic exam
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19
Q

when performing a neurologic exam, what findings are you looking for?

A

focal neurologic abnormalities 🚩

  • Altered mental status 🚩
  • CN exam
  • Motor - extremity weakness, pronator drift
  • DTR - assess asymmetry or a Babinski
  • Gait
  • Coordination testing
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20
Q

what symptoms are clinical red flags?

table

A
  • altered mental status
  • seizure
  • fever
  • neurologic sx
  • visual changes
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21
Q

what associated conditions are clinical red flags?

A
  • pregnancy or post-preg status
  • SLE
  • Behcet’s disease
  • vasculitis
  • sarcoidosis
  • cancer

all require immunomodulators - high risk for infection

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22
Q

are diagnostics always needed for HA?

A

no!
Indicated if pt is at “high risk” for serious underlying etiology

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23
Q

diagnostic labs for HA

A
  • CBC, blood cultures - suspected infectious etiology
  • CMP
  • Coag panel - suspected bleed or need for LP
  • ESR/CRP - suspected temporal arteritis
  • hCG - females of reproductive age
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24
Q

Indications for Imaging for HA complaint

A
  1. Abnml neuro exam to include altered mental status, cognitive impairment, or a focal deficit
  2. New, severe HA of sudden onset
  3. HIV-positive patients with presentation of a new headache
  4. Concern for increased ICP in a patient requiring an LP
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25
Q

if indicated, what imaging do you get for HA complaint

A

CT w/o contrast

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26
Q

indications for a CT before a LP

A
  1. AMS
  2. new onset of seizures (within 1 wk)
  3. Immunocomp
  4. focal neuro signs
  5. papilledema
  6. H/o CNS disease
  7. Mass lesion, stroke, or focal infection
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27
Q

LP are indicated if differentials include:

A
  • meningitis
  • encephalitis
  • intracranial hypotension
  • pseudotumor cerebri
  • subarachnoid hemorrhage (if CT is negative)
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28
Q

a CT is most reliable for a SAH if pt presents within what time?

A

within 6 hrs

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29
Q
  1. slow onset, lasting up to 72 hours
  2. +/- preceding aura
    - MC lightheadedness and visual changes (scotoma and scintillations)
  3. Unilateral HA - throbbing, pulsatile in nature
  4. Worse with physical activity
  5. Associated with N/V, photophobia, phonophobia
  6. Patients prefer to lie still in a quiet and dark room
  7. Neuro exam is normal
A

migraine

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30
Q

management for migraine

A

Analgesic + antiemetic + antihistamine

  • ketorolac (Toradol) 30 mg IV or 60 mg IM (kids 0.5 mg/kg)
  • prochlorperazine (Compazine) 10 mg IV (kids 0.15 mg/kg)
  • diphenhydramine (Benadryl) 25 to 50 mg IV (kids 1 mg/kg)
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31
Q

Adding what medication to reduce risk of recurrent headache within first 3 days

A

corticosteroid - dexamethasone 10-24 mg mg IV/IM

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32
Q

what migraine management is known to cause movement disorders

A

prochlorperazine (Compazine) - antiemetic

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33
Q

alt management for migraine?

A
  1. Triptan: sumatriptan (Imitrex) 6 mg SC (kids 0.1 mg/kg) or 20 mg intranasally
    - useful if patient has not pretreated with triptan prior to ED arrival
  2. Ergot derivatives + pretreatment with antiemetic +/-antihistamine
    - Ex: Dihydroergotamine (DHE 45) 1 mg IV + metoclopramide +/- diphenhydramine
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34
Q

CI for triptans

A

CI in pregnancy, CAD, uncontrolled hypertension or CVD

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35
Q

CI for ergot?

A

CI : HTN, ischemic heart disease, PAD, pregnancy

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36
Q

alt medications for migraine in pregnant pts?

A

acetaminophen, opioids, metoclopramide and corticosteroid are safe

37
Q

NSAIDs are safe during pregnancy when?

A

1st and 2nd trimester only

38
Q

what management options are CI during pregnancy

A

Triptans
ergotamine
caffeine

39
Q

preventative meds for migraines

A
  1. Rx: sumatriptan (Imitrex) 25 mg, 50 mg, or 100 mg
    - Dosing: 1 tab at onset, repeat after 2 hours; max 200 mg/d
  2. Rx: Midrin
    - Dosing: 2 capsules PO at onset of headache, then 1 capsule PO q1hr until HA relieved up to a cumulative dose of 5 capsules/12 hr
  3. Pt Ed on triggers and lifestyle modifications
40
Q

Unilateral, excruciating pain causing patient to “pace” or “rock back and forth”

A

Cluster Headache
orbital, supraorbital, or temporal pain

41
Q

cluster HA Pain lasts how long without treatment?

A

12-180 minutes

42
Q

cluster HA would have what associated sx?

A

ipsilateral sx - lacrimation, conjunctival injection, nasal congestion/rhinorrhea, ptosis and/or miosis, edema of the eyelid/face, sweating of the forehead/face
Neuro exam is normal

43
Q

how long do pts have cluster HA for?

A

Recurring attacks daily for > wk and remitting for at least 4 wks

  • a circadian/circannual pattern is noticed over a period of time
  • avg time between attacks 6 mo - 2 yrs
44
Q

Cluster HA attacks can be precipitated by ___ or ___

A

ETOH or vasodilators

45
Q

management for cluster HA

A
  1. High flow O2 (HFO2) x 15 min
    - 100% oxygen administered at 12 L/min through a nonrebreathing face mask
  2. Sumatriptan (Imitrex) - if unresolved w/ O2
46
Q

Alt options for cluster HA if unresolved with O2 and triptan?

A
  • Intranasal lidocaine
  • Oral ergotamine/caffeine
  • IV dihydroergotamine (DHE 45)
47
Q

what is a Cluster HAs disposition?

A

Discharge home, f/u with neurology for preventative therapy

48
Q

what Transitional therapies may be started in ED for cluster HAs?

A
  • corticosteroids (prednisone 60–80 mg/d tapered over 2 weeks)
  • naratriptan (Amerge) 2.5 mg twice daily
  • ergotamine 2 mg at bedtime or twice daily
49
Q
  1. Gradual onset of a constant, non-throbbing pain
  2. Diffuse, occipital, frontal or bandlike
  3. Lasting hrs or for the entire day
  4. Associated sx
    - N, photophobia (milder < migraine)
  5. Precipitating factors - tension, emotional stress, and fatigue
  6. Neuro exam is normal
A

Tension Headache

50
Q

management/disposition for Tension Headache

A
  1. NSAIDs or non-opiate analgesic +/- caffeine +/- antiemetic/sedative
    - ketorolac + Compazine/Reglan + diphenhydramine IV for acute relief in ED
    - Aspirin-Acetaminophen-Caffeine (Excedrin) for outpatient use
  2. Muscle relaxant if muscle tension is noted
  3. Refer to PCP for prophylactic or tx of underlying stress disorder
51
Q

how do brain tumors present early in disease?

A
  • Pain is intermittent with no focal neurological signs
  • HA increase in frequency and duration over weeks-months (classic hx)
52
Q

how does a brain tumor present later in disease?

A
  • Constant pain - once CSF flow obstruction occurs or intracranial hypertension develops
  • focal neurologic s/s
53
Q
  1. Pain is mild-moderate in severity
  2. Deep, aching in nature - bilateral or unilateral
  3. increased in frequency or constant pain
  4. Worse upon awakening and with valsalva
  5. Associated s/s possible - N/V, seizures, mental status change, +/- focal neurological deficit
A

brain tumor

54
Q

diagnostic eval for brain tumor

A

CT scan with IV contrast will confirm dx
MRI is more sensitive but not as readily available in ED

need to have good kidneys

55
Q

Emergent neurological/neurosurgical consultation indications

A
  • large, symptomatic tumors
  • signs of increased ICP
  • impending herniation
56
Q

what medication is given to reduce cerebral edema for brain tumors?

A

IV glucocorticoids

57
Q

Secondary prevention with antiseizure agent for brain tumors?

A

levetiracetam (Keppra), topiramate (Topamax), lamotrigine (Lamictal), valproic acid, and lacosamide (Vimpat)

58
Q

what management to do if signs of impending herniation on imaging

A

Secure airway

59
Q
  1. H/o head injury
  2. Variable onset
    - Pain can begin immediately after trauma or onset may be weeks after trauma
  3. Non-specific HA - may be similar to tension/migraine presentations
  4. Associated sx - fatigue, dizziness, vertigo, insomnia, depression, irritability, anxiety, loss of concentration and memory, personality changes and noise sensitivity
A

Post-traumatic Headache/Syndrome
AKA: Post Concussive Syndrome is a sequela of traumatic brain injury (TBI).

60
Q

when is diagnotic work-up needed for a TBI?

A

CT w/o contrast if recent trauma w/o previous evaluation

61
Q

tx for Post-traumatic Headache/Syndrome

A
  1. Uncomplicated cases can be DC home with simple reassurance, symptomatic therapy and f/u with PCP
  • Most pts improve within 3 mo
  • F/u with PCP for evaluation of prophylactic therapy
  • Non-opiate pain relievers, antiemetics
62
Q

important pt education for Post-traumatic Headache/Syndrome

A
  1. avoid activity that could lead to second injury while symptomatic
  2. avoid activity that exacerbates sx
  3. gradual return to normal activity once symptoms resolve
63
Q

when to refer Post-traumatic Headache/Syndrome

A
  • ophthalmology if visual complaints
  • ENT if vertigo is present
  • neuropsych if prominent mental illness symptoms
64
Q

A syndrome characterized by papilledema, increased ICP (with normal CSF), and normal/small-sized ventricles on imaging

A

Idiopathic Intracranial Hypertension

65
Q

sx in Idiopathic Intracranial Hypertension
from most frequent to least

A
  1. HA
  2. Transient visual obscurations
  3. Intracranial noises (pulsatile tinnitus)
  4. Scotoma/scintillations
  5. Back pain
  6. Retrobulbar pain (pain behind the eye)
  7. Diplopia
  8. Sustained visual loss (will become permanent if treatment is delayed)
66
Q

PE findings of Idiopathic Intracranial Hypertension

A
  • papilledema, visual field loss, 6th CN (abducens) palsy (loss of lateral gaze)
  • other CN may be affected but much less commonly
67
Q

diagnostic evals for Idiopathic Intracranial Hypertension

A
  1. CT scan brain without contrast - normal
  2. Lumbar Puncture - avoid valsalva to avoid falsely elevated pressure; CSF fluid analysis normal
68
Q

what opening pressure is diagnostic in idiopathic intracranial HTN during LP?

A
  1. > 25 cm H2O in adults
  2. > 28 cmH2O in children
69
Q

management for idiopathic intracranial HTN

A
  1. Removal of CSF during LP until 10-20 cm H2O is reached
    - 1 mL of CSF = 1 cm H2O
    - Serial LP’s are controversial
  2. Visual sx - combo of oral acetazolamide
  3. New dx - admit for further eval and development of long-term management
  4. Previous dx - discuss with pts neurologist/neurosurgeon regarding disposition
70
Q

Add what medication if worsening visual sx despite max acetazolamide for idiopathic intracrainal HTN?

A

thiazide diuretic

71
Q

presentation of Post-Dural Puncture/Intracranial Hypotension

A
  1. Recent hx of LP - MC etiology
    - rarely occurring spontaneously or after head/spine trauma
  2. Onset is usually within 24-48 hours after LP
  3. Location may be bifrontal, occipital or involving the neck/upper shoulders
  4. HA worse in upright position, improves in supine position
  5. Associates sx
    - auditory - tinnitus, hearing loss
    - vision - diplopia, blurred vision, or photophobia
    - N/V
    - neck stiffness, low back pain
    - vertigo, dizziness
72
Q

work-up for Post-Dural Puncture/Intracranial Hypotension

A
  1. Avoid repeat LP
    - if performed, opening pressure is usually < 6 cm H2O
  2. MRI/CT not needed to make dx but if performed it will confirm showing diffuse enhancement of the meninges
73
Q

management for Post-Dural Puncture/Intracranial Hypotension

A
  1. Recumbency for 18–24 hours
  2. IV fluids
  3. Non opiate analgesics +/- caffeine
  4. Most HA resolve within 1 wk w/o tx
  5. Consult anesthesiology to determine the need for epidural blood patch
74
Q

An inflammation of the brain that develops into a central pus-filled cavity surrounded by a layer of granulation tissue and an outer fibrous capsule

A

brain abscess

75
Q

how do brain abscesses spread?

A

hematogenous spread
direct contiguous infection
direct seeding by neurosurgery or penetrating trauma

76
Q

presentation of brain abscess

A
  1. HA
  2. Focal neurologic deficits
  3. Fever
  4. Seizure
  5. S/S of increased ICP - papilledema, N/V, change in LOC, confusion
77
Q

work-up for brain abscess?

A
  1. DX: CT / MRI brain with contrast
  2. CBC - elevated WBC
  3. CMP - assess end-organ function
  4. Inflammatory markers (CRP, ESR) - elevated in ⅔ of pts
  5. Blood CX x2 - before first abx dose
78
Q

management for Odontogenic source brain abscess

A

IV PCN G (alt. ceftriaxone PLUS metronidazole)

79
Q

tx for Post-neurologic procedure sourced brain abscess?

A

vancomycin PLUS ceftazidime

80
Q

General tx for brain abscess

A
  1. Empiric parenteral abx based upon suspected source
    All others - Cefotaxime (alt. ceftriaxone) PLUS metronidazole 500 milligrams IV every 6 h
  2. Steroids ONLY IF significant peri-abscess edema with associated mass effect and increased ICP
  3. Admit and consult neurosurgery for consideration of abscess aspiration
81
Q

A collection of pyogenic material that accumulates in the epidural space between the dura and vertebral periosteum

A

Spinal Epidural Abscess

82
Q

Spinal Epidural Abscess MC occurs where?

A

thoracic and lumbar spine

83
Q

MC pathogen of Spinal Epidural Abscess

soft tissue

A

S. aureus
Hematogenous spread from soft tissue, urine or rsp source

84
Q

RF for spinal epidural abscess

A
  • IVDU
  • Immunosuppression
  • Spinal procedure
85
Q

presentation of spinal epidural abscess

A
  1. Early: back pain, fever, spinal tenderness → radicular pain, hyperreflexia, and nuchal rigidity
  2. Followed by progressive neurologic deficits (cauda equina)
    - fecal or urinary incontinence→motor weakness → paralysis
    - decreased rectal tone and perineal sensation
86
Q

diagnostics for spinal epidural abscess

A
  1. MRI with contrast of the spine is preferred imaging
    - Alt. CT with contrast is the alternative if MRI isn’t available
  2. CBC - leukocytosis (60-70% of patients)
  3. Elevated ESR/CRP
  4. Blood cultures
87
Q

Spinal Epidural Abscess: if an epidural abscess is suspected, what procedure is CI?

A

LP

88
Q

management for spinal epidural abscess

A
  1. Urgent consult neurosurgery
  2. Empiric abx:
    - Indications - unavoidable delay in surgery, signs of neurologic dysfunction or sepsis
    - vancomycin + ceftazidime

Emergency Medicine (20 decks)

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