Publication Date: February 2022 (Volume 24, Supplement 2)
CME Credits: 4 AMA PRA Category 1 Credits™. CME expires 02/15/2025. This course is included with an Emergency Medicine Practice subscription
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Stroke CME credits, subject to your state and institutional approval.
Emergency clinicians must have a high in-dex of suspicion and a judicious approach to evaluating the chief complaint (ie, headache) of patients with suspected subarachnoid hemorrhage, as accurate initial diagnosis and management are critical to optimizing outcomes. Aneurysmal subarachnoid hemorrhage ac-counts for a small percentage of strokes, but contributes significantly to the morbidity rate in stroke. The diagnosis is challenging and has devastating consequences if missed. This review evaluates the literature and current evidence, including controversies and recent guidelines, to support a best-practice approach to the diagnosis and treatment of patients with spontaneous subarachnoid hemorrhage.
When you begin your shift in the ED, your first patient is a middle-aged woman clutching her head in her hands, complaining of the sudden onset of the “worst headache of her life.” You are concerned for subarachnoid hemorrhage. You treat her pain with 1 g of acetaminophen and obtain a noncontrast head CT. She now states that her headache has improved and that she needs to go pick up her kids. Pending the results of the CT scan, what else needs to be done to determine her disposition? Is additional workup needed?
While you are considering options, another patient with a history of migraine arrives complaining of a sudden-onset, severe headache that has lasted 12 hours. Is this her usual migraine, or could this be something more significant such as a spontaneous subarachn oid hemorrhage? She states that she usually sees flashing lights prior to headache onset, but this time she had no aura. You obtain a head CT, which is normal. You also perform a lumbar puncture, which shows some clearing of red blood cells from tube 1 to tube 4. You consider that it may have been a traumatic tap, but how can you be certain? Just as you are pondering this, the lab calls to say there is xanthochromia, so you diagnose spontaneous subarachnoid hemorrhage. While awaiting neurosurgical consultation, what else should be done to treat this patient in the ED?
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