The salient feature in your history that is missing is perhaps the way in
which the headache came on. Any patient with a severe sudden onset headache
is at risk of SAH until proven otherwise. As with many things in medicine
the history is often more useful than the signs.
I remember sending a patient with headache plus collapse home as he was
perfectly OK by the time he arrived in A+E. The card was picked up by Reg
at the time, we recalled the patient, scanned them and found an aneurysm!
It was a warning bleed that we hear so much about.
One could argue that the patients we really want to diagnose SAH in are
those with no signs, these are the ones who have the best chance of a full
neuorologically intact lifespan if the physician picks up the early
(hopefully minor) bleed amenable to surgery. Diagnosing the grade 4 (GCS 3)
patient is only a result if you are a transplant surgeon/recipient.
In an audot of patients presenting to the ED in Manchester with headache.
10% had serious pathology (i.e. requiring further admission, not including
migraine). Unpublished data but similar to that seen in many textbooks.
Simon Carley
Anaesthetics / Intensive Care
Stepping Hill Hospital
Stockport
England
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> From: [log in to unmask]
> To: [log in to unmask]
> Subject: Head Problems
> Date: 05 October 1998 12:51
>
> Called yesterday to a male age 48 who had a "severe migraine". Vomiting
and
> complained of severe pain at the back of his head that he had not
experienced
> before. ABC's & LOC o.k but pulse @100 and BP 139/112 Very distressed
state.
> Given O2 etc
>
> Some heated discussion took place with another provider who insisted that
it
> was only a "migraine", while I thought it was possibly more serious.
Changes
> in elevation on helo transfer exacerbated pain. Refered from DGH to
neuro
> unit for scan.
>
> My question to the list: I have seen intracranial bleeds before but they
have
> all involved changes in pupils and LOC as well as peripheral weakness.
How
> common is it to have only a severe headache, especially at the back of
the
> head, with little or no other symptoms (if it is an itracranial bleed).
One
> view is S/S based on teextbook signs of which he had none, while my
intuition
> is that it could be more serious. Any opinions?
>
> Davy Gunn
>
>
>
>
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