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Headache is a common reason that adults seek medical care, accounting for approximately 13 million visits each year in the United States to physicians offices, urgent care clinics, and emergency departments A broad range of disorders can lead to headache This chapter will deal only with the approach to a new acute headache not due to trauma in adolescents and adults The challenge in the initial evaluation of acute headache is to identify those conditions that are lifethreatening In the emergency department setting, approximately 1% of patients seeking medical attention for acute headache will have a life-threatening condition, whereas the prevalence of life-threatening conditions in the office practice setting is considerably lower Regardless of the underlying cause, headache is currently believed to occur as a result of the release of neuropeptides from trigeminal nerve endings that encapsulate the blood vessels of the pia mater and dura mater, resulting in neurogenic inflammation Because this represents a final common pathway for many etiologies, diminution of headache in response to typical migraine therapies (such as serotonin receptor antagonists or ketorolac) does not rule out critical conditions such as subarachnoid hemorrhage or meningitis as the underlying cause

Table 2 7 Clinical features associated with acute headache that warrant urgent or emergent neuroimaging

Prior to lumbar puncture Abnormal neurologic examination Abnormal mental status Abnormal funduscopic examination (papilledema; loss of venous pulsations) Meningeal signs Emergent (conduct prior to leaving office or emergency department) Abnormal neurologic examination Abnormal mental status Thunderclap headache Urgent (scheduled prior to leaving office or emergency department) HIV-positive patient1 Age > 50 years (normal neurologic examination)

Use CT with or without contrast or MRI if HIV positive Source: American College of Emergency Physicians Clinical Policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache Ann Emerg Med 2002 Jan;39(1):108 22

Usage No inventory management, eg, services No inventory management with goods issue No planning MRP Consumption-based planning

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has a narrow QRS complex and is reliable, albeit often slow (30 50 beats/min) Treatment is often necessary because of resulting hypotension and low cardiac output Intravenous atropine (1 mg) usually restores AV conduction temporarily, but if the escape complex is wide or if repeated atropine treatments are needed, temporary ventricular pacing is indicated The prognosis for these patients is only slightly worse than for patients in whom AV block did not develop In anterior infarctions, the site of block is distal, below the AV node, and usually a result of extensive damage of the His-Purkinje system and bundle branches New firstdegree block (prolongation of the PR interval) is unusual in anterior infarction; Mobitz type II AV block or complete heart block may be preceded by intraventricular conduction defects or may occur abruptly The escape rhythm, if present, is an unreliable wide-complex idioventricular rhythm Urgent ventricular pacing is mandatory, but even with successful pacing, morbidity and mortality are high because of the extensive myocardial damage New conduction abnormalities such as right or left bundle branch block or fascicular blocks may presage progression, often sudden, to second- or third-degree AV block Temporary ventricular pacing is recommended for new-onset alternating bilateral bundle branch block, bifascicular block, or bundle branch block with worsening first-degree AV block Patients with anterior infarction who progress to second- or third-degree block even transiently should be considered for insertion of a prophylactic permanent ventricular pacemaker before discharge

The severity of cardiac dysfunction is proportionate to the extent of myocardial necrosis but is exacerbated by preexisting dysfunction and ongoing ischemia Patients who have normal BP, no signs of heart failure, and normal urinary output have a good prognosis Those with hypotension or evidence of more than mild heart failure should have bedside right heart catheterization and continuous measurements of arterial pressure These measurements permit the accurate assessment of cardiac function, facilitate the correct choice of therapy, and provide important prognostic information Table 10 6 categorizes patients based on these hemodynamic findings 1 Acute LV failure Basilar rales are common in acute myocardial infarction, but dyspnea, more diffuse rales, and arterial hypoxemia usually indicate LV failure Because both the physical examination and chest radiograph correlate poorly with hemodynamic measurements and because the central venous pressure does not correlate with the pulmonary capillary wedge pressure (PCWP), right heart catheterization may be useful in cases of suspected cardiogenic shock General measures include supplemental oxygen to increase arterial saturation to above 95% and elevation of the trunk Diuretics are usually the initial therapy unless RV infarction is present Intravenous furosemide (10 40 mg) or bumetanide (05 1 mg) is preferred because of the reliably rapid onset and short duration of action of these drugs Higher dosages can be given if an

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