1. Richard Shih, MD, FACEP The Diagnosis and Management of ED Headache Patients: When Must Cranial CT and LP Both Be Performed in Order to Exclude the Diagnosis of SAH?

2. Richard Shih, MD, FACEP Richard Shih, MD, FACEP Program Director Department of Emergency Medicine Morristown Memorial Hospital, Morristown, NJ

3. Richard Shih, MD, FACEP Emergency Medicine Associates Atlantic City, NJ September 26-27, 2006

4. Richard Shih, MD, FACEP 2006 Advanced Emergency & Acute Care Medicine and Technology Conference 2006 Advanced Emergency & Acute Care Medicine and Technology Conference

5. Richard Shih, MD, FACEP Richard Shih, MD, FACEP Program Director Department of Emergency Medicine Morristown Memorial Hospital, Morristown, NJ

6. Richard Shih, MD, FACEP Disclosures All past advisory board or speakers’ bureau activities have expired within the past year All past advisory board or speakers’ bureau activities have expired within the past year

7. Richard Shih, MD, FACEP Sessions Objectives Discuss which ED patients are at greatest risk for SAH Discuss which ED patients are at greatest risk for SAH Discuss the CT evaluation for SAH Discuss the CT evaluation for SAH Discuss the role of LP in SAH ED evaluation Discuss the role of LP in SAH ED evaluation

8. Richard Shih, MD, FACEP Case Presentation… 63 yo F presents to ED CC: Severe HA Continous, worst of life, non- throbbing x 3 days PMHx: HTN, DM She is requesting morphine

9. Richard Shih, MD, FACEP Subarachnoid Hemorrhage Serious impairment of death in 40-60% Serious impairment of death in 40-60% Outcome: early diagnosis & intervention Outcome: early diagnosis & intervention Early rebleeding (days-wks): 26-73% Early rebleeding (days-wks): 26-73% Missed diagnosis: up to 50% with 1 st physician Missed diagnosis: up to 50% with 1 st physician Missed diagnosis: worse M & M Missed diagnosis: worse M & M 50% with neurologic complicaitons

10. Richard Shih, MD, FACEP Patients With Greatest Risk For SAH HA to ED: ~1% with SAH HA to ED: ~1% with SAH Worst HA of life: Worst HA of life: (-) CNS exam:12% SAH (-) CNS exam:12% SAH (+) CNS exam:25% SAH (+) CNS exam:25% SAH Thunderclap headache (“top of head blown off,” “Hit on head with a hammer”) : Thunderclap headache (“top of head blown off,” “Hit on head with a hammer”) : develops in seconds develops in seconds maximal intensity in minutes maximal intensity in minutes lasts hours to days lasts hours to days

11. Richard Shih, MD, FACEP SAH Missed Diagnosis Kowalski et al: JAMA 2004 Kowalski et al: JAMA 2004 Missed diagnosis:12% Missed diagnosis:12% 36%: migraine or tension headache 36%: migraine or tension headache Missed diagnosis factors: Missed diagnosis factors: normal mental status, small SAH volume and right sided aneurysm normal mental status, small SAH volume and right sided aneurysm Diagnostic error: Diagnostic error: Failure to obtain CT scan: 73% Failure to obtain CT scan: 73% Misinterpretation of tests:23% Misinterpretation of tests:23%

12. Richard Shih, MD, FACEP Relief of Headache Symptoms No randomized studies No randomized studies Many case reports: Many case reports: Relief of symptoms with pain meds Relief of symptoms with pain meds ED discharge ED discharge Return to ED with serious pathology Return to ED with serious pathology

13. Richard Shih, MD, FACEP CT Scan Detection of SAH Non-contrast studies, 3 mm cuts Non-contrast studies, 3 mm cuts Sensitivity decreases over time: Sensitivity decreases over time: Within 12 hrs:98% Within 12 hrs:98% 24 hrs:93% 24 hrs:93% Day 5:85% Day 5:85% Day 7:50% Day 7:50%

14. Richard Shih, MD, FACEP Van Der Wee et al: J Neurol Neurosurgery Psychiatry 1995 CT scan within 12 hrs CT scan within 12 hrs Neuroradiologist reading scan Neuroradiologist reading scan (-) CT & (+) LP: 2/119 (-) CT & (+) LP: 2/119 Optimal setting for CT scanning: Optimal setting for CT scanning: Early presentation Early presentation Neuroradiologist Neuroradiologist

15. Richard Shih, MD, FACEP SAH Evaluation: (-) CT & Discharge HA evaluation at a University ED with HA & (-) CT: HA evaluation at a University ED with HA & (-) CT: No LP performed:50% No LP performed:50% (-) CT, no LP & ED discharge: ?? (-) CT, no LP & ED discharge: ??

16. Richard Shih, MD, FACEP Case Cont’d 63 yo F presents to ED CC: Severe HA Continous, worst of life, non- throbbing x 3 days PMHx: HTN, DM She is requesting morphine

17. Richard Shih, MD, FACEP Case Cont’d CT scan ordered She received morphine (4 mg) twice with good pain relief Prior to CT scan: she eloped ED return 2 days later: IC bleed

18. Richard Shih, MD, FACEPConclusions Missed diagnosis of SAH is associated with M & M CT scan evaluation for SAH is excellent but not 100% Do HA patients with (-) CT always need an LP?

19. Richard Shih, MD, FACEP Questions? www.FERNE.org shih100@yahoo.com 973-971-5800 ferne_ema_2006_shih_sah_ctlp_092706_finalcd 5/20/2015 7:24 PM