Optimal ED Headache Patient Evaluation Strategies: What Does the ACEP Clinical Policy Tell Us?

1. Optimal ED Headache Patient Evaluation Strategies:What Does the ACEP Clinical Policy Tell Us?

2. 2006 Advanced Emergency & Acute Care Medicine and Technology Conference

3. Emergency Medicine AssociatesAtlantic City, NJSeptember 26-27, 2006

4. William Dalsey, MD, FACEPChairman Department of Emergency MedicineKimball Medical Center Lakewood, NJ

5. 2006 Advanced Emergency & Acute Care Medicine and Technology Conference

6. Disclosures • All past advisory board or speakers’ bureau activities have expired within the past year

7. ACEP Clinical Policy HA “Clinical Policy: Critical Issues in the Evaluation and Management of Patients Presenting to the Emergency Department with Acute Headache”

8. Global Objectives • Maximize patient outcome • Utilize health care resources well • Improve Treatment • Optimize evidence-based medicine • Enhance ED practice

9. Sessions Objectives • Briefly review the ACEP Clinical Policy process • Review key concepts of the HA Policy • Consider critical questions • Examine recommendations

10. Case Presentation… 38 year old female presents to the Emergency Department with a “bad” headache Pain began shortly after a fight with her family The onset was sudden and associated with nausea and vomited X 1 HA is right sided She has been drinking ETOH She has a history of intermittent headaches without neuroimaging She denies trauma or drug use

11. Case Presentation… The patient appears to be in moderately severe pain Afebrile VS: BP of 160/100 RR 22 HR 85 She has a nonfocal neurologic exam Symptoms began about 30 minutes ago Hx DM, HTN, smoker No recent illness No meningeal signs

12. ACEP Clinical Policy HA Symptom Based Policy 1999 Revised Policy 2002

13. Clinical Questions Does the response to therapy predict the etiology of an acute headache? When can a lumbar puncture be safely performed without a neuroimaging study? Which patients require a neuroimaging study in the ED? Is there a need for cerebral angiography in patients with a thunderclap headache and a negative ct and LP?

14. Response to Treatment Pathophysiology of HA pain Arteries, veins, nerves, muscles Neurogenic inflammation and serotonin 5-HT receptors Compare the results with a conventional training protocol. Most people do at least two exercises per muscle group, perform three sets and perhaps 12 or 15 reps per set. Allowing just five seconds per rep, that makes for at least 36 minutes of exercise per workout. This is usually done three times per week. So in six weeks, a conventional program would involve 648 minutes of exercise. That's 42 times more than the subjects in our study. Are your results in the last six weeks 42 times better than theirs? I doubt it. Remember, these golfers were exercising in a way that did not involve stretching or moving the weight over a full range of motion. So how did this affect a full range of motion activity like a golf drive? Every one of them showed an improvement. The increase in drive distance varied from 5 to 31 yards. Keep in mind that these subjects had been golfing for up to 40 years and had handicaps as low as eleven. So getting any improvement in golfers who already play at this level is impressive. Getting it with 14 minutes of exercise spread over six weeks is truly revolutionary. The fact is every sport -- even a finesse sport like golf -- is improved by an increase in strength. Muscles are responsible for all movement in the body and stronger muscles deliver more power to every aspect of movement, irrespective of its range of motion. Since this study, I've gone on to improve this method of training. Further research showed that static hold times could be reduced to even less than what the golfers used. Workouts can be spaced further apart as a trainee gets stronger. I work with advanced trainees who train once every six weeks, yet they gain strength on every exercise each time they work out. The weights they hoist are enormous. I believe the time is coming when most people will have a better understanding of the role of proper, efficient strength training methods and frequency. For the guy who wants maximum results with minimum time invested, an ultra-brief but ultra-intense workout will be performed about as often as he gets a haircut. Anything more is just lifting weights as a busy work hobby. Train smart!

15. Response to Treatment Literature: no randomized prospective controlled trials Case Reports/Series: Seymour: 3 patients 2 ICH, 1 SAH Gross: 3 patients bleeding Lipton: 1 patient carbon monoxide

16. Response to Treatment Level C Recommendation : pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of HA

17. Can an LP be Performed Without a CT? Rationale Limitations of CT: CT, reader, time, HBG Risk of Herniation

18. Can an LP be Performed Without a CT? Heinrich Quincke 1890 Furbinger 4 deaths 1896 Duffy 15/30 patients with ICH Duffy 7/44 patient with ICH French 1/70 SAH Zisfein 1/38 known IC mass effect Duke Study 111 pts 17 CNS finding 3/17 contraindications

19. Can an LP be Performed Without a CT? Level C Recommendation: adults patients with signs of increased ICP, papilledema, absent venous pulsations, focal neurologic findings should have neuroimaging before an LP

20. Neuroimaging of HA in ED? 1% of ED HA patients Societal factors Outcome measured Reassurance

21. Neuroimaging of HA in ED? AAN Guideline 1994 17 studies Recommendation 1: not for typical migraine Recommendation 2: CT for atypical HA, seizures, focal neuro findings Recommendation 3: not enough evidence for other patients

22. Neuroimaging of HA in ED? ACEP Headache Policy 1996 Rules: CT for sudden severe HA, suspected intracranial infecton, and neurologic deficits

23. Neuroimaging of HA in ED? US Headache Consortium 2000 1. CT if unexplained neurologic abnormality 2. Insufficient evidence to base on symptoms 3. Not warranted in migraine w/o neuro findings 4. Insufficient evidence for tension HA 5. Can’t recommended CT vs. MRI

24. Neuroimaging of HA in ED? Literature conflicting on “worst HA of your life” Presence of abnormal neurologic findings increase likelihood positive findings 3 fold and a normal exam reduced the odds positive findings by 30% US HA Consortium Ramirez-Lassepas 468 pts abnormal neuro findings had a PPV 39% for CT finding Symptoms did not reliably predict positive CTs US HA Consortium

25. Neuroimaging of HA in ED? Acute sudden-onset Headache vs Worst HA Mitchell 1/27 patients with findings Ramirez-Lassepas 468 pts no correlation Reinus 17 worst HA of life 1/17 positive Mills 28% positive Harling 35/49 thunderclap HA positive Lledo 12/27 9SAH, 1ICH, 2 meningitis

26. Neuroimaging of HA in ED? • Patients with HIV Disease • Lipton 49pts 35% mass lesions • Rothman 110 pts 24% focal lesions

27. Neuroimaging of HA in ED? Level B Recommendations: 1. CT with abnormal neurologic findings 2. Sudden-onset HA 3. HIV patients with new type of HA

28. Neuroimaging of HA in ED? Level C Recommendation: Consider CT in patients > 50 with new type of HA

29. Cerebral Angiography? Rationale: CT/LP missed SAH Day and Rashkin: 1986 case report 42 yo Raps: 7 pts with aneurysms of 54 Hughes: 2 pts SAH and vasospasm

30. Cerebral Angiography? Wijdicks: 71 pts 6 angio no findings Slivka and Philbrook: 6 pts vasospasm Harling 49 pts no findings Other CNS causes case reports: cerebral venous thrombosis, carotid or vertebral artery dissection

31. Cerebral Angiography? Level C Recommendation: Patients with a normal CT and LP don’t need emergent cerebral angiography

32. Case Presentation So what Happened?

33. Questions? www.FERNE.org sparkledmd@aol.com ferne_ema_2006_dalsey_sah_aceppolicy_092606_finalcd 10/1/2014 5:57 AM