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Utility of Red Flags in the Headache Patient in the ED

Utility of Red Flags in the Headache Patient in the ED. L. Garcia-Castrillo, MD, SEMES Department of Emergency Medicine University Hospital Marques de Valdecilla Cantabria , Spain. Teaching Points to be Addressed. What is the usefulness of the clinical warning criteria (red flags) ?

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Utility of Red Flags in the Headache Patient in the ED

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  1. Utility of Red Flags in the Headache Patient in the ED L. Garcia-Castrillo, MD, SEMES Department of Emergency Medicine University Hospital Marques de Valdecilla Cantabria, Spain

  2. Teaching Points to be Addressed • What is the usefulness of the clinical warning criteria (red flags) ? • How do we use the information from the critical warning criteria? • Is there any special group of patients?

  3. Objectives for HA Patients in ED • Identify Secondary HA • Rule out lifethreatening conditions • Pain control. • Arrange followup.

  4. Objectives for HA Patients in ED • Identify Secondary HA • Rule out lifethreatening conditions • Pain control. • Arrange followup.

  5. HA in the ED Final diagnosis HA 1-4% of all cases in ED 20% Secondary HA 80% Primary HA Only less than 2-4% life threatening

  6. How do we rule out lifethreatening conditions ?

  7. Clinical History Rule out lifethreatening conditions ICP Neurologic exam Neuroimaging and LP

  8. Red Flags • Pain History • First ,Worst headache, Thunderclap • Change in presentation, progressive • Awakes during sleep. • Trigger by exercise , sexual activity, Valsalva. • Localization. • Clinical • Nausea, vomiting • Fever • Neurology exam • Signs,Symptoms • Seizures

  9. Clinical History Neurologic exam Rule out life threatening conditions NO Red Flags Treat, Discharge YES Neuroimaging, LP ICP NO YES

  10. Relevant contributions • 1994Frishberg BM. “The utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations” Neurology 1994;44:1191-97. • 1994. AAN“The utility of Neuroimaging in the Evaluation of patients with normal neurologic examinations” • 1996. ACEP“Clinical Policy for the initial Approach to adolescents and Adults presenting to the Emergency department with Chief Complaint of Headache” • 2000. US Headache Consortium“Evidence based Guidelines in Primary care setting: Neuroimaging in non acute Headache” • 2002. ACEP“Clinical Policy: Critical Issues in the Evaluation and Management of patients Presenting to the Emergency Department with Acute Headache”

  11. Red Flags rentability, limitations • What are the study groups • Similar to ED population? • Selection bias • What is the gold Standard • Neuroimaging CT, MRI • Including LP • Including angiography • Including follow up

  12. Abnormal Neurolgic exam Frishberg BM. Evidence based Guidelines in Primary Care Setting: Neuroimaging in Patients with Nonacute headache American Academy of Neurology 2000. http//www.aan.com

  13. Nausea and Vomiting Duarte J. Headache of recent onset in adults: a prospective population-based study. Acta Neurol Scand 1996;94:67-70

  14. Rapidly progressing HA Ramirez-Lassepas M. Predictors of Intracranial Pathologic Findings in Patients Who Seek Emergency Care Because Headache. Arch Neuro. 1997;54:1506-09

  15. Awakes from sleep Mitchell CS. Computed tomography in the headache patient: is routine evaluation really necessary? Headache 1993;33:82-86

  16. Worst HA Mitchell CS. Computed tomography in the headache patient: is routine evaluation really necessary? Headache 1993;33:82-86

  17. Stiff Neck Attia J. Does this Adult patient have acute Meningitis. JAMA 1999;282:175-181.; Morgenstern LB. Worst Headache and subarachoid Hemorrage: Prospective, modern Computed Tomography and Spinal Fluid Analysis.1998;32:297-304

  18. HA worsens with Valsalva Duarte J. Headache of recent onset in adults: a prospective population-based study. Acta Neurol Scand 1996;94:67-70

  19. Clinical application LLR+ 2,2 LLR+ 3 LLR- 0,7 Neuroimaging/Lp threshold LLR- 0,7

  20. Special Groups • Age >50 • HIV patients

  21. Age over 55 Ramirez-Lassepas M. Predictors of Intracranial Pathologic Findings in Patients Who Seek Emergency Care Because Headache. Arch Neuro. 1997;54:1506-09

  22. HIV infected Patients Rothman RE. A decision guideline for Emergency Department Utilization of Noncontrast Head Computed Tomography in HIV-infected Patients. Academic Emergency Medicine 1999;6:1010-19

  23. Teaching points to be addressed • What is the usefulness of the clinical warning criteria (red flags) ? • Neurologic exam, Rapidly progressing, Awakes from sleep, worsens with Valsalva are the most powerful indicators, while nausea, vomiting, stiffness neck and worse headache are less.

  24. Teaching points to be addressed • How do we use the information from the critical warning criteria? • The diagnostic characteristics of each test allows a formal analysis for the neuroimaging/LP decision

  25. Teaching points to be addressed • Is there any special group of patients? • Patients over 50 and IHV have higher prevalence of ICP than the normal population and the diagnostic tests have greater power

  26. Summary • Clinical history and neurologic exam are the cornerstone of the HA management • More high quality research is need to clarify utility of clinical sings. • A formal approach helps in the neuroimaging/LP decision

  27. Questions?

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