Evidence-Based Approach To Diagnosis And Management Of Aneurysmal Subarachnoid Hemorrhage In The Emergency Department

Thomas, Lisa E. MD
Edlow, Jonathan MD
Goldstein, Joshua N. MD, PhD, FAAEM
Bunney, Bradshaw E. MD, FACEP
Little, Neal MD, FACEP

Authors
Lisa E. Thomas, MD
Department of Emergency Medicine, Brigham & Women's Hospital & Massachusetts General Hospital, Boston, MA
Jonathan Edlow, MD
Vice Chair, Department of Emergency Medicine Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School, Boston, MA
Joshua N. Goldstein, MD, PhD, FAAEM
Instructor in Surgery (Emergency Medicine), Harvard Medical School, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
Peer Reviewers
E. Bradshaw Bunney, MD, FACEP
Associate Professor, Residency Director, Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL
Neal Little, MD, FACEP
Adjunct Clinical Assistant Professor, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI

Emergency Medicine Practice 11(7):p 1-26, July 2009.

You walk into a crowded evening shift in the emergency department (ED). Your first patient is a middle-aged woman lying with her hands clutching her head, complaining of the “worst headache of her life.” You are worried about a subarachnoid hemorrhage (SAH). You treat her pain and order a noncontrast head computed tomography (CT), which is negative. She now says that her headache is better and that she needs to go home to pick up her kids. Does she really need a lumbar puncture (LP)? She eventually agrees to stay for an LP, which is also negative. Can she go home now? Does she need any additional workup?

While you are thinking about this, another patient with a history of migraine arrives complaining of sudden-onset, severe headache that has lasted 12 hours. Is this headache her usual migraine or could this be an SAH? After further history is obtained, you are concerned about an SAH and you obtain a CT, which is normal. You perform an LP, which shows some clearing of red blood cells (RBCs) from tube 1 to tube 4, and you think it may have been a traumatic tap, but how can you be sure? Just as you are pondering this, the lab calls to say there is xanthochromia. You make the diagnosis of SAH. After calling for neurosurgical consultation, what else should you do in the ED to treat this patient?