Hunt & Hess Classification of Subarachnoid Hemorrhage (SAH)

Hunt & Hess Classification of Subarachnoid Hemorrhage (SAH)

Classifies severity of SAH to predict mortality based on signs and symptoms.

GRADE	Signs & Symptoms
I	Mild headache, alert and oriented, minimal (if any) nuchal rigidity
II	Full nuchal rigidity, moderate-severe headache, alert and oriented, no neurological deficit (besides cranial nerve palsy)
III	Lethargy or confusion, mild focal neurological deficits
IV	Stuporous, more severe focal deficit
V	Comatose, showing signs of severe neurological impairment (example: posturing)

 

Patients with a Grade I bleed have an approximate 30% mortality.

Patients with a Grade II bleed have an approximate 40% mortality.

Patients with a Grade III bleed have an approximate 50% mortality.

Patients with a Grade IV bleed have an approximate 80% mortality.

Patients with a Grade V bleed have an approximate 90% mortality.

MDM - Subarachnoid Hemorrhage (SAH)

[##]-year-old [male/female] presents with [headache/altered mental status] with history and exam consistent with likely subarachnoid hemorrhage (SAH).

Initial considerations in this patient included SAH from ruptured aneurysm, non-aneurysmal bleeding, and trauma, epidural and subdural hemorrhage, intracranial mass, cerebrovascular accident (CVA), transient ischemic attack (TIA), meningitis, encephalitis, and cerebral venous thrombosis among others.

Patient presented [within 6/12/24 hours] of onset of headache concerning for SAH.  Patient noted to have associated [neuro deficits/nuchal rigidity].  CT scan obtained [with/without] clear evidence of SAH.  A lumbar puncture [was not performed due to clear evidence of SAH on CT/was performed with evidence of xanthochrmia consistent with SAH/was not performed due to patient refusal/was unsuccessful prompting us to obtain CT angiogram].  Patient was noted to have a Hunt & Hess Grade [I-V] score as noted above on presentation to the ED.  Patient noted to have [no] history of [anticoagulant or antiplatelet/anticoagulant/antiplatelet] use with [no indication for reversal/reversal of Coumadin initiated with prothrombin complex concentrate (Kcentra)/fresh frozen plasma (FFP) and vitamin K/reversal of Aspirin initiated with DDAVP/reversal of Plavix initiated with platelets/reversal of Dabigatran (Pradaxa) initiated with Idarucizumab (Praxbind)].

Patient was intubated [due to respiratory failure/evidence of inability to protect there airway] as noted above. 

Patient noted to be hypertensive on presentation with [some/minimal] improvement noted with administration of analgesics.  Despite absence of clear consensus recommendations on blood pressure control in the setting of SAH, we initiated treatment with [Nicardipine/Labetalol/Esmolol] with a goal systolic blood pressure of less than 160 mmHg [after consultation with neurosurgery].

Patient noted to be hypotensive on presentation with [IV fluids given/IV fluids and vasopressors initiated] to maintain a goal mean arterial pressure of greater than 80 mmHg.

Patient given Nimodipine via [oral route/NG/OG tube] to decrease incidence of delayed cerebral ischemia.  Seizure prophylaxis initiated in the ED with [Keppra/etc.].  Case discussed with Dr. [NAME] the neuro-interventionalist with plan to [admit/transfer] for endovascular [intervention/clipping/coiling].  We discussed concern for SAH and plan for admission with the [patient/family] with associated risks and benefits, and they demonstrated understanding and agreement with this plan and provided appropriate consent.

https://wikem.org/wiki/Subarachnoid_hemorrhage

https://emcrit.org/emcrit/sah/

https://www.mdcalc.com/hunt-hess-classification-subarachnoid-hemorrhage#use-cases

MDM - Stye (Hordeolum)

[##]-year-old [male/female] presents with history and exam consistent with stye (hordeolum) to the [right/left upper/lower] eyelid.

Initial considerations in this patient included stye, orbital and periorbital cellulitis, allergic reaction, chalazion, blepharitis, dacrocystitis, and conjunctivitis from allergic, bacterial and viral etiologies among others.

Patient presented with erythema and swelling to the [right/left upper/lower] eyelid [with/without] significant surrounding erythema.  Patient noted to have pustule to the affected eyelid consistent with stye.  Patient noted to have no evidence of associated purulent drainage from the affected eye.  Patient noted to have no associated visual deficits.

Prior to discharge, we discussed return precautions, specifically for evidence of progression to periorbital or orbital cellulitis, treatment with warm compresses [and topical antibiotic ointment/systemic antibiotics due to associated erythema suggestive of early periorbital cellulitis], and follow up with [primary care provider/ophthalmology] within [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement with this plan.

https://www.aafp.org/afp/1998/0601/p2695.html

MDM - Elderly Mechanical Fall (Negative CT)

[##]-year-old [male/female] presents with history and exam consistent with likely mechanical fall [with soft tissue abrasions] without evidence of significant intracranial injury at this time.

Initial considerations in this patient included intracranial hemorrhages including subarachnoid, subdural epidural hemorrhages, brain contusions, delayed intracranial hemorrhages, cervical spine fractures and dislocations, spinal cord injuries, musculoskeletal injuries, syncope from cardiac etiologies including dysrhythmia and other neurologic etiologies including cerebrovascular accident (CVA) and transient ischemic attack (TIA), and fall syndromes (history of recurrent falls) among others.

Patient presented after [## hours] after a fall [at home/assisted living facility/public place] described by the [patient/bystanders] as “[tripping/stumbling/etc.]” consistent with likely mechanical fall (non-syncopal fall from standing).  A 12-lead EKG was obtained with [no evidence of dysrhythmia, ischemia or infarction/atrial fibrillation without evidence of rapid ventricular response/describe finding].  The patient [reported/denied] current use of anticoagulants [specifically Warfarin (Coumadin)/Rivaroxaban (Xarelto)/Apixaban (Eliquis)/Dabigatran (Pradaxa)/Enoxaparin (Lovenox)/but did report use of anti-platelet agent (aspirin/Plavix)].  Patient was noted to have a neurological exam with [no evidence of focal deficits/other].  CT scans of the head [and cervical spine] were obtained with no evidence of significant intracranial hemorrhage [and no evidence of acute spinal injuries].

The patient [and family] were questioned on fall history with [no report of frequent/prior falls/report of prior episodes and discussion of the importance of close follow up with primary care provider to discuss what can be done to decrease fall risk].  A gait assessment was performed in the ED [with mobility device/cane/walker] and [noted to be unremarkable/notable for slow, unsteady gait].  The patient lives [alone/with family] and was noted to have [a family member/friend who is able to check up on them over the next several days/no family or friends who are able to check up on them consistently on discharge].

Prior to discharge, we discussed return precautions, specifically emphasizing the signs of delayed intracranial hemorrhage, and close follow up with primary care provider in the next [2-3 days/week] to discuss ways to decrease fall risk [and consideration of whether the benefits of anticoagulation outweigh the risks, and the patient [and family] demonstrated understanding and agreement with this plan.

[Due to concern for delayed hemorrhage in a patient who remains a fall risk and has limited social support, we discussed admission for observation and consideration of repeat CT scans with the patient [and family].  We discussed admission with [Dr. Name/admitting hospitalist] who evaluated the patient in the ED, and agreed with planned admission.]

https://www.hippoed.com/em/ercast/episode/mechanicalfalls/mechanicalfalls

Timed Up & Go Test: https://www.cdc.gov/steadi/pdf/TUG_Test-print.pdf
https://gempodcast.com/2018/11/09/retiring-the-term-mechanical-fall-for-older-patients/

MDM - Electrical Injury

[##]-year-old [male/female] presents with history and exam consistent with [low/high voltage] electrical injury [with dysrhythmia/superficial cutaneous burns/etc.].

Initial considerations in this patient included complications from electrical injury including dysrhythmias including ventricular and atrial arrhythmias, cutaneous burns, cardiovascular and central nervous system injuries, orthopedic injuries including fractures, dislocations and compartment syndrome, and rhabdomyolysis among others.

Patient presented with report of electrical injury from [household/industrial] source consistent with [low voltage (<1000 Volts)/high voltage (>1000 Volts) DC/AC current] exposure.  A 12-lead EKG was obtained with [no evidence of dysrhythmia, ischemia or infarction/notable for evidence of atrial fibrillation/frequent premature atrial/ventricular contractions/other specific abnormality].  Patient was noted to have [no evidence of significant cutaneous burns/first degree burns at the point of contact with electrical source with appropriate burn care provided in the ED].  Patient felt to have [no other concerning features with electrical exposure/high risk features including prolonged exposure/wet skin/loss of consciousness (LOC)].  Labs were [not obtained in patient felt to have no high risk features or findings on exam to suggest significant injury/obtained to include electrolytes/creatinine kinase/troponin/etc. and noted to be normal/notable for abnormality].  Patient noted to have [no focal deficits/subjective complaints of numbness/tingling with no significant focal deficits/describe abnormality] on neurological exam in the ED.

Prior to discharge, we discussed return precautions, specifically for evidence of significant electrical injury, symptomatic treatment, and recommended follow up with primary care provider in [1-2 weeks/2-3 days], and the patient demonstrated understanding and agreement with this plan.

https://www.ebmedicine.net/topics/burns/electric-shock-burns
http://www.emdocs.net/electrical-injury/

MDM - Influenza (Admit)

[##]-year-old [male/female] presents with [fever/body aches/upper respiratory symptoms] with history and exam consistent with [seasonal] influenza.

Initial considerations in this patient included influenza, bacterial and viral etiologies of upper respiratory infection (URI), bronchitis, pneumonia, sinusitis, toxic exposure, sepsis, meningitis, encephalitis, and other pulmonary or cardiac etiologies among others.

Patient presented with symptoms suggestive of influenza during appropriate season.  Patient noted to [not] have significant risk factors for complications from influenza [specifically age less than 2 years/age greater than 65 years/pregnancy through to 2 weeks after delivery/chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus)/immunosuppression, including that caused by medications or HIV/persons younger than 19 years of age who are receiving long-term aspirin therapy/American Indians and Alaska Natives/extreme obesity (BMI ≥40 kg/m²)/patients in nursing homes or chronic care facilities].  A chest x-ray was obtained in the evaluation of this patient and was notable for [right/left/upper/middle/bilateral/multifocal consolidation(s) with/without associated effusion].  Labs were obtained and were notable for [leukocytosis with a leftward shift/etc.].  Patient was noted to have evidence of [fever/tachycardia/tachypnea/etc.] on presentation [with/without significant improvement] after treatment with [IV fluids/anti-pyretics/antibiotics].  Blood cultures [were/were not] obtained due to planned admission.  Confirmatory testing for influenza obtained in patient felt to require admission and noted to be [negative/positive].

Influenza felt to be likely cause of symptoms with antiviral treatment initiated in the ED [with Oseltamavir (Tamiflu)/Zanamivir (Relenza)/Peramivir (Rapivab) and empiric antibiotic coverage due to evidence of sepsis].  Patient felt to not be appropriate for outpatient treatment based on [evidence of sepsis, absence of good social support].  We discussed planned admission with the patient who demonstrates understanding and agreement with this plan.  We discussed case with Dr. [NAME] who evaluated the patient and agrees with need for admission to [general floor/telemetry unit/step-down unit/ICU].

Note: This is based on the 2018 recommendations for treatment of seasonal influenza from the Infectious Disease Society of America (IDSA).

https://rebelem.com/idsa-guideline-on-seasonal-influenza-management-2018/

https://www.idsociety.org/practice-guideline/influenza/

MDM - Influenza (Discharge)

[##]-year-old [male/female] presents with [fever/body aches/upper respiratory symptoms] with history and exam consistent with [seasonal] influenza.

Initial considerations in this patient included influenza, bacterial and viral etiologies of upper respiratory infection (URI), bronchitis, pneumonia, sinusitis, toxic exposure, sepsis, meningitis, encephalitis, and other pulmonary or cardiac etiologies among others.

Patient presented with symptoms suggestive of influenza during appropriate season.  Patient noted to [not] have significant risk factors for complications from influenza [specifically age less than 2 years/age greater than 65 years/pregnancy through to 2 weeks after delivery/chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus)/immunosuppression, including that caused by medications or HIV/persons younger than 19 years of age who are receiving long-term aspirin therapy/American Indians and Alaska Natives/extreme obesity (BMI ≥40 kg/m²)/patients in nursing homes or chronic care facilities].  Confirmatory testing for influenza felt [not to be indicated as the results were unlikely to change management/obtained in patient felt to be high risk and noted to be negative/positive].  No evidence of pneumonia on history or exam [and no evidence of consolidations on chest x-ray]. 

Influenza felt to be likely cause of symptoms in patient presenting [within 48 hours of onset of symptoms/over 48 hours from onset of symptoms] with antiviral treatment felt to be [indicated after discussion of potential benefits and risks with the patient/indicated in patient with risk factors for complications/indicated in patient with household contacts who are high risk for complications/indicated in a healthcare worker caring for high risk individuals].  Prior to discharge, we discussed return precautions, specifically for symptoms suggestive of bacterial co-infection or worsening illness, and recommended follow up with primary care provider within [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement with this plan.

Note: This is based on the 2018 recommendations for treatment of seasonal influenza from the Infectious Disease Society of America (IDSA).

https://rebelem.com/idsa-guideline-on-seasonal-influenza-management-2018/
https://www.idsociety.org/practice-guideline/influenza/