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 - Post-Lumbar Puncture Headache

[##-year-old male/female] with headache with history and exam consistent with likely post-lumbar puncture (LP) headache (also known as a postdural puncture headache).

Initial consideration in this patient included post-LP headache, tension headache, migraine, cluster headache, meningitis, encephalitis, and intracranial hemorrhage or tumor among others.

Patient presented with report of headache that is worsened with upright position and improved with lying supine within [24-48] hours of having undergone LP.  Patient noted to have a normal neurologic exam without report of any other preceding trauma.  Treatment initiated in the ED with [oral/intravenous] caffeine with [minimal/significant/no] improvement.  We discussed therapeutic blood patch with anesthesia and the patient, and after discussion of risks, benefits and alternatives the patient was [transferred to anesthesia/treated in the ED] with [significant improvement/resolution of headache].

Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time.  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement.

https://rebelem.com/post-lumbar-puncture-headaches/

MDM - Tension Headache

[##-year-old male/female] with headache with history and exam consistent with likely tension headache.

Initial consideration in this patient included tension headache, migraine, cluster headache, meningitis, encephalitis, subarachnoid hemorrhage (SAH), venous sinus thrombosis, and intracranial hemorrhage or tumor among others.

Patient presented with headache and a normal neurologic exam without report of preceding trauma.  Headache described as [tightness/pressure] in the [right/left/bilateral temporal/frontal/parietal] head without report of associated [nausea/blurred vision/photophobia], or other features suggestive of migraine headache.  Patient reports recent [decreased caffeine intake/insomnia/stress] suggestive of tension-type headache.  Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time [in patient meeting none of the Ottawa SAH rules as noted above].  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.  No indication for neuroimaging at this time based on normal neurologic exam in patient with headache with features suggestive of tension-type headache.  Patient reported significant improvement with [treatment] prior to discharge from ED.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement.

https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation
https://rebelem.com/the-ottawa-sah-clinical-decision-rule/

Procedure Note - Greater Occipital Nerve (GON) Block

Greater Occipital Nerve (GON) Block Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided [written/verbal] consent.  A timeout procedure was performed prior to initiating the procedure. 

The patient was placed in a seated and the approximate location of the greater occipital nerve (GON) was identified based on landmarks (the index finger was placed on the occipital protuberance with the thumb placed on the mastoid process (either side)-measured 1/3 the distance from the occipital protuberance as the likely location of the GON).  The area was cleaned appropriately using [alcohol/chlorhexadine/betadine].  Using a 23-gauge needle [3-5 mL of 1/2% lidocaine/2-4 mL of 0.25/0.5% bupivicaine] was infiltrated at the site of the GON using a 'fanning technique' (1 mL of anesthetic injected immediately adjacent to GON, 1 mL medial to the GON, and 1 mL lateral to the GON for maximal infiltration (may be repeated bilaterally)).

The patient was monitored following the procedures and reported [moderate/significant] relief in pain.  The patient tolerated the procedure well without complications.

http://www.emdocs.net/pain-profiles-ed-migraine-management-the-new-kid-on-the-block/

Procedure Note - Sphenopalantine Ganglion (SPG) Block

Sphenopalantine Ganglion (SPG) Block Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided [written/verbal] consent.  We specifically discussed risk of a bitter taste from the anesthetic, nausea, trauma resulting in epistaxis, lightheadedness, and numbness in the posterior pharynx among others.  A timeout procedure was performed prior to initiating the procedure. 

The patient was placed in a supine position with the head tilted into a 'sniffing' position.  The patient was placed on a cardiac monitor (because of administration of anesthetic in a highly vascular area).  The nasal passage was anesthesized with 1 mL of 1% lidocaine per nostril aerosolized using an atomizer.  A cotton-tip applicator was soaked in [1/2]% lidocaine and advanced along the superior border of the middle turbinate of each nostril until the tip contacts the mucosa overlying the sphenopalantine galglion (SPG).

The applicators were left in place [for 10 minutes/until the patient felt relief], and were then gently removed.  The patient tolerated the procedure well without complications.

https://www.aliem.com/trick-sphenopalatine-ganglion-block-primary-headaches/

MDM - Migraine Headache

[##]-year-old [male/female] with headache with history and exam consistent with likely migraine.

Initial consideration in this patient included migraine, cluster headache, tension headache, meningitis, encephalitis, subarachnoid hemorrhage (SAH), venous sinus thrombosis, and intracranial hemorrhage or tumor among others.  

Patient presented with headache suggestive of likely migraine based on [headache lasting 4-72 hours with unilateral location, pulsating quality, moderate to severe pain intensity and avoidance of routine physical activity with associated nausea and/or vomiting, photophobia, and phonophobia].  Patient noted to have a normal neurologic exam without report of preceding trauma.  Patient [did/did not] describe associated aura suggestive of typical migraine.  Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time.  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.  

Neuroimaging was felt to [not be indicated at this time based on normal neurologic exam in patient with headache with features suggestive of migraine/obtained in this patient due to report of headache that differs in character from prior migraines/other concerning feature(s)].  After discussion of available options for treatment [the patient was given Metoclopramide (Reglan)/Prochlorperazine (Compazine)/Haloperidol (Haldol)/Dexamethasone (Decadron) with Diphenhydramine (Benadryl)/Ketorolac (Toradol)/Acetaminophen (Ofirmev)/a sphenopalantine ganglion (SPG) block/a greater occipital nerve (GON) block].  Patient reported significant improvement with treatment prior to discharge from ED.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation and consideration of possible imaging or referral to Neurology, and the patient demonstrated understanding and agreement.

https://www.aliem.com/trick-sphenopalatine-ganglion-block-primary-headaches/
http://www.emdocs.net/pain-profiles-ed-migraine-management-the-new-kid-on-the-block/

Decision Rule - Ottawa Subarachnoid Hemorrhage (SAH) Rule

Ottawa Subarachnoid Hemorrhage (SAH) Rule:

-Age ≥40 . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]
-Neck pain or stiffness   . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]
-Witnessed loss of consciousness . . . . . . .  [No (0 points)/Yes (+1 point)]
-Onset during exertion  . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]
-Thunderclap headache   . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]
  (Defined as headache peaking within 1 second)  
-Limited neck flexion on examination . . . .  [No (0 points)/Yes (+1 point)]

TOTAL SCORE = [## points]

A subarachnoid hemorrhage (SAH) cannot be ruled out if one or more criteria above are met.  
Provider may consider avoiding further subarachnoid hemorrhage (SAH)-specific workup in patients who meet all negative criteria.

https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation

Discharge Instructions - Migraine Headache

As discussed in the Emergency Department prior to discharge, you have been diagnosed with a migraine headache.  Migraine headaches or "migraines" are a kind of headache that can happen in adults and children.  They are more common in women than in men.  Migraines often start off mild and then get worse.

Symptoms of migraine can include:

-Headache that gets worse over several hours and is usually throbbing.  It often affects 1 side of the head or is described as being behind one of the eyes.

-Nausea and sometimes vomiting

-Feeling sensitive to light and noise.  Lying down in a quiet, dark room often helps.

-An aura which is a symptom or feeling that happens before or during the migraine headache.  Each person's aura is different, but in most cases the aura affects the vision.  You might see flashing lights, bright spots, or zig-zag lines, or lose part of your vision.  Or you might have numbness and tingling of the lips, lower face, and fingers of one hand.  Some people hear sounds or have ringing in their ears as part of their aura.  The aura usually lasts a few minutes to an hour and then goes away, but most often lasts 15 to 30 minutes.

-Women who get migraines with an aura usually cannot take birth control pills.  That's because they might increase the risk of stroke.

Many people get other symptoms that happen several hours or even a day before the migraine headache.  Doctors call these "premonitory" or "prodromal" symptoms.  They might include yawning, feeling depressed, irritability, food cravings, constipation, or a stiff neck.

Some people find that their migraines are triggered by certain things.  If you can avoid some of these things, you can lower your chances of getting migraines.  You can also keep a "headache calendar."  In the calendar, write down every time you have a migraine and what you ate and did before it started.  That way you can find out if there is anything you should avoid eating or doing.  You can also write down what medicine you took and whether or not it helped.

Common migraine triggers include stress, hormonal changes, skipping meals or not eating enough, changes in the weather, sleeping too much or too little, bright or flashing lights, drinking alcohol, and certain drinks or foods, such as red wine, aged cheese, and hot dogs

If your migraines are frequent or severe, your doctor can suggest others ways to help prevent them. For example, it might help to learn relaxation techniques and ways to manage stress.

There are also medicines that can help.

For mild migraines, your doctor might suggest an over-the-counter medicine such as Acetaminophen (Tylenol), Ibuprofen (Advil, Motrin), or Naproxen (Aleve).  There is also a medicine that combines Acetaminophen, Aspirin, and Caffeine (brand name Excedrin).

For more severe migraines, there are prescription medicines that can help.  You may have been prescribed a prescription medication ending with ‘-triptan,’ such as Sumatriptan (brand name Imitrex) or Rizatriptan (Maxalt).  These medications can cause drowsiness, so you should NOT DRIVE WITHIN 8-12 HOURS OF TAKING THEM.  You should also follow up with your primary care provider since these medications should not be taken long term in patient’s with a significant family history of heart disease.

You may alternatively have been prescribed a prescription medication that is a combination of Acetaminophen, Butalbital, and Caffeine (brand name Fioricet).  This medications can cause drowsiness, so you should NOT DRIVE WITHIN 8 HOURS OF TAKING IT.

If you have severe nausea or vomiting with your migraines, there are medicines that can help with that, too.  If you have been prescribed a medication for nausea, take it as prescribed.

You should follow up with your primary care provider to discuss additional treatment options, including medications that can decrease the frequency of migraines or prevent them, and for consideration of referral to Neurology for further management.

Do not try to treat frequent migraines on your own with non-prescription pain medicines.  Taking non-prescription pain medicines too often can actually cause more headaches later.

Return to the Emergency Department for worsening or persistent headache, vision changes, slurred speech, weakness or numbness in the face or extremities, fever, inability to tolerate fluids by mouth despite treatment, or any new or concerning symptoms.

Discharge Instructions - Tension Headache

As discussed in the Emergency Department prior to discharge, you have been diagnosed with a tension headache.  A tension type headache tends to cause pressure over both sides of the head in the area of the temples.  It is usually triggered by various stressors.

Symptoms of tension type headaches (TTH) include:

-Pressure or tightness around both sides of the head or neck

-Mild to moderate pain that is steady and does not throb

-Pain is not worsened by activity

-Pain can increase or decrease in severity over the course of the headache

-There may be tenderness in the muscles of the head, neck, or shoulders

People with TTH often feel stress or tension before their headache.  Unlike migraine, tension headaches occur without other symptoms such as nausea, vomiting, sensitivity to lights and sounds, or an aura.  However, some people have symptoms of both tension and migraine headache.

Some people find that their tension headaches are triggered by certain things.  If you can avoid some of these things, you can lower your chances of getting a headache.  You can also keep a "headache calendar."  In the calendar, write down every time you have a headache and what you ate and did before it started.  That way you can find out if there is anything you should avoid eating or doing.  You can also write down what medicine you took and whether or not it helped.

For tension headaches, your doctor might suggest an over-the-counter medicine such as Acetaminophen (Tylenol), Ibuprofen (Advil, Motrin), or Naproxen (Aleve).  There is also a medicine that combines Acetaminophen, Aspirin, and Caffeine (brand name Excedrin).

Return to the Emergency Department for worsening or persistent headache, vision changes, slurred speech, weakness or numbness in the face or extremities, fever, inability to tolerate fluids by mouth despite treatment, or any new or concerning symptoms.

Procedure Note - Lumbar Puncture (LP)

Lumbar Puncture Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided consent.  A timeout procedure was performed prior to initiating the procedure.  

The performing physician and support staff donned appropriate sterile garments, including surgical masks, sterile gloves, and caps.  The patient was placed in the [left/right lateral recumbent/seated and flexed] position with help from the supporting staff.  The area was cleansed and draped in usual sterile fashion using [betadine/chlorhexidine] scrub.  Anesthesia was achieved with [##] mL of lidocaine injected subcutaneously.  

A [##] gauge [##] inch spinal needle was placed in the [L2-L3/L3-L4/L4-L5] interspace.  On the [first/second/etc.] attempt, [clear/bloody/straw-colored] cerebral spinal fluid was obtained.  The opening pressure was [##] cm of H2O. 

CSF was collected into 4 tubes.  These were sent for the usual tests with 1 tube to be held for further analysis if needed.  A sterile bandage was placed over the puncture site.

The patient had no immediate complications and tolerated the procedure well.