HEADACHEGeneral Medical Emergencies 99(iii) Add vancomycin 1.5 g i.v. 12-hourly, if patient has known or
suspected otitis media or sinusitis, or Gram-positive diplococci
are seen in the cerebrospinal fluid (CSF), or a pneumococcal
antigen assay on CSF is positive.4 Give dexamethasone 0.15 mg/kg up to 10 mg i.v. then 6-hourly at the same
time as the antibiotics, if bacterial meningitis is strongly suspected, particu-
larly when ill or obtunded, although its efficacy is unclear.
5 Then perform a CT scan, especially if there are focal neurological signs,
papilloedema or mental obtundation.
(i) Even if this CT scan is normal, omit the lumbar puncture until
these signs improve or disappear.
6 Consider lumbar puncture (LP) without CT if there are no focal neurological
signs and the patient has a normal mental state, particularly if a CT scan is
unavailable.
7 Admit the patient under the medical team, or to the ICU if altered mental
status or haemodynamically unstable.
Subarachnoid haemorrhage
DIAGNOSIS
1 The majority of cases are associated with a ruptured berry aneurysm, in
patients who may have a family history, hypertension, polycystic kidneys or
coarctation of the aorta.
(i) The remainder are due to an arteriovenous malformation, or
rarely coagulopathy and vasculitis.
2 Ask about any prodromal episodes of headache or diplopia due to a ‘warning
leak’. These may precede a sudden, severe ‘worst headache ever’, sometimes
following exertion.
3 Lethargy, nausea, vomiting and meningism with photophobia and neck
stiffness occur, although fever is usually absent or is low grade.
(i) A IIIrd nerve oculomotor palsy suggests bleeding from a
posterior communicating artery aneurysm.
4 Less typical presentations include acute confusion, transient loss of con-
sciousness with recovery, or coma when a stiff neck and sub-hyaloid
(pre-retinal) haemorrhage are useful diagnostic pointers on examination.
5 Gain i.v. access and send blood for FBC, coagulation profile, U&Es, blood sugar
and a group and hold. Attach a cardiac monitor and pulse oximeter to the
patient.
6 Perform an ECG and request a CXR.