Emergency Medicine

HEADACHE

General Medical Emergencies 101

MANAGEMENT

1 Give oxygen, and treat seizures with midazolam 0.05–0.1 mg/kg up to 10 mg
i.v., or diazepam 0.1–0.2 mg/kg up to 20 mg i.v., or lorazepam 0.07 mg/kg up
to 4 mg i.v.

2 Refer a patient with an extradural or subdural haematoma to the neurosurgi-
cal team.

3 Otherwise refer the patient to the medical team for full investigation.

Temporal arteritis

DIAGNOSIS

1 This occurs in patients over 50 years, with relentless, diffuse or bitemporal
headache often associated with a history of malaise, weight loss and myalgia.
(i) Occasionally there is pain on chewing (jaw claudication).
(ii) Polymyalgia rheumatica (PMR) with shoulder girdle weakness
and discomfort coexist in 30% of patients.

2 Look for localized scalp tenderness, hyperaesthesia and decreased temporal
arterial pulsation.

3 Send blood for an urgent ESR (one of the few times this is really necessary in
the ED!).

4 The immediate danger is sudden visual loss due to ophthalmic artery
involvement, which may affect both eyes if steroid treatment is delayed.

MANAGEMENT

1 Commence prednisolone 60 mg orally if the ESR is raised >50 mm/h, or if
the result is not available immediately.

2 Refer the patient to the medical or ophthalmology team for admission for
urgent temporal artery biopsy and continued high-dose steroid therapy.

ACUTE NARROW-ANGLE GLAUCOMA
See page 422.

Hypertensive encephalopathy

DIAGNOSIS

1 This is due to an acute accelerated or malignant hypertensive crisis, related
to rapid onset hypertension with headache, nausea and vomiting, confusion,
and blurred vision.

2 Ask about drug non-compliance if known hypertension, renal disease,
autoimmune disease such as SLE or scleroderma, and recreational drug use
such as cocaine or amphetamines.