Anne Walton Advanced Trainee Emergency Care Institute

Emergency - Quality, Education and Safety Teleconference

For smaller Eds

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House rules

Agenda

• 3 Case discussions - Headache • Review clinical context • Learning points and take home messages • Next meeting

• We encourage participation, comments or questions

throughout – we want to reflect YOUR needs and interests

Case 1 • 46 male, presented to hospital A, on Sunday @1722hrs • PC: Frontal headache, nausea, neck stiffness and

vomiting at triage • Nil significant PMHx given at triage • Afebrile, strong regular pulse, assigned ATS Category 3

Case 1 - assessment • Seen by JMO 2055hrs • Mild, gradual onset headache that morning whilst lying

down • 1400hours, worsening of headache – ‘agony’ • Vomited at home, associated with photophobia, neck

stiffness, post occular pain and subjective fever • Pain 8-9 earlier that day, currently 4-5/10

Case 1 – pmhx/ exam • No history migraines, but recurrent sinusitis reported • No foreign travel/ coryzal symptoms • A headache 1/52 prior, which lasted <24 hours and was

not as severe as today • Exam unremarkable, routine blood work = normal

Thoughts ??

Case 1 – progress • DW FACEM – need CT +/- LP • “CT showed no obvious abnormalities”. Advised that

absence of photophobia means not SAH • Given ibuprofen/ oxycodone, t/f to ESSU for analgesia • 0530, pt wanted to leave – seen by RMO, d/c with

panadeine forte and ibuprofen and told to contact GP

Case 1 – re-present • 15 days later, referred by GP to hospital B for ‘acute

work up of headaches’ • No abnormal clinical signs, 3/52 history of headache,

worse during sexual activity and felt like ‘being hit with a bat’. Radiation to occiput/ lower back

• Seen by JMO and DW medical registrar – provisional diagnosis chronic headache on background of overuse of Panadeine forte.

• No need for LP. Previous CT ‘normal’ – will not repeat • Discharged

Thoughts ??

Case 1 – catastrophe • 25 days later – collapse/ headache whilst walking • Decorticate positioning and obstructive breathing • Large left frontal ICH • TF to ICU – unsurvivable haemorrhage, declared brain

dead. Proceeded to organ donation • Review of first CT scan showed ‘subtle signs of

subarachnoid blood and an anterior communicating artery aneurysm’

What contributed to this outcome?

System • Diagnostic anchoring • Premature closure

Skills • CT reporting • Understanding the literature on SAH

Staffing • Senior supervision and review – ‘represent’ = high

risk

Would you have managed this

differently ??

The problem • Up to 5% of ED presentations are with headache • Vast majority of pathologies are benign – how do

we screen for a identify the sinister ones?

Subarachnoid haemorrhage – the evidence

• Still controversial – who needs an LP in SAH? • CT within 6 hours of onset and interpreted by

neuroradiology = up to 100% sensitive • After 6 hours, sensitivity drops – negative CT under 6

hours, discuss pros/cons with patient • LP may be helpful in providing alternative diagnosis • Lack of symptoms/ signs at time of assessment is

NOT predictive for excluding SAH

ECI clinical tool

Case 2 • 15 year old Aboriginal male to rural ED • Complex psychosocial history • Daily marijuana use, irregular school attendance • Headache/ fever/ nausea/ vomiting/ meningism

Case 2 – initial management • Treated empirically for meningitis – iv ceftriaxone and

acyclovir • LP from ED – opening pressure 28.5mmH2O, clear,

colourless fluid, negative fungus India Ink stain, Entero-Virus PCR positive

• Treated for viral encephalitis – discharged when clinically improved

Thoughts ??

Case 2 - progress • Re-presented 5 more times with ongoing intractable

headache, neck stiffness, vomiting • Had one presentation by ambulance with headache and

haemoptysis • Haemoptysis not documented • Handed over to adult medical team as deemed

unsuitable for paediatric admission given social situation

• Repeat LP – no significant findings. ICP pressure within range

Case 2 - progress • Re-presented a further 4 times, eventually admitted

under adult cardiologist – t/f care to tertiary paediatric neurologist due to intractable pain

• Following t/f – had repeat LP and grew Cryptococcal Gatti

• MRI showed cerebellar abscess and evidence of raised ICP

• Left lower lung lobe mass was identified with cryptococcal origins

Case 2 – learning points • Cognitive bias - Psychosocial situation – rationale for re-presentations

not fully addressed - Found one positive test (enterovirus), diagnostic

anchoring • Failure to review all evidence – eg abnormal ICP • Communication failure

- Haemoptysis was important clue, confirmation bias • High risk population – high index of suspicion

Case 2 - outcome • TF back to rural hospital and then d/c home 3 days later

with outpatient follow up • Represented to rural ED 2 days later with seizures and

raised ICP • TF back to tertiary hospital and VP shunt inserted • Uncomplicated recovery • Re-presented to ED once for r/v after trip and fall with

minor head injury • No further presentations to any ED facility within LHD

Red flag modules • There are often recurring themes when reviewing

adverse events • Not all adverse events or poor outcomes may be

predicted or prevented, but there may often be ‘red flags’

• Re-presentation with the same symptom is a ‘red flag’ and the patient should be reviewed carefully, ideally by a senior medical officer and all investigations and results revisited and reviewed

ECI Red flag modules

Case 3 • 32 year old female, 15 weeks pregnant • 0157hrs: BIBA in with sudden onset of severe headache • With ambulance crew, patient was able to walk, equal

strength all limbs • No history of headaches • Ambulance officers administered 5mg morphine iv for

pain • ATS category 3 and placed in side room • GCS at triage = 14/15

Case 3 - progress • 0215 – HR 75, BP 138/74, RR 10, sats 97% RA • Nursing staff noted patient was pale, rousable to voice

but not opening her eyes. Breathing heavily and unable to squeeze hand to command

• Transferred to resuscitation room • 0228hrs, RR 7, GCS 7/15 • 0256 – collateral history from husband: patient vomited

and complained of blurred vision at home. Examined by medical officer

Differentials at this point ??

Case 3 - progress • 0330: GCS 6/15 • 0356: 400micrograms naloxone administered

• 0416: GCS 6/15 and RR 11 • 0514: right pupil more dilated than left. MO aware.

400micrograms naloxone administered

• 0530: GCS 5/15 • 0600: CT brain showed large cerebellar

haemorrhage

What contributed to this outcome? Cognitive error

• IV Morphine attributed as cause for respiratory depression/ drowsiness – diagnostic anchoring

• Failure to review all evidence eg husband’s information – information synthesis

Patient factors • Pregnancy + radiation – what is best for mother is best

for foetus

Skills/ staffing • “Ostrich effect” – 0157 arrival CT scan 0600

Summary • Headache is common presentation in ED • High index of suspicion is required • Severity of pathology does not necessarily correlate well with

degree of pain or absence of neurological deficit • What processes or pathways do you have in your ED that

might help navigate this difficult diagnosis?

• ECI clinical tool (neurology headache): https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/neurology/headache

E-QuESTs so far • Atypical Chest Pain - ACS • Sepsis in the elderly • Abdominal Pain in the elderly - AAA & Ischaemic gut • Acute scrotum

Suggested future topics

• Minor head injury • Paediatrics • Eye emergencies • Transfer/ retrieval issues, including clinical handover

• Any feedback on these topics or other suggestions?