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PAGE
Practice Parameter:
for the
22 || Guideline
Evaluating AnOf
Apparent
Management
Acute
Unprovoked
First
And Chronic Pain Seizure
In
In Adults
EvidenceSickle
Cell(An
Disease.
Based Approach).
American
Pain Society.
American Academy of
Neurology
4 | The Management of Sickle
Clinical
Policy:National
Critical
3 | Cell
Disease.
PAGE
PAGE
Issues In of
The
Evaluation
Institutes
Health,
National
And
Management
Of
Heart Lung and Blood
Adult Patients Presenting
Institute.
To The Emergency
Department With Seizures.
American College of
PAGE 2 | Guideline for the
Emergency Physicians
Management Of Acute
And Chronic Pain In
EFNSCell
Guideline
PAGE 4 |Sickle
Disease.On The
Management
Of Status
American
Pain Society.
Epilepticus. European
Federation Of Neurological
Societies
PAGE
5 | Editorial Comment
Current Guidelines For
Management
Of Seizures
Sickle Cell Disease:
In
The Emergency
Management
Of AcuteDepartment
Complications
I
nInthis
thisissue
issueofofEM
EMPractice
PracticeGuidelines
GuidelinesUpdate,
Update,32practice
guidelines
guidelines
that
address
the
management
seizures
are readdressing the management of sickle cellofdisease
(SCD)
are
viewed.
The
recommendations
within
the
3
documents
focus
reviewed. As a result of numerous SCD-related complications,
on
decisionmaking
around
the patientdiminished
with seizures
refractory to
patients
with SCD have
significantly
life expectancy.
first-line
therapy,
the
management
of
patients
with
an
unprovoked
Although most patients will be followed by subspecialty
hemafirst seizure, and options for anticonvulsant drug delivery.
tologists, SCD is fundamentally a “‘disease of emergencies.”’
Status
epilepticus
complicates
to 7%with
of seizures
in the emerEmergency
clinicians
should beup
familiar
the recommenda1
Pagency
department
(ED),
with
a
significant
mortality
rate.
tions around management of acute SCD complications, because
tients
with
ongoing
seizures
demand
immediate
general
resuscifailure to appreciate the nuances of care in these brittle patients
tative and specific therapeutic maneuvers; good evidence exists
may place them at risk for short-term morbidity and mortality. The
to direct clinicians in managing these dangerous presentations.
methodology
these practice
guidelines
varies greatly–from
Stable
seizureofpatients
commonly
seek emergency
care for firstevidencebased
to
expert
opinion–and
thus
must becomplaints
applied to
time seizures, breakthrough seizures, or unrelated
emergency
practice
withanticonvulsant
caution and pragmatism.
that
affect their
ongoing
therapy. High-quality
trials examining issues that arise in the care of these patients
are few; however, consensus-based recommendations offer
PracticetoGuideline
Impact controversial testing and treatguidance
clinicians navigating
• Inscenarios.
the management of acute SCD pain crises, bolus normal
ment
saline is not recommended unless the patient is hypovolemic. In euvolemic
patients,
Practice
Guideline
Impactintravenous hydration should not
• Intravenous
(IV) lorazepam
is first-line
exceed 1.5 times
maintenance
with D5therapy
½ NS. for active seizures. Patients who continue to seize after 2 benzodiazepine
• doses
In the management
of acute
painorcrises,
specific recshould be treated
with SCD
propofol
barbiturates.
ommendations exist with regard to opiate choice and adju• Diagnostic
lumbar puncture is indicated in immunocomprovant medications.
mised patients with an unprovoked first seizure.
• In patients with SCD and suspected infection, criteria exist to
• EEG
monitoring
is indicated
to rule
out nonconvulsive status
identify
candidates
for outpatient
treatment.
epilepticus in patients receiving aggressive therapy for gen• eralized
Separateconvulsive
algorithmsstatus
exist epilepticus.
for the diagnosis and treatment of
stroke in adults and children with SCD.
December
January 2010
2009
Volume 2,
1, Number 1
2
Editor-In-Chief
Editor-In-Chief
Reuben J. Strayer, MD
Reuben Professor
J. Strayer,
MD
Assistant
of Emergency
Medicine, Mount Sinai
Assistant
Emergency
School
of Professor
Medicine, of
New
York, NY Medicine,
Mount Sinai School of Medicine, New York, NY
Editorial Board
Editorial
BoardMD, FACEP
Andy
Jagoda,
Professor and Chair, Department of Emergency Medicine
Andy Sinai
Jagoda,
MD,
FACEP New York, NY
Mount
School
of Medicine,
Professor and Chair, Department of Emergency Medicine
Erik
MD,ofMS
MountKulstad,
Sinai School
Medicine, New York, NY
Research Director, Department of Emergency Medicine, Advocate
Erik
Kulstad,
MD,
MS
Christ Medical Center, Oak Lawn, IL
Research Director, Advocate Christ Medical Center
Eddy
S. Lang,
MDCM, Medicine,
CCFP (EM),
Department
of Emergency
Oak CSPQ
Lawn, IL
Associate Professor, McGill University, SMBD Jewish General
Eddy
S.
Lang,
MDCM,
CCFP
(EM),
CSPQ
Hospital, Montreal, Canada
Associate Professor, McGill University, SMBD Jewish General
Lewis
Nelson,Canada
MD
Hospital,S.Montreal,
Director, Fellowship in Medical Toxicology, New York City Poison
Lewis
S.
Nelson,
MD Professor, Department of Emergency
Control Center, Associate
Director, Fellowship
in Medical
New York City Poison
Medicine,
NYU Medical
Center,Toxicology,
New York, NY
Control Center, Associate Professor, Department of Emergency
Gregory
M. Press,
RDMS
Medicine, NYU
MedicalMD,
Center,
New York, NY
Assistant Professor, Director of Emergency Ultrasound, Emergency
Gregory
M.
Press,
MD,
RDMS
Ultrasound Fellowship Director, Department of Emergency Medicine,
Assistant Professor,
ofMedical
Emergency
Ultrasound,
University
of Texas atDirector
Houston
School,
Houston,Emergency
TX
Ultrasound Fellowship Director, Department of Emergency Medicine,
Maia
Rutman,
University
of TexasMD
at Houston Medical School, Houston, TX
Medical Director, Pediatric Emergency Services, DartmouthMaia Rutman,
Hitchcock
MedicalMD
Center; Assistant Professor of Pediatric
Medical Director,
Pediatric
Emergency
Services,
Emergency
Medicine,
Dartmouth
Medical
School,DartmouthLebanon, NH
Hitchcock Medical Center; Assistant Professor of Pediatric
Scott
M. Silvers,
MD
Emergency
Medicine,
Dartmouth Medical School, Lebanon, NH
Chair, Department of Emergency Medicine, Mayo Clinic,
Scott M. Silvers,
MD
Jacksonville,
FL
Chair, Department of Emergency Medicine
Scott
Weingart,
MD, FACEP
Mayo Clinic,
Jacksonville,
FL
Assistant Professor, Department of Emergency Medicine, Elmhurst
Scott
Weingart,
MD
FACEP
Hospital Center, Mount Sinai School of Medicine, New York, NY
Assistant Professor, Department of Emergency Medicine, Elmhurst
Hospital Center, Mount Sinai School of Medicine, New York, NY
Prior to beginning this activity, see “Physician CME Information” on
page
7. beginning this activity, see “Physician CME Information” on
Prior to
page 9.
Editor’s Note: To read more about this publication and the
background and methodologies for practice guideline developEditor’s Note: To read more about this publication
ment, go to: http://www.ebmedicine.net/introduction
and the background and methodologies for practice
guideline development, http://www.ebmedicine.net/
content.php?action=showPage&pid=107&cat_id=16
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Current Guidelines For Management Of Seizures In The Emergency Department
Practice Parameter: Evaluating An Apparent Unprovoked First
Seizure In Adults (An Evidence-Based Approach).2
Neurology. 2007;69:1996-2007.
Link to this: http://www.neurology.org/cgi/reprint/69/21/1996 T
his document was developed by a group of neurologists organized by the American Academy of Neurology (AAN) in collaboration with the American Epilepsy Society; the methodology is
adapted from the AAN Clinical Practice Guideline Process Manual.3
The group identified 5 questions based on a literature search from
1966 to 2004, and it was carried out according to explicit criteria. Article inclusion and exclusion criteria are specified and selected details
around the review process are described.
neurodiagnostic evaluation, because it has a substantial yield.
Recommendation 2 (Level B): For an adult with an apparent unprovoked first seizure, the EEG should be considered as part of the
neurodiagnostic evaluation because it has value in determining risk
of seizure recurrence.
For an adult presenting with an apparent unprovoked first seizure, should a brain imaging study (CT, MRI) be routinely ordered?
Recommendation 3 (Level B): For an adult presenting with an apparent unprovoked first seizure, brain imaging studies using CT or
MRI should be considered as part of the neurodiagnostic evaluation.
Evidence was evaluated for quality according to predefined, specified criteria and assigned to 1 of 4 classes (I, II, III, IV). Recommendations were graded at 4 levels: A, B, C, U, based primarily on the
strength of evidence for each question. Level A: established as true;
Level B: probably true; Level C: possibly true; Level U: data inadequate or conflicting. The target provider population is not defined.
The Practice Parameter applies to adults 18 years of age and older
presenting with a first unprovoked seizure (ie, excluding patients with
diagnosed seizure disorders and seizures resulting from an obvious
cause such as trauma and stroke).
For an adult presenting with an apparent unprovoked first
seizure, should blood counts, blood glucose, and electrolyte
panels be routinely ordered?
Recommendation 4 (Level U): There are insufficient data to support
or refute routine recommendation of laboratory tests such as blood
glucose, blood counts, and electrolyte panels for an adult presenting
with an apparent unprovoked first seizure, though they may be helpful in specific clinical circumstances.
The Conflict of Interest statement notes “Drafts of the guidelines have
been reviewed by at least 3 AAN committees, a network of neurologists, Neurology peer reviewers, and representatives from related
fields,” and “The AAN forbids commercial participation in, or funding
of, guideline projects.” The authors report no conflicts of interest.
The following questions and recommendations are abstracted from
the Practice Parameter. To view the original document in its entirety,
click here: http://www.neurology.org/cgi/reprint/69/21/1996
For an adult presenting with an apparent unprovoked first seizure, should lumbar puncture be routinely performed?
Recommendation 5 (Level B): There are insufficient data to support
or refute recommending routine lumbar puncture in the adult initially
presenting with an apparent unprovoked first seizure; however, in
special clinical circumstances (eg, febrile patients), it may be helpful.
In an adult presenting with an apparent unprovoked first seizure,
should toxicologic screening be routinely ordered?
Recommendation 6 (Level B): There are insufficient data to support
or refute a routine recommendation for toxicology screening; however, it may be helpful in specific clinical circumstances. ■
In an adult presenting with an apparently unprovoked first
seizure, should an EEG be ordered routinely?
Recommendation 1 (Level B): For an adult with an apparent unprovoked first seizure, the EEG should be considered as part of the
EM Practice Guidelines Update © 2010
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Current Guidelines For Management Of Seizures In The Emergency Department
Clinical Policy: Critical Issues In The Evaluation And Management Of
Adult Patients Presenting To The Emergency Department With Seizures.1
Annals of Emergency Medicine. 2004;43:605-625.
Link to this: http://www.acep.org/WorkArea/DownloadAsset.aspx?id=8820
T
his document was developed by a committee and subcommittee organized and funded by the American College of Emergency Physicians (ACEP). Panel members are listed; their
affiliations/qualifications are not. The group identified 6 critical questions and utilized an explicit strategy for their literature search and
review. Evidence was evaluated for quality according to predefined
criteria and sorted into 4 classes (I, II, III, or X-fatally flawed). Recommendations were graded based on the strength of evidence for each
question. A: high degree of certainty; B: moderate degree of certainty; C: based on preliminary, inconclusive, or conflicting evidence
or panel consensus. Disclosures were reported for the subcommittee
for this policy. The policy targets clinicians working in hospital-based
EDs. The guidelines presented in the policy apply to adult patients
presenting to the ED with seizures. Pediatric patients are excluded.
Which new-onset seizure patients who have returned to normal
baseline need to be admitted to the hospital and/or started on an
antiepileptic drug?
Recommendation 6 (Level C): Patients with a normal neurologic
examination can be discharged from the ED with outpatient follow-up.
Recommendation 7 (Level C): Patients with a normal neurologic
examination, no comorbidities, and no known structural brain disease
do not need to be started on an antiepileptic drug in the ED.
What are effective phenytoin or fosphenytoin dosing strategies
for preventing seizure recurrence in patients who present to
the ED after having had a seizure with a subtherapeutic serum
phenytoin level?
Recommendation 8 (Level C): Administer an intravenous or oral
loading dose of phenytoin or intravenous or intramuscular fosphenytoin, and restart daily oral maintenance dosing.
What laboratory tests are indicated in the otherwise healthy
adult patient with a new-onset seizure who has returned to a
baseline normal neurologic status?
Recommendation 1 (Level B): Determine a serum glucose and sodium level on patients with a first-time seizure with no comorbidities
who have returned to their baseline.
Recommendation 2 (Level B): Obtain a pregnancy test if a woman
is of childbearing age.
Recommendation 3 (Level B): Perform a lumbar puncture, after
a head computed tomography (CT) scan, either in the ED or after
admission, on patients who are immunocompromised.
What agent(s) should be administered to a patient in status
epilepticus who continues to seize after having received
benzodiazepine and phenytoin?
Recommendation 9 (Level C): Administer 1 of the following agents
intravenously: “high-dose phenytoin,” phenobarbital, valproic acid,
midazolam infusion, pentobarbital infusion, or propofol infusion.
When should EEG testing be performed in the ED?
Recommendation 10 (Level C): Consider an emergent EEG in
patients suspected of being in nonconvulsive status epilepticus or in
subtle convulsive status epilepticus, patients who have received a
long-acting paralytic, or patients who are in a drug-induced coma. ■
Which new-onset seizure patients who have returned to a
normal baseline require a head CT scan in the ED?
Recommendation 4 (Level B): When feasible, perform a neuroimaging of the brain in the ED on patients with a first-time seizure.
Recommendation 5 (Level B): Deferred outpatient neuroimaging
may be used when reliable follow-up is available.
EM Practice Guidelines Update © 2010
© 2004 American College of Emergency Physicians® (ACEP). Reprinted with permission from ACEP. All rights reserved.
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Current Guidelines For Management Of Seizures In The Emergency Department
EFNS Guideline On The Management Of Status Epilepticus.4
European Journal of Neurology. 2006;11:577-581.
Link to this: http://www.efns.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2006_management_of_status_epilepticus.pdf
T
his document was developed by a task force comprised of 7
neurologists organized by the European Federation of Neurological Societies (EFNS), a consortium comprised of 43 European
national neurological societies based in Austria. The development
process was carried out in accordance with a preparation document
generated by the EFNS in 2004.5 The group designated a single member to carry out the literature search according to reported parameters.
Evidence was evaluated for quality based on criteria specified in the
preparation document and sorted into 4 classes (I, II, III, IV). Recommendations were graded (A-established as effective; B-probably effective; C-possibly effective, GPP - the opinion of the panel reported as
good practice points "where there was a lack of evidence but consensus was clear") based on the strength of evidence for each question.
Initial pharmacological treatment of generalized convulsive
status epilepticus (GCSE)
Recommendation 2 (Level A): Treat partial status epilepticus and
GCSE with lorazepam 4 mg IV; repeat in 10 minutes if seizures persist. Phenytoin 15 to 18 mg/kg or equivalent fosphenytoin is recommended "if necessary." An alternate regimen is diazepam 10 mg IV
followed by phenytoin 15 to 18 mg/kg or equivalent fosphenytoin;
repeat diazepam in 10 minutes if seizures persist.
Pharmacological treatment for refractory GCSE and subtle
status epilepticus
Recommendation 3 (Level GPP): Infuse anesthetic doses of midazolam, propofol, or barbiturates titrated against an EEG burst suppression pattern. Initiate treatment with non-sedating antiepileptic
agents simultaneously. Thiopental: 100 to 200 mg bolus over 20
seconds with 50 mg boluses every 2 to 3 minutes until seizures are
controlled, then infusion 3 to 5 mg/kg/hr. Pentobarbital: 10 to 20 mg/
kg bolus followed by an infusion of 0.5 to 3 mg/kg/hr. Midazolam: 0.2
mg/kg bolus followed by an infusion of 0.1 to 0.4 mg/kg/hr. Propofol:
2 mg/kg bolus followed by an infusion of 5 to 10 mg/kg/hr.
A funding source is not identified. Panelists' conflicts of interest were
reported as none declared. The target is identified as adults with status
epilepticus "in critical care situations." Debate around the definition of
status epilepticus is described; studies on patients with seizures lasting 5, 10, and 30 minutes were included. Recommendations in this
document are reported in narrative style; those recommendations that
pertain to emergency medicine are summarized here.
Pharmacological treatment for non-convulsive status epilepticus
(NCSE)
Recommendation 4 (Level GPP): Ongoing NCSE is less dangerous than GCSE; therefore, non-anesthetizing anticonvulsants may be
tried initially. Phenobarbital: 20 mg/kg IV. Valproic acid: 25 to 45 mg/
kg IV infused at a maximum rate of 6 mg/kg/min. ■
General initial management
Recommendation 1 (Level GPP): Support airway and ventilation;
monitor blood pressure and ECG waveform; perform blood gas analysis; supplement glucose and thiamine as required; measure serum
antiepileptic drug levels, electrolytes (including magnesium), blood
counts, hepatic and renal function tests. Identify and treat the underlying cause.
EM Practice Guidelines Update © 2010
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Current Guidelines For Management Of Seizures In The Emergency Department
Editorial Comment
The patient in status epilepticus presents an immediate resuscitative
challenge to the emergency clinician, as efforts to terminate seizures
must be carried out simultaneously with measures to support the
airway, breathing, and circulation as well as diagnostic maneuvers directed at identifying dangerous underlying disorders. Emergency providers should not be distracted by definitions of status epilepticus that
vary across sources and treat as status epilepticus any patient who
arrives seizing or any patient who has a seizure in the ED that does
not self-terminate or respond to initial therapies. When confronted
with a patient in status epilepticus who does not respond to benzodiazepine treatment, the clinician should consider underlying causes
that require specific therapies, such as hypoglycemia, hyponatremia,
eclampsia, and toxic exposures amenable to antidotes (eg, isoniazid, heterocyclic antidepressants, cyanide, carbon monoxide). Most
patients with refractory status should be intubated and started on a
barbiturate or propofol infusion with or without high-dose phenytoin
and/or intravenous valproate. Hypotension should be anticipated and
managed in these cases.
Another AAN Practice Parameter published in the same issue as the
guideline abstracted here looked specifically at the utility of brain CT
in the ED in various populations of patients who present with seizure.6 Their conclusions are similar to the recommendations made in
the abstracted report on evaluating the first seizure; in addition, the
panel makes a class II recommendation that patients who present
with chronic seizures are more likely to have an abnormal brain CT if
there is an abnormal neurologic examination, a predisposing history
of neurologic disease, or a focal seizure onset.
The EEG provides important information regarding prognosis and
seizure classification; however, it is not required in the ED when
dangerous etiologies of seizure have been ruled out and the patient
has returned to clinical baseline. The chief indications for performing
an emergent EEG are to assess the patient paralyzed and intubated
for status epilepticus, and to rule out nonconvulsive status epilepticus
in the patient with altered mentation, especially in patients who do
not return to baseline after a generalized seizure. The emergency
clinician is not compelled to initiate anticonvulsant therapy in uncomplicated cases; however, this decision is ideally made in collaboration
with the neurologist who will see the patient in follow-up.
If the seizure has terminated and ABCs are stable, the emergency
clinician must determine whether the patient had a seizure or another episodic disorder such as syncope or complex migraine. If a
presumptive diagnosis of seizure is made in a patient not known for
seizures, management is directed at finding dangerous and reversible causes. A non-contrast brain CT is indicated in most patients
with first seizure to rule out structural causes. In younger patients
where radiation concerns are more prominent, MRI is an alternative.
Although laboratory studies are of low yield in patients whose symptoms have resolved, serum chemistry analysis in the ED is prudent.
Lumbar puncture should be performed on immunocompromised
patients and patients for whom central nervous system infection is a
significant concern. Although toxicologic causes of seizures can be
life-threatening, undirected toxicology testing such as a urine drug
screen is unlikely to alter ED management. It is worth special mention that alcohol-related or alcohol-withdrawal seizure is a diagnosis
of exclusion; alcoholics are at particular risk for several other dangerous causes of seizures.
EM Practice Guidelines Update © 2010
Although fosphenytoin can be infused more quickly than phenytoin, it
does not work faster or cause fewer adverse effects than phenytoin
and should not be routinely used in place of its much less expensive
parent.7,8 Fosphenytoin is preferred in cases where the patient cannot complain of pain if extravasation occurs (eg, a comatose patient)
or when intramuscular delivery is required. In patients who will not
be quickly discharged from the department, oral phenytoin loading
is underutilized; in uncomplicated patients at low risk for immediate
recurrent seizure, oral loading is effective and offers benefits of convenience, cost, and safety.8,9 ■
5
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Current Guidelines For Management Of Seizures In The Emergency Department
References
1.
5.
American College of Emergency Physicians. Clinical policy: Critical issues in the
evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. 2004;43:605-625. (Systematic review)
2.
Krumholz A, Wiebe S, Gronseth G, Shinnar S, Levisohn P, Ting T, et al. Practice parameter: Evaluating an apparent unprovoked first seizure in adults (an
evidence-based review): Report of the Quality Standards Subcommittee of the
American Academy of Neurology and the American Epilepsy Society. Neurology.
2007;69:1996-2007. (Systematic review)
3.
Quality Standards Subcommittee and the Therapeutics and Technology Assessment
Subcommittee of the American Academy of Neurology. Clinical Practice Guideline
sus document)
Process Manual. St. Paul, MN: American Academy of Neurology; 2004. (Textbook)
4.
Brainin M, Barnes M, Baron J-C, Gilhus N, Hughes R, Selmaj K, et al. Guidance
for the preparation of neurological management guidelines by EFNS scientific task
forces – revised recommendations 2004. Eur J Neurol. 2004;11:577-581. (Consen-
Meierkork H, Boon P, Engelsen B, Göcke K, Shorvon S, Tinuper P, et al. EFNS
guideline on the management of status epilepticus. Eur J Neurol. 2006;13:445-450.
(Systematic review)
6.
Harden C, Huff J, Schwartz T, Dubinsky R, et al. Reassessment: Neuroimaging in
the emergency patient presenting with seizure (an evidence-based review): Report
of the Therapeutics and Technology Assessment Subcommittee of the American
Academy of Neurology. Neurology. 2007;69:1772-1780. (Systematic review)
7.
Coplin W, Rhoney D, Rebuck J, Clements E, Cochran M, O’Neil B, et al. Randomized evaluation of adverse events and length-of-stay with routine emergency department use of phenytoin or fosphenytoin. Neurol Res. 2002;24:842-848. (Prospective, randomized; 256 patients)
8.
Swadron S, Rudis M, Azimian K, Beringer P, et al. A comparison of phenytoin-loading techniques in the emergency department. Acad Emerg Med. 2004 11:244-252.
(Prospective, Randomized; 45 patients)
9.
Osborn H, Zisfein J, Sparano R. Single-dose oral phenytoin loading. Ann Emerg
Med. 1987;16:407-412. (Prospective, 44 patients)
To write a letter to the editor, email Reuben Strayer, MD, Editor-In-Chief, at:
[email protected]
Opinions expressed are not necessarily those of this publication. Mention of products
EM Practice Guidelines Update (ISSN Online: 1949-8314) is published monthly
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based on strength of evidence.
Years
Evidence-B
ased Appro
ach
To Diagnos
is
Of Aneurys And Management
ma
Hemorrhag l Subarachnoid
e In The Em
ergency
Departmen
t
Improving Patien
t Care
July 2009
Authors
Volume 11,
Lisa E. Thoma
Number 7
s, MD
Department
of Emerge
Hospital &
ncy
Massachusetts Medicine, Brigham
& Women
Jonathan
General Hospita
’s
Edlow, MD
l, Boston,
Vice Chair,
MA
Department
Beth Israel
of Emerge
Deaconess
ncy
Medicine,
Medical Center;Medicine
Harvard Medica
Associate
l School,
Joshua N.
Boston, MA Professor of
Goldstein,
Instructor
MD, PhD,
in Surgery
FAAEM
(Emergency
School, Departm
Medicine),
General Hospita ent of Emergency
Harvard Medica
Medicine,
l, Boston,
Massachusetts l
MA
Peer Review
ers
You walk into
a crowded
Your first patien
evening shift
in the emerg
her head, compl t is a middle-aged
woman lying ency department (ED).
with her hands
about a subara aining of the “wors
t heada
noncontrast chnoid hemorrhage (SAH che of her life.” You clutching
head compu
are worried
E. Bradshaw
says that her
ted tomography ). You treat her pain
Bunney,
Associate
MD, FACEP
and order
headache is
Professor,
(CT), which
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kids. Does
Residency
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Chicago,
University
ent of
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of Illinois
at Chicago
an LP, which a lumbar puncture
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Arbor, MI
lasted 12 hours s complaining of sudde another patient with
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discuss the classic presentation
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suspected
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general principle
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you be sure? and you think
the ED.
calls to say
diagnosis of
s of acute
SAH manage
there is xanth
Just as you
5. Identify
SAH. After
ment in
common
are
ochromia.
should you
calling for
pitfalls in
You
neurosurgic
do in the ED
the diagnos
is of SAH.
al consultation make the
to treat this
Date of original
patient?
, what else
release: July
Date of most
1, 2009
recent
Editor-in-Ch
Andy Jagoda, ief
MD, FACEP
Professor
and Chair,
Department
of Emergen
cy
Sinai School Medicine, Mount
of Medicine
Director, Mount
; Medical
Sinai Hospital,
York, NY
New
Editorial
Chattano
oga, TN
Michael A.
Gibbs,
Chief, Departm MD, FACEP
ent of Emergen
Medicine,
cy
Maine Medical
Portland,
Center,
ME
Charles V.
Pollack, Jr.,
FACEP
MA, MD,
Chairman,
Department
Emergency
of
Medicine
Termination review: April 27,
2009
date: July
1, 2012
Medium:
Prior to beginni
Print and
online
ng this activity,
see “Physic
Information”
ian CME
on page 27.
University
Medical Center,
Nashville
, TN
Internationa
Steven A.
, Pennsylv
Hospital,
Godwin,
Universit
ania Jenny Walker,
Board
l Editors
MD, FACEP
MD, MPH,
Health System, y of Pennsylv
Assistant
William J.
Assistant
MSW
Professor
ania
Peter Camero
Brady, MD
Philadelp
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and Emergen
Medicine
hia, PA
n, MD
Professor
Family Medicine r; Division Chief,
Residenc
cy Michael S. Radeos,
Chair, Emergen
of
y Director,
University
, Departm
and MedicineEmergency Medicine
of Commun
cy Medicine
MD, MPH
Assistant
of Florida
ent
Monash Universit
ity and Preventiv
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Professor
HSC,
Jacksonv
Emergency Vice Chair of
Medicine,
of Emergen
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Medicine,
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Melbourn
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Mount Sinai
cy
Weill
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of Virginia
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Amin Antoine
of
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Charlotte
y, New York,
MD, FACEP
CEO, Medical
sville, VA
Kazzi, MD,
Ron M. Walls,
NY.
Robert L.
Associate
FAAEM
Rogers,
MD
Assessment, Practice Risk
Professor
Peter DeBlieux
Professo
FAAEM, FACP MD, FACEP,
and Vice
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, MD
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Thomas Jefferson
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of
, New York,
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Maarten
Church, VA
,
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Mayo Clinic
Falls
NY
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Simons,
Philadelp
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Medicine,
MD, PhD
hia, PA
Emergency
Rocheste
Editors
Medicine
Francis M.
r, MN Keith A. Marill,
Scott Silvers,
Director, OLVG
Residenc
MD
Fesmire
Assistant
Nicholas
y
MD, FACEP
Director, Heart-St , MD, FACEP
Hospital,
Medical Director,
Professor,
Genes,
Amsterdam,
Department
Emergency
Chief Resident MD, PhD
The Netherla
Erlanger Medical roke Center,
Department
Emergency
of
Medicine,
nds
,
of
Mount
General Hospital,
Medicine,
Massachusetts
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Emergency
Sinai
Professor,
Jacksonv
Mayo Clinic,
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UT College
t
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School, Boston, Harvard Medical
Residenc
New York,
of Medicine
y,
NY
MA
,
Corey M.
Slovis, MD,
Lisa Jacobso
Accreditation:
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n, MD
This activity
Chief Resident
and Chair,
(ACCME)
has been
of Emergen
Department
through the
of Medicine , Mount Sinai School
cy Medicine
Thomas,
sponsorship planned and impleme
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Dr.
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of EB Medicin
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discussed Edlow, Dr. Bunney,
y, New York, cy Medicine
e. EB Medicin in accordance with
Dr. Little,
in this educatio
NY
the Essentia
and
e is
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2010
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