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EMU 365: Best Emergency Medicine Articles of the Year 2018

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domingo, 22 de noviembre de 2015

HSA: controversias

emDocs - November 20, 2015 - Authors: Long B and Koyfman A // Edited by: Robertson J
"The challenge of emergency medicine is to determine if a patient has a serious and/or deadly condition, even when he or she presents with a common chief complaint. Headache is a chief complaint that accounts for 2% of emergency department (ED) visits. Subarachnoid hemorrhage (SAH) is one condition that emergency physicians must diagnose, as it is serious and potentially deadly. Accounting for 1% of headaches, SAH is most commonly due to arterial aneurysm rupture. The classic presentation of SAH is a sudden, severe headache. This warning sign occurs in up to 97% of cases. Close to 85% of subarachnoid hemorrhages are non-traumatic. Approximately 80% of non-traumatic SAH are due to aneurysm rupture, while 10% are due to peri-mesencephalic hemorrhage.4-7 Risk factors for rupture include size and aneurysm location. One third to half of patients will experience a sentinel headache that precedes the subarachnoid hemorrhage. With 25% mortality within 2 hours of initial bleeding and 40% mortality at one week, missing this diagnosis can be deadly...
Subarachnoid hemorrhage is a deadly disease and can present in a variety of ways, most commonly sudden, severe headache. Multiple diagnostic regimens exist, including non-contrast CT only, CT/LP, and CT/CTA. Many of these pathways have significant controversy. Within 6 hours of headache onset, a CT only approach does have literature support for risk stratifying patients to less than 1% risk of SAH. However, after 6 hours, the sensitivity of non-contrast head CT decreases. A test threshold of 1% does seem acceptable currently. Ultimately, a shared decision making model should be followed."