Supervising: AH
Curriculum Codes: CC1, CC7, CC12, CC14, CC19, CC21, HAP2, HAP17
Management Case -
A patient that staff didn't want to allow access to the hospital, ?opiate seeking, challenging behavior. Attending for the third time with the same problem.
- You can only refuse entrance if patient has an ASBO, and doesn't need immediate medical help - see frequent attender guidelines.
- Potential opiate seekers should be given analgesia, even opiates. Remember IVDUs have opiates at home, so there's a reason they're coming into hospital. Look at the college pain guidelines which specifically mention this.
- As they are a reattender, this patient must be seen by the most senior Doctor present according to Consultant sign off guidelines - RCEM standards. As they are a frequent attender, college guidelines also state that they should be seen by a senior doctor.
- If the patient is difficult, and refusing examination you must decide whether they have capacity to refuse. This can be difficult. RCEM Guidelines.
If they don't have capacity, sedate as appropriate, in the patient's best interests - to allow you to safely assess the patient.
Case Discussion
Patient with history of migraine, who attended with collapse and headache, ?SAH.
- Remember that transient loss of consciousness + headache could easily be a SAH.
- Migraine patients don't normally come to the ED with their headache.
- If you have an SAH, the aneurysm pops, you loose cerebral perfusion, get TLOC, and then blood flow returns. They may rebleed. The only way to exclude is CT (read the Stiell paper: within 6 hours, CT alone is normally sufficient) and LP.
- RCEM have a flowchart
- There are NICE guidelines
Other Headache Links
Hamid's CTR on LPs in SAH.
London network guidelines on headache: http://www.londonscn.nhs.uk/publication/adults-with-headache-edu-videos/
TLOC headache guidelines: http://www.londonscn.nhs.uk/publication/adults-with-transient-loss-of-consciousness-edu-videos/
http://adultemergencymedicine.blogspot.co.uk/search/label/headache
The Ottawa headache rules.
