the patient presents with headache of unknown etiology to the emergency department. After evaluating for red flag symptoms on the clinical history and deciding on any or all appropriate laboratory investigations and imaging the following is a general treatment guideline.
Gentle intravenous hydration and ketorolac 30 mg IV, intramuscular will last longer but some people prefer not to have a shot. It's also recommended to choose an anti emetic. Typically Compazine between 2.5 to 10 mg, metoclopramide between 5 to 10 mg or droperidol, up to 2.5 mg (it's a QT Prolonger see may want to get EKG).
Did it get better? If so safe to go home, consider dexamethasone 10 mg intravenous out the door, with outpatient follow-up
Not getting better? Consider whether the patient has any contraindications to ergot alkaloids (cardiovascular disease serotonergic agents or other vasoconstrictors onboard, history of myocardial infarction, pregnancy, hypertensive, hypersensitivity, history of basilar migraine etc.)
If no contraindications go ahead with 0.5 mg IV as a test dose.
If the patient tolerates the ergot alkaloids go ahead and give another 0.5 mg IV up to an hour later
If there are no contraindications 1 g intravenous valproate over an hour.
If resolved safe to go home with follow up, consider given dexamethasone 10 mg intravenous out the door.
However is not getting better consider opioid. If there opioid naïve and they get better out the door with outpatient follow-up. If they are not opioid naïve or they are not getting better on an opioid consider a neurology consult.
Keep in mind:
valproate should be avoided in the setting of liver disease, hypersensitivity that's been documented or in the rare instance of urea cycle disorder.
No comments:
Post a Comment