Case study: Don’t miss subarachnoid hemorrhage
Subarachnoid hemorrhage may not be detected by computed tomography (CT) scan, or by lumbar puncture if the tap is performed fewer than 12 hours from the onset of symptoms, warns Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, clinical nurse specialist for the ED at Northwestern Memorial Hospital in Chicago.
Steinmann points to the following case study: A 23-year-old female presented to triage with the "worst headache of her life." She reported that the headache started an hour ago after she had carried groceries up three flights of stairs. The patient related a history of migraine headaches, but said "this was different." Her vital signs were all within normal limits. She was alert and oriented, pupils were equal and reactive to light, she denied nuchal rigidity, and demonstrated no neurologic deficits.
The woman received prochlorperazine 10 mg slowly via intravenous push and a liter of normal saline. "She received complete relief of the headache within 30 minutes," says Steinmann. A CT scan was negative, and she subsequently was discharged home to follow up with her physician. The woman returned to the ED 14 hours later stating that her headache had returned and was worse than ever. Her vital signs remained within normal limits. She remained alert and oriented, pupils were equal and reactive, but she had mild nuchal rigidity. She again received prochlorperazine 10 mg slow via intravenous push, with complete relief of the headache.
A lumbar puncture was performed, which was positive for xanthochromia, and the diagnosis of subarachnoid hemorrhage was made. "She was admitted to the surgical intensive care unit and subsequently underwent clipping of a leaking arteriovenous malformation," says Steinmann.
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