ER Basics for Rookies

A patient presents with a sudden, severe headache — “the worst headache of my life.” They’re awake, vitals are stable. Do you call it a migraine, give pain meds, and discharge? Not so fast. This could be a subarachnoid hemorrhage (SAH) — a time-critical emergency that rookies often miss.

Why It Matters

• SAH is most often caused by ruptured intracranial aneurysm.
• Mortality: up to 30–40% at 30 days.
• Survivors often left with major neurological deficits.
• Missed SAH = malpractice nightmare — one of the most litigated ED diagnoses.

Classic Presentation

• Thunderclap headache: abrupt onset, maximal intensity within 1 minute.
• Often described as “worst headache ever.”
• May occur during exertion, sexual activity, or Valsalva.

Associated Features

• Nausea, vomiting.
• Photophobia, neck stiffness (meningeal irritation).
• LOC at onset in some cases.
• Focal neuro deficits or seizures in ~25%.

Step 1: Initial ED Assessment

• ABCs: airway protection if decreased GCS.
• Neuro exam: cranial nerves, motor, speech, pupillary reactivity.
• Vital signs: hypertension, bradycardia may indicate rising ICP.

Step 2: Imaging

• Non-contrast CT head is first-line.
  • Sensitivity:
    • ~98% within first 6 hrs.
    • Falls to <85% after 6–12 hrs.
• If CT negative but suspicion high → Lumbar puncture for xanthochromia (bilirubin breakdown).
• CTA head often performed if aneurysm suspected, or as part of CT stroke protocol.

Step 3: Labs

• CBC, renal function, coagulation profile.
• Type & crossmatch (for possible surgery).

Step 4: ED Management

• Blood pressure control: target SBP <140 mmHg (nicardipine, labetalol).
• Pain control & antiemetics: reduces rebleeding risk from surges.
• Nimodipine: 60 mg PO/NG q4h (neuroprotective, prevents vasospasm).
• Seizure management: treat if seizures occur (levetiracetam often used).
• Reverse anticoagulation/antiplatelets if applicable.
• Neurosurgery/neuro ICU consult urgently — definitive management = aneurysm coiling or clipping.

Pitfalls Rookies Make

• Dismissing thunderclap headache as migraine, tension headache, or viral illness.
• Relying on negative CT >6 hrs after onset without LP.
• Forgetting nimodipine — one of the few interventions proven to improve outcomes.
• Treating only the pain without addressing BP control or workup.
• Not consulting neurosurgery early.

Rookie Pearls

• “Worst headache of life” = SAH until proven otherwise.
• CT within 6 hrs is very sensitive, but beyond that you must LP or CTA.
• Even a normal neuro exam does not rule out SAH.
• Always document onset time, risk factors, and your rationale for ruling in/out.
• Involve neurosurgery early — definitive care is procedural, not medical.

Take-Home Message

For rookies:

• SAH = thunderclap headache + high stakes.
• CT first, then LP or CTA if suspicion remains.
• Treat BP, start nimodipine, consult neurosurgery.
• Don’t dismiss patients who look “too well” — many SAH patients walk into the ED.

Remember: Missing SAH is one of the biggest rookie mistakes in emergency medicine — don’t let it be yours.