Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
For Thunderclap Headache Sah Evaluation, frame the differential by acuity and pathophysiology, then align diagnostics to the leading hypotheses. Prioritize stabilization while obtaining high‑yield studies such as CBC/BMP (Baseline labs), CXR/targeted imaging (Common ED complaints), Troponin/EKG (chest pain) (ACS rule-out). Incorporate bedside imaging and targeted labs to define severity and identify complications; synthesize results with clinical trajectory to refine the working diagnosis and disposition needs.
Treatment Strategy & Disposition
Initiate disease‑directed therapy alongside supportive care, titrating to objective response. Pharmacologic options commonly include Analgesics, Antiemetics. Use validated frameworks (e.g., Diagnostic Pathway at a Glance) to guide escalation and site of care. Address precipitating factors, de‑escalate empiric therapies with data, and arrange follow‑up for monitoring and risk‑factor modification; admit patients with instability, high risk of deterioration, or needs for close monitoring.
Epidemiology / Risk Factors
- Varies by presentation; age/comorbidities matter
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC/BMP | Baseline labs | Abnormalities | |
| CXR/targeted imaging | Common ED complaints | Findings vary | |
| Troponin/EKG (chest pain) | ACS rule-out | MI changes | Use risk tools |
Diagnostic Pathway at a Glance
| Time from onset | Next step |
|---|---|
| ≤6 hours | Noncontrast CT (high sensitivity) |
| >6 hours or CT negative | LP for xanthochromia or CTA per protocol |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Nimodipine | DHP CCB (cerebral) | Hours | Prevents DCI/vasospasm | Hypotension |
| Analgesia/antiemetic | Symptomatic | Minutes | Comfort; reduce BP surges | Sedation/QT |
| BP control (labetalol/nicardipine) | Antihypertensives | Minutes | Aneurysmal rupture risk reduction | Hypotension |
Prognosis / Complications
- Outcomes tied to emergency and timeliness of care
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
Notes
Discuss risks and benefits of LP vs CTA with patients when both are reasonable. Watch for rebleed and vasospasm if SAH confirmed.