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decision rule for subarachnoid hemorrhage?

12 Apr

THOSE CANADIANS ARE AT IT AGAIN:
–study by Ottawa docs, Perry et al. reviewed nicely in an AAEM/Common Sense article (see reference)
–tried to identify a set of clinical characteristics to make a decision rule for those who need SAH workup

BASIC STRUCTURE:
–1,999 patients, 130 diagnosed with SAH
–SAH diagnosis defined by +CT, xanthrochromia, or >5 x 10^6/L RBCs + aneurysm/AVM on cerebral angiography

–included:

  • adults (>16 yo)
  • chief complaint = headache
  • GCS 15
  • non-traumatic
  • peak intensity of HA within 1 hr

–excluded:

  • >2 wks after symptom onset
  • prior SAH
  • previous CT and/or LP workup
  • 3 similar HA’s within past six months
  • papilledema/focal neuro symptom
  • prior hydrocephalus or cerebral neoplasm

RULES THEY CAME UP WITH:
–all have sensitivity 100%, but specificity sucked (28-39%)

the rules (each set works to help rule-out SAH):

  • age >40, neck pain/stiffness, witnessed LOC, DBP > 100mmHg
  • arrival by EMS, age>45, vomiting, DBP > 100
  • arrival by EMS, age 45-55, neck pain/stiffness, SBP > 160

BOTTOM LINE:
–nice study, helps think about why we do what we do, but isolated population
–the extra H&P details (age, BP, vomiting, neck pain/stiffness, etc.) are not very specific for SAH, but together might be sensitive (reminds me of appendicitis)
not ready for primetime just yet, but food for thought

Submitted by S. Lee.

Reference(s): AAEM/RSA review, picture

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