Headache, Confusion & Delirium

“Delirium (acute confusional state) is common in hospital medicine. In the elderly, the prevalence of delirium ranges from 11%-42%.”
— Siddiqui et al. (2006)

CAP 17 – Headache

EM Curriculum: (click to view)

Headache

The presentation of a patient with a severe headache to the Emergency Department is a common one. Whilst most are benign in nature, a small percentage represent potentially devastating aetiologies.

The task of the ED doctor is to differentiate between the two.

The doctor must be guided by the knowledge that:

  • Extensive investigation of all cases will result in many false positive

  • Failure to identify headaches due to serious aetiologies can result in fatal, or irreversible, outcomes

The International Headache Society classifies headaches into primary and secondary groupings.

  • Primary headaches are those where the specific aetiology is not fully understood e.g. migraine.
  • Secondary headaches have a clear and understandable origin e.g. ruptured aneurysm.

Primary causes are sometimes referred to as benign. However, this term is misleading as they are associated with considerable morbidity and indirect mortality.

Acute, severe headache is a common symptom of patients presenting to the Emergency Department. In 90% of cases, the cause will be one of the primary headache syndromes.

Delirium

Delirium (acute confusional state) is common in hospital medicine. In the elderly, the prevalence of delirium ranges from 11%-42% (Siddiqui et al., 2006).

Patients with delirium have:

  • Increased length of hospital stay

  • Higher risk of complications in both medical and surgical settings

  • Higher mortality, both in hospital and up to 6 months following discharge (APA, 1999)

It is estimated that one-third of cases are preventable (Inouye et al., 1999). However, the detection and documentation of delirium by Emergency Physicians is poor, with reported sensitivity rates as low as 35% (Hustey and Meldon, 2002).

It is an essential skill for Emergency Physicians to be able to identify, rationally assess and implement effective initial treatment strategies in confused elderly patients.

Learning Outcomes from completing the tasks

Headache:

  • Describe a pragmatic, focussed method of eliciting the relevant history of an acute headache

  • List an appropriate differential diagnosis for acute headaches

  • Describe a logical method to rule in, or rule out, the principle causes of acute headaches

  • Demonstrate when primary headache syndromes require further investigation

  • List an appropriate differential diagnosis for acute secondary headache

  • Describe a logical method to rule in, or rule out, the principle causes of acute secondary headache

  • Describe characteristic findings on lumbar puncture and CT of the more important differential diagnoses of acute secondary headache

Delirium:

  • Summarise the morbidity and mortality associated with acute confusion in the elderly

  • Outline, with examples, common presentations and precipitants

  • Create and justify a structured, pragmatic approach to the investigation of the acutely-confused elderly patient

  • Explain how to implement appropriate treatment strategies, after considering a differential diagnosis

  • Highlight the pitfalls that may be encountered in the management of the acutely-confused elderly patient

Learning Outcome from face-to-face teaching

  • Formulate appropriate differential diagnoses and management strategies for patients presenting with headaches.

  • Revise lumbar puncture indication and techniques in the Emergency Department and be able to interpret basic CSF results.

  • Appropriately investigate and formulate management plans in acute delirium and confusion, especially in older patients.

Tasks

Complete the following before the face-to-face session:

Task 1: Primary Headache

Duration: 60 mins

These two modules cover the spectrum of primary and secondary headaches that present to the Emergency Department. Primary Headaches and Secondary Headaches.

Task 2: Diagnosing Acute Headaches

Duration: 20 mins

Read the following document from MPS casebooks. This is a very good document based on case series of misdiagnosed headaches with dire consequences. Well worth a read. Pages 8-14 only.

Task 3: Acute Confusion in the ED

Duration: 14 mins

Listen to this RCEMFoamed podcast by Leicester's Dr Acheson and Dr Banerjee. It covers acute confusion in the emergency department.

Task 4: Delerium IPE Summary [#EM3]

Duration: 30 mins

This is summary from the IPE session held in the department serves as a good introduction to the subject and how we can identify patients with delirium. It also covers why it is important that we identify patients with delirium in the ED. You can listen to the audio from the session as well as review the slides, don't forget to also check out the infographic.

For another quick summary we also have Lightning Learning.

#EM3 Content

LIGHTNING LEARNING

SIMBLogs

EMERGENCY PROTOCOLS

You should familiarise yourself with relevant Local Guidelines, for East Midlands Trainees we are aiming to host these on the website shortly (although this may password protected).

In the meantime please review your local guidelines relevant to chest pain.

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“An elderly lady has been brought to your department by her family who say she has been getting progressively more confused over the past week and they don’t feel she is safe at home anymore.”
“A 20 year old lady attends the ED with a history of daily headache, it is in the front of her head and worse when she lies down. She feels sick with it but has not vomited.”

ADDITIONAL RESOURCES

Here are some extra resources to review if you want more information:

Emergency Medicine Cases:

As part of their "Best Case Ever" series they look at a case from America of a repeat attender with a headache. If you haven't heard any of these before it is worth going to their website and having a look - several of these appear in other modules.

Headache Podcasts:

"Welcome to the Headache: The Journal of Head and Face Pain podcast channel. Headache is the official publication of the American Headache Society. Headache publishes original, peer-reviewed work in all areas of head and face pain. This channel features audio files and occasional videos intended for patients and practitioners alike, related to papers published in the journal."

SEMEP Video:

Paediatric Headaches: Be HeadSmart

Each week in the UK, around ten children or teenagers are diagnosed with a brain tumour in the UK. The time taken from a child’s first symptoms to diagnosis of a brain tumour for half of the children to be diagnosed is currently 12-13 weeks (median) in the UK.

The aim of the HeadSmart campaign is to reduce the time it takes to diagnose children and young people with brain tumours in the UK by education.

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form:

Updated: 4th January 2017