‘Headache’ Found to Be Symptom of Much More Serious Condition - Case of the Month - @ JEMS.com

‘Headache’ Found to Be Symptom of Much More Serious Condition

Alcoholic patient complains “something is really wrong”



Fred W. Wurster III, AAS, NREMT-P | From the July 2012 Issue | Thursday, July 5, 2012

It’s a Thursday afternoon, and you’re dispatched to a local substance abuse rehabilitation facility for a person complaining of a headache. While en route, you and your partner discuss how many times you’ve responded to this facility for calls that don’t seem legitimate. Additional information is obtained from the 9-1-1 center that reveals you’re responding to a 48-year-old male complaining of a headache and dizziness. You arrive and are escorted to the patient, who’s located at the nursing station. The patient is seated and holding his head with his hands. You introduce yourself and ask what’s wrong.

Patient Assessment
The patient responds by whispering his name and saying he has a headache and that it hurts to open his eyes. You question the patient about his reasons for being treated at the facility, and he reports he’s an alcoholic who drinks approximately one gallon of vodka a day and has since he was 14. He has been “clean” for six days.

The patient denies any other medical conditions, reporting that he doesn’t take any prescribed medications and has an allergy to Penicillin. According to the patient’s chart, he’s taken several medications to aid in his detoxification process. You and your partner look at each and try not to pass judgment because you’ve encountered many patients here in the past who haven’t been truthful with their complaints.

While you continue to question the patient, he suddenly grabs the back of his head and states, “This is the worst headache I’ve ever had; it feels like someone is cutting into my brain.” You obtain a baseline set of vital signs that reveal the following: BP=168/118; HR=92 and regular; RR=18 and non-labored.

The patient begins to writhe in pain, complains about increasing pain in his head and vomits twice profusely. You secure the patient and stretcher and prepare for transport. You apply the ECG monitor and administer 4 LPM of oxygen. You establish an IV and administer 4 mg of Zofran for nausea. As you begin transport, you ask the patient how he’s feeling, but he doesn’t answer. You ask again and note that he now has sonorous respirations.

Current vital signs are now: BP=198/168; HR=110; RR=8 and are shallow and abnormal in pattern. You begin to assist the patient with ventilations with a bag-valve mask and your partner notifies the hospital of the sudden change to the patient’s condition.

While you ventilate the patient, he becomes extremely agitated and begins to thrash around. Although he’s not seizing, he becomes difficult to control. This continues for a few minutes, and then he suddenly becomes somewhat alert and says, “something is really wrong.”

A repeat set of vital signs still shows a dramatically elevated blood pressure at 218/176, with a HR=118, and now the patient’s respirations seem more normal at 14 per minute. You conduct a blood glucose test, and it’s 86 mg/dL. The patient’s skin doesn’t feel hot, and all the other physical exam findings are within normal limits.

About five blocks away from the hospital, the patient lets out a scream that startles you and your partner. He clutches his head, and then becomes unresponsive. You immediately start ventilating again, because his respirations are extremely shallow and irregular. You notice he has extremely unequal pupils and that his pressure has increased substantially to 276/224 with a HR of 126 and RR of 6.

You continue to assist the patient’s ventilations and prepare for intubation. The patient is successfully intubated with ease, as he has no gag reflex. He’s sedated with 5 mg of Versed as part of your post-intubation sedation protocol, and then you arrive at the hospital. The patient remains unresponsive with unchanged vitals. The emergency department (ED) staff takes him to radiology for a computed tomography scan.

A few moments later, the ED physician informs you that the patient is in extremely critical condition. He tells you the patient has a substantial subarachnoid hemorrhage and has just gone into cardiac arrest. Resuscitation attempts are unsuccessful, and the patient is pronounced dead about 30 minutes later.

Subarachnoid Hemorrhage
A subarachnoid hemorrhage occurs when blood enters the subarachnoid space because of a variety of reasons. It usually occurs from a ruptured cerebral aneurysm or as a result of a traumatic head injury. The classic or textbook symptoms of one are a rapid onset of a “thunder-clap” headache, which is often reported to be the worst headache someone has ever experienced. Other associated symptoms include vomiting, confusion, decreased levels of consciousness and sometime seizure activity.

Subarachnoid hemorrhage has a 50% mortality rate, and of that 50%, about half the patients expire before reaching a hospital. Patients who survive usually have some form of lasting effects, and early recognition and rapid transporting to an appropriate facility is paramount to their survival.

Prehospital treatment should be supportive of symptoms (if allowable by your protocol) and should be initiated as soon as possible to optimize the outcome for your patient. JEMS


Connect: Have a thought or feedback about this? Add your comment now
Related Topics: Case of the Month, subarachnoid hemorrhage, Fred Wurster, Jems Case of the Month


Fred W. Wurster III, AAS, NREMT-PFred W. Wurster III, AAS, NREMT-P, has spent 20 years in emergency services both as a career and volunteer provider. He’s currently the Director of Training for the Good Fellowship Training Institute in West Chester, Pa. and a flight paramedic with PennSTAR, the Hospital of the University of Pennsylvania, in Philadelphia, Pa. He is also a technical editor for JEMS. Contact him at sgtmedic4@comcast.net.


What's Your Take? Comment Now ...

Buyer's Guide Featured Companies

Featured Careers & Jobs in EMS

Get JEMS in Your Inbox


Fire EMS Blogs

Blogger Browser

Today's Featured Posts


EMS Airway Clinic

Improving Survival from Cardiac Arrest Using ACD-CPR + ITD

Using active compression-decompression CPR with an ITD has been shown to improve 1-year survival from cardiac arrest by 33%.
More >

Multimedia Thumb

Over Half of Seattle Fire Stations Test Positive for MRSA

Surprisingly high results come from test kits based on earlier study.
Watch It >

Multimedia Thumb

AMR Crew Rescues Mississippi Driver from Fiery Crash

Rescue during crash in Jackson is caught on video.
Watch It >

Multimedia Thumb

Tempe’s Drug Dilemma

Dealing with overdoses.
Watch It >

Multimedia Thumb

I’m a Paramedic

Profile of a Northshore LIJ medic.
Watch It >

Multimedia Thumb

Nightwatch Series Premiere Party

JEMS Editor-in-Chief A.J. Heightman attends the series premiere of A&E's new reality show, "Nightwatch."
More >

Multimedia Thumb

Ottawa Chemical Investigation

Chemicals and suspicious package are probed at two locations
More >

Multimedia Thumb

Cincinnati Overpass Collapse

Fatal pancake collapse occurs during demolition.
More >

Multimedia Thumb

The AmbuBus®, Bus Stretcher Conversion Kit - EMS Today 2013

AmbuBus®, Bus Stretcher all-hazards preparedness & response tool
Watch It >

Multimedia Thumb

Braun Ambulances' EZ Door Forward

Helps to create a safer ambulance module.
Watch It >

Multimedia Thumb

Field Bridge Xpress ePCR on iPad, Android, Kindle Fire

Sneak peek of customizable run forms & more.
Watch It >

More Product Videos >