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ED nurse initiated Rx of the patient presenting with headache


  • patients with headache often waiting excessive long periods in ED waiting rooms awaiting a cubicle to be free
  • these patients are at risk of time critical delays in important diagnoses such as subarachnoid haemorrhage (SAH) and meningitis
  • their time to diagnosis could be reduced and their symptoms partly relieved by nurse initiated ED Rx, although it is recognised that these presentations can be complex and warrant timely medical assessment to properly exclude important red flags.
  • the following is a suggested framework for ED's who have nurses accredited to undertake ED nurse initiated treatment including the ordering of pathology tests.

specific history and examination

  • headache in a febrile patient with no meningism nor rash is very common, these patients could be initially managed with oral analgesics whilst awaiting medical assessment
    • fever, cough and headache in Winter is suggestive of influenza and these patients should be regarded as infectious and precautions taken to prevent spread to others

specific nurse initiated Rx for adults with headache

red flags to escalate medical referral

  • sudden onset headache suggests subarachnoid haemorrhage (SAH)
  • syncope with headache suggests subarachnoid haemorrhage (SAH)
  • fever with neck stiffness suggests meningitis
  • fever with purpuric or petechial rash suggests meningococcal septicaemia
  • blood glucose > 25 or diabetic with ketones in urine
  • acutely altered mental state
  • seizure
  • new neurologic symptoms suggests stroke (CVA) or other intracranial event
  • hypotension
  • pregnancy - could it be pre-eclampsia and eclampsia or sinus thrombosis
  • recent head trauma with other features to suggest possible intracranial bleed such as vomiting
  • recent falls in the elderly, particularly if on anticoagulants such as warfarin or clopidogrel

possible meningitis or meningococcal septicaemia

  • these patients should be seen urgently by a ED doctor and considered for iv antibiotics ASAP within 30 minutes
  • iv access
  • bloods for FBE, U&E, blood cultures

possible SAH

  • these patients should be seen urgently by a ED doctor and considered for urgent CT brain
  • iv access
  • bloods for FBE, U&E

probable migraine in a patient with PH migraine and no red flags

  • if not managing with oral analgesics, consider admission to EOU:
    • iv access
    • discuss with ED doctor to consider order for iv N Saline plus chlorpromazine infusion and transfer to EOU in a quiet environment
nursing/headache.txt · Last modified: 2012/07/23 13:46 (external edit)