Rosen & Barkin's 5-Minute Emergency Medicine Consult (320 page)

Treatment strategy

• Abortive therapy with antiemetics, triptans, DHE, or nonsteroidals
  
• Opioids only if no response to several of the above
  
• Corticosteroids to avoid post-ED headache recurrence
  

FOLLOW-UP

• Persistent severe headache or focal neurologic deficits
  
• Intractable vomiting, electrolyte imbalance, or inability to take oral food or fluid
  
• Coexisting medication overuse headache
  

• Headache relief
  
• Pathologic cause of headache excluded
  

Chronic migraine or frequent episodic migraine should be referred to a clinician with relevant expertise

• Maintain headache diary to identify and avoid triggers
  
• Persistent primary care follow-up to identify an effective oral migraine therapeutic
  

• Opioids should not be used as first-line therapy in the ED
  
• Migraine likely to recur after ED discharge—patients should go home with prescription
  
• Distinguish between migraine, a chronic, recurrent disorder, and new onset progressive headaches
  

• Friedman BW, Lipton RB. Headache in the emergency department.
  Curr Pain Headache Rep
  . 2011;15:302–307.
  
• Friedman BW, Serrano D, Reed M, et al. Use of the emergency department for severe headache. A population-based study.
  Headache
  . 2009;49:21–30.
  
• Schellenberg ES,Dryden DM,Pasichnyk D, et al. Acute MigraineTreatment in Emergency Settings.
  Comparative Effectiveness Review
  No. 84. AHRQPublication No. 12 (13)-EHC142-EF. Rockville, MD: Agency for Healthcare Research and Quality. November2012.
  www.Effectivehealthcare.gov/reports/final.cfm
  .
  

CODES

• 346.00 Migraine with aura, without mention of intractable migraine without mention of status migrainosus
  
• 346.10 Migraine without aura, without mention of intractable migraine without mention of status migrainosus
  
• 346.90 Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus
  

BASICS

• Sounds created by physiologic processes or functional and structural anomalies of the heart.
  
• Stenotic lesions:
  
  • Pressure overload in the chamber preceding the valve, leading to hypertrophy of the chamber in an attempt to overcome the increased resistance
    
• Regurgitant lesions:
  
  • Volume overload of the chamber preceding the valve, leading to chamber dilatation in an attempt to accommodate the regurgitant blood volume
    
• Genetic abnormalities:
  
  • Congenital defects associated with abnormal cardiac blood flow
    

• Aortic stenosis:
  
  • Rheumatic heart disease
    
  • Congenital bicuspid valve
    
  • Calcification
    
  • Prosthetic valve
    
• Aortic regurgitation:
  
  • Rheumatic heart disease
    
  • Endocarditis
    
  • Aortic dissection
    
  • Prosthetic valve
    
• Mitral stenosis:
  
  • Rheumatic heart disease
    
  • Rheumatologic disorders (systemic lupus erythematosus)
    
  • Calcification
    
  • Cardiac tumors (atrial myxoma)
    
  • Congenital
    
  • Prosthetic valve
    
• Mitral regurgitation, acute:
  
  • Endocarditis
    
  • Papillary muscle rupture or dysfunction
    
  • Rupture of chordae tendineae
    
  • Prosthetic valve
    
• Mitral regurgitation, chronic:
  
  • Rheumatic heart disease
    
  • Mitral valve prolapse
    
  • Connective tissue disease (Marfan syndrome)
    
• Mitral valve prolapse:
  
  • Congenital
    
  • Connective tissue disease
    
• Tricuspid stenosis:
  
  • Rheumatic heart disease
    
• Tricuspid regurgitation:
  
  • Rheumatic heart disease
    
  • Endocarditis
    
  • Pulmonary HTN
    
• Pericardial friction rub:
  
  • Pericarditis
    
  • Pericardial effusion
    
• Ventricular septal defect:
  
  • Congenital
    
  • Traumatic
    
  • Postinfarction
    
• Ventricular assist device
  
  • Implantable pump supplements or replaces ventricular function
    

• Pulmonic stenosis:
  
  • Congenital
    
  • Maternal–fetal rubella exposure
    
  • Rheumatic heart disease
    
• Pulmonic regurgitation:
  
  • Congenital
    
  • Rheumatic heart disease
    
  • Pulmonary HTN
    
• Atrial septal defect:
  
  • Congenital
    
• Patent ductus arteriosus:
  
  • Congenital
    
  • Prematurity
    
  • Maternal–fetal rubella exposure
    
• Coarctation of the aorta:
  
  • Congenital
    
  • Turner syndrome
    
• Hypertrophic cardiomyopathy/idiopathic hypertrophic subaortic stenosis:
  
  • Congenital
    
  • Genetic predisposition
    

DIAGNOSIS

• Aortic stenosis:
  
  • Systolic crescendo–decrescendo murmur radiating to carotids
    
  • Carotid pulse described as parvus et tardus: Diminished intensity and late upstroke
    
  • Angina
    
  • Dyspnea on exertion
    
  • Exertional syncope
    
• Aortic regurgitation:
  
  • Diastolic blowing murmur at left sternal border
    
  • Pulmonary edema
    
  • Dyspnea
    
  • Tachycardia
    
  • Chest pain
    
  • Widened pulse pressure
    
  • Austin Flint murmur: Diastolic rumble from exposure of mitral valve to regurgitant flow
    
  • Corrigan pulse or water hammer pulse: Rapid upstroke and downstroke of the carotid pulse
    
  • Quincke pulse: Pulsations seen at nail beds
    
  • de Musset sign: Head bobbing with carotid pulse
    
• Mitral stenosis:
  
  • Diastolic, rumbling murmur at apex
    
  • Loud S
    ₁
    with opening snap
    
  • Dyspnea
    
  • Orthopnea
    
  • Hemoptysis
    
  • Pulmonary edema
    
  • Emboli to systemic circulation
    
  • Atrial fibrillation
    
• Mitral regurgitation, acute:
  
  • Systolic, harsh, crescendo–decrescendo murmur at apex
    
  • Pulmonary edema
    
• Mitral regurgitation, chronic:
  
  • Holosystolic murmur at apex radiating to axilla
    
  • Dyspnea on exertion
    
  • Fatigue
    
  • Atrial fibrillation
    
• Mitral valve prolapse:
  
  • Early to mid-systolic click often followed by systolic murmur
    
  • Palpitations
    
  • Chest pain
    
• Tricuspid stenosis:
  
  • Diastolic, high-pitched murmur
    
  • Peripheral edema
    
  • Hepatosplenomegaly
    
  • Ascites
    
  • Fatigue
    
  • Atrial fibrillation
    
  • Large A wave in the jugular venous pulse
    
• Tricuspid regurgitation:
  
  • Holosystolic, blowing murmur along left sternal border
    
  • Peripheral edema
    
  • Hepatosplenomegaly
    
  • Ascites
    
  • Atrial fibrillation
    
  • Large V wave in the jugular venous pulse
    
• Patent ductus arteriosus:
  
  • Continuous machinery murmur
    
  • CHF
    
• Pericardial friction rub:
  
  • Intermittent murmur
    
  • Systolic and/or diastolic component
    
• Ventricular septal defect:
  
  • Harsh, holosystolic murmur loudest along lower left sternal border
    
• Ventricular assist device:
  
  • Mechanical hum at apex
    
  • Continuous or pulsatile
    
  • May have adequate perfusion without palpable pulse or measurable BP