1. Case Evaluation How do you think you did? What do you think you did well? What would you have done differently? How do you think your colleagues did?

2. Diagnosis? Intractable Headache Intracranial hemorrhage Hypercoagulable state

3. General Assessment of the Headache Patient Mental status Full neurologic examination –Cranial Nerves –Motor control –Sensory control –Reflexes –Cerebellar examination Head to Toe Examination

4. Management of Pain in Headaches Narcotics Compazine (studied in migraines) Toradol / Ketoralac (NSAID) Triptans

5. High Risk Headaches Trauma Anticoagulation Intracranial lesions Hypertension Pregnancy (Eclampsia) Microvascular disease Neurologic deficit

6. MRI for Hyperacute Bleeding Field Strength is Important –< 1.5 Teslas not good for detection –Newer machines 1.5 to 3 Teslas Advanced Sequences better at detection –FLAIR (Fluid attenuated inversion recovery) –PD (Proton density) –GRE (gradient echo)

7. MRI for Hyperacute: Studies Three small studies have been performed –All less than 20 patients –Machines varied (1.5 to 3.0 teslas) Detection rate was high –However two studies missed at least 1 patient –One study missed most patients on T1 and T2 –FLAIR appears to be the most specific

8. Coma Cocktail Do the DON’T D – Dextrose O – Oxygen N – Narcan T – Thiamine

9. Neuroprotective Sedation Concept – Intubation can increase risk of bleeding and worsen outcomes in head injury and bleed patients Data - Limited

10. Neuroprotective Medications Lidocaine 1.5mg/kg bolus Fentanyl 2mcg/kg bolus Vecuronium –Defasiculation dose0.01mg/kg –Paralyzing dose0.1mg/kg Etomidate0.3mg/kg Succinylcholine1.5mg/kg