Emergency Severity Index Pt.2: Practice Cases – 11 Headache

October 11, 2019

[Music] Facilitator 2 (FA2): Okay, let’s go back and watch some
more video cases here. [Patient, sitting in a chair, clutching her head with her eyes closed…moans…] Patient (P): I have an awful headache. I can’t stand the pain. I’ve had
headaches before, but not like this one. Nurse (N): You look really miserable. You know on a
scale of 0 to 10, if 10 was the worst pain you could ever imagine,
how would you rate it right now? P: A 10+ – I can’t stand it. N: when did this
start? P: Today, about an hour ago. I went to the bathroom. I moved my bowels and it
started right after that. N: Okay. Are you having any nausea or vomiting? P: I feel sick to my stomach. Can’t you give me something for the pain? N: No, not right now.
You’re going to see the doctor in a few minutes, so first I need to ask you a
couple more questions and get your blood pressure, okay?
How old are you? P: 35
N: Okay. N: And do you have any medical problems?
P: No. N: Do you take any medications
everyday for any reason? P: No.
N: Okay, and do you have any allergies to medications?
P: No. N: Okay. [Music] Facilitator 1 (FA1): This is an ESI level 2.
This patient has a new onset severe headache that is a typical presentation for a subarachnoid
hemorrhage. This is a high-risk situation. Headaches are frequent complaints and
are worthy of a little further discussion. Patients that present with
their typical migraine headache are often triaged as ESI Level 3. They usually
require an IV with fluid and IV pain medication. However,
migraine patients that know they only require an IM selective serotonin
agonist (Imitrex), an anti migraine medicine, will require only 1 resource, an IM
medication and therefore will be classified as ESI Level 4. Even a patient
with a typical migraine that presents in severe pain, vomiting at triage, even
though it is a typical headache could be triaged as ESI Level 2 due to severe
pain. To summarize, with headaches history is important to rule out a high-risk
situation. Then you really need to assess how the patient looks and finally how
many resources you might anticipate will be needed. In this particular scenario,
the patient met ESI Level 2 criteria. FA2: Okay, so headaches are kind of
messy and grey sometimes. So, what do you guys think about that scenario? Registered Nurse 2 (RN2): Well, I think that scenario opened my eyes to how I treat headaches and especially
people with migraines. Because you didn’t think, well, you know it’s just a headache
so you don’t really think much about the bleeding or like a possible tumor or
something. But I do agree with that level that she should be a 2, because of
her, I think, the reason why that was a 2 mainly because of her
pain and her instability. Am I correct? Registered Nurse 1 (RN1): I think the connection with the
bowel movement was really important too. And she looked so awful too.
RN2: Yeah, she did. RN1: Although some migraine people do, but the bowel movement connection was
important, I think. FA1: Definitely that [bellos a very] heavy bowel movement was certainly a tip-off
that this could be a subarachnoid creator. Good. FA2: That’s what put her over edge.
Any other headache kind of questions? RN1: No. Just the “worst headache I’ve ever had in my life” – do you up the
acuity for that statement? FA2: “Worst headache of their life” – usually once
they say that, it’s pretty tough to not make them a Level 2 patient. RN1: Even in a migraine person who has frequent migraines? FA2: It’s their worst migraine
and worse than their normal grand migraine and it’s not typical
migraine, then I probably would. FA1: I would too. Absolutely. RN1: Although, they sometimes say that because they want pain medication fast, I think. Registered Nurse 3 (RN3): Well, you have to take them
at their word when you’re triaging them. FA1: Exactly.
RN1: Sure. Okay.

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