Approximately 15 minutes later, you note the husband at the bedside and approach the headache patient for a re-evaluation.

She is a thin African American, lying still with her eyes shut and the head of the bed up at 45 degrees. She speaks clearly, but slowly.

You read from the history already documented that she has a history of headaches, and has been having headaches intermittently for the past three days. She has taken Ibuprofen at times, which seems to help. She came yesterday, and after the meds felt much better, but today the headache came back. On a scale of 1-10, when she came in, the headache pain was graded at 10. Now she feels much better and the pain is only 2. The pain is not throbbing, but constant, and not localized to any particular part of the head.

You try to ask the usual CLORIDE (Chronicity, Location, Onset, Radiation, Intensity, Duration, and Exacerbating/alleviating factors) questions about the pain but history is difficult as she is very slow to answer. Her speech is clear and it doesn’t seem like the usual reaction to drowsiness from Compazine.

You do find out (with the husband's help) that these headaches the past three days are different from her previous headaches because they are more severe in intensity of pain, and are recurrent. Usually she gets tension headaches, which get better with Ibuprofen. Initially the ibuprofen seemed to help, but yesterday’s and today’s headaches were the worst headaches she has ever had and didn’t get better with ibuprofen. The pain is generalized all over her head, and the onset is very sudden. There is no radiation. The pain is very intense at first, but seems to get better with the medication we gave her. The headache yesterday lasted a few hours, and today it has been a few hours. She’s not sure what brings the headache on, but lying down with her head elevated seems to help.

ROS: She denies fever, photophobia, neck pain, or trauma. She denies any visual changes, toothaches, sinus drainage, ear pain, chest pain, shortness of breath, abdominal complaints, rashes, or weakness.

FH: There is a family history of migraines.
SH: No drug or alcohol abuse
Admission vital signs (from three hours earlier): BP=128/70, HR=88, RR=18, Afebrile, Sat=96% on room air
PE:
HEENT: Pupils mid position, reactive, and she has no papilladema. Neck is supple, teeth are in good repair without tenderness. No sinus tenderness. Throat normal.
Heart: RRR and normal
Lungs: Clear and normal
ABD: Soft and normal
Ext: No rashes or lesions
Neurologic: Cranial nerves normal
Motor 5/5 throughout
Sensory intact
Reflex’s normal
Cerebellar (finger to nose) normal.

Mental status: She is very slow in answering questions, but she has no slurred speech. She is not alert (preferring to lay with her eyes closed, and taking time to answer), but oriented x3 (it takes her 15 seconds to tell you the month, and another 15 seconds to tell you what is the date—but she gets both correct). Her GCS =14.

Because of the unusual nature of the headache (severe, intermittent, with a positional component) and because she notes that they are the ‘worst’ headaches and sudden in onset, you decide to add on a CT with the understanding you will be doing an LP if the CT is negative. While it is not typical for headaches from a subarachnoid hemorrhage to be intermittent, the sudden onset and description of ‘worst’ headache are worrisome enough red flags for you to pursue further workup, especially as you think her slowness cannot be entirely explained by the medications. Many refer to this type of a headache as a thunder clap headache (TCH). You also order some baseline labs and an acucheck.

About 20 minutes later, as you are walking by the patient’s room, as the nurse calls out for some help. When you go in, you see the nurse doing a sternal rub without response. The nurse tells you the patient is not breathing but has a pulse.

You grab the ambu bag on the wall, put the HOB down flat, and begin to assist respirations as you move the patient to the resuscitation area.

When you ask what happened, the nurse notes she was in the room doing the acucheck when she noticed the patient had stopped breathing. She seemed like she was sleeping, but when she didn’t respond, she realized she was not conscious or breathing.

As you get to the resuscitation area and ready intubation equipment, the patient begins to spontaneously breath and over the next 3-4 minutes starts waking up. VS on arrival to resuscitation room were: BP 155/85, RR=0, P=70

1. What CNS structures maintain consciousness?
2.  What could have happened?
3.  What do you order?

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