LRTI: Discharge Criteria and Continued stay criteria

🏥 LRTI - Discharge Criteria & Continued Stay Criteria

Lower Respiratory Tract Infection Management Decision Points

✅ DISCHARGE CRITERIA - Click to Expand

✅ Criteria for Safe Hospital Discharge

Patients should meet ALL criteria before discharge is considered safe and appropriate.

Clinical Stability Criteria

📊 Vital Signs Normalization

• Temperature: ≤ 37.5°C (99.5°F) for ≥24 hours without antipyretics
• Heart Rate: 60-100 bpm (or baseline rate if known)
• Respiratory Rate: 12-20 breaths/minute
• Blood Pressure: Systolic ≥90 mmHg, Diastolic ≥60 mmHg (no vasopressors)
• SpO₂: ≥92% on room air (or baseline for COPD patients)
• Alert & Oriented: Normal mental status (no confusion/delirium)

🫁 Respiratory Function

• No Respiratory Distress: No tachypnea, stridor, or use of accessory muscles
• Adequate Oxygenation: pO₂ ≥60 mmHg on room air (or stable baseline)
• No Hypercapnia: pCO₂ normal range or chronic baseline
• Effective Cough: Able to expectorate secretions
• No Supplemental O₂ Requirement: Or minimal requirement (<2-3 L/min)

💊 Oral Intake & Medications

• Adequate Oral Intake: Able to eat and drink without difficulty
• No Dysphagia: No aspiration risk, normal swallowing
• Tolerating Oral Medications: No IV medications required
• Nausea/Vomiting Controlled: Not requiring IV antiemetics
• Bowel Function Intact: Regular bowel movements

Infectious Disease Criteria

🧬 Laboratory & Microbiological

• WBC Count: ≤11,000/μL (normalized or trending down)
• CRP/Procalcitonin: Normalized or significantly decreased
• Blood Cultures: Negative (if initially positive)
• Sputum Culture: No new pathogenic organisms identified
• No Fever: Afebrile for ≥24-48 hours
• Antibiotic Course: Completed appropriate duration (7-10 days for CAP)

📋 Discharge Readiness Checklist

☐

Vital Signs Stable - HR 60-100, RR 12-20, BP >90/60, SpO₂ >92%

☐

Afebrile - Temperature ≤37.5°C for ≥24 hours

☐

Adequate Oxygenation - SpO₂ ≥92% on room air

☐

Oral Intake Adequate - Eating/drinking well, no dysphagia

☐

Medication Tolerance - All antibiotics by mouth, no IV required

☐

Clinical Improvement - Cough, dyspnea improving

☐

Lab Normalization - WBC ≤11,000, CRP trending down

☐

Follow-up Arranged - Outpatient appointment within 1-2 weeks

⛔ CONTINUED STAY CRITERIA - Click to Expand

⛔ Criteria for Continued Hospitalization

Patients meeting ANY of these criteria should NOT be discharged.

Clinical Instability - RED FLAGS

🚨 Vital Sign Abnormalities

• Persistent Fever: Temperature >38°C despite antibiotics (>48-72 hours)
• Tachycardia: HR >120 bpm persistently
• Tachypnea: RR >24 breaths/minute or acute worsening
• Hypotension: SBP <90 mmHg requiring vasopressor support
• Hypoxemia: SpO₂ <90% on room air, requiring supplemental O₂
• Altered Mental Status: Confusion, delirium, decreased LOC

🫁 Respiratory Compromise

• Respiratory Distress: Use of accessory muscles, stridor, grunting
• Hypoxemia: pO₂ <60 mmHg despite supplemental oxygen
• Hypercapnia: pCO₂ >50 mmHg with respiratory acidosis
• Need for Mechanical Ventilation: Current intubation or impending need

Infectious Disease Criteria - RED FLAGS

🧬 Microbiological/Laboratory Concerns

• Positive Blood Cultures: Bacteremia present, requires investigation
• Persistent WBC Elevation: WBC >15,000/μL with left shift
• Rising CRP/Procalcitonin: Increasing inflammatory markers despite therapy
• Resistant Organisms: MRSA, MDR gram-negatives, fungal agents
• Treatment Failure: No improvement by 48-72 hours on antibiotics

⛔ Continued Stay RED FLAG Checklist

☐

Fever >48-72 hours - Temperature remains >38°C despite antibiotics

☐

Hypoxemia - SpO₂ <90% or pO₂ <60 mmHg

☐

Respiratory Distress - RR >24 or accessory muscle use

☐

Hemodynamic Instability - Hypotension, tachycardia, or shock

☐

Altered Mental Status - New confusion, delirium, decreased LOC

☐

Positive Blood Cultures - Evidence of bacteremia

☐

Resistant Organisms - MRSA, MDR gram-negatives, fungi

📋 CLINICAL ASSESSMENT TOOLS - Click to Expand

📋 Clinical Assessment Tools

CURB-65 Score at Discharge Assessment

CURB-65 Score	Discharge Readiness	Action
0-1 (Low Risk)	Excellent candidate for discharge	Discharge with outpatient follow-up; oral antibiotics
2 (Intermediate)	Safe to discharge if clinically stable	Monitor 24 hours; transition to oral meds
≥3 (High Risk)	Requires continued hospitalization	Do NOT discharge; continue IV antibiotics

PSI (Pneumonia Severity Index) - Risk Stratification

PSI Class	Mortality	Discharge Recommendation
Class I	<0.1%	✅ Safe outpatient management
Class II	0.6%	✅ Consider discharge after observation
Class III	0.9-1.3%	⚠️ Brief hospitalization required
Class IV	6.8-8.2%	❌ Hospitalization required
Class V	27-31%	❌ ICU-level care required

📞 FOLLOW-UP & DISCHARGE INSTRUCTIONS - Click to Expand

📞 Discharge & Follow-up Care Planning

Follow-up Schedule

Timeframe	Action/Assessment	By Whom
24-48 hours	Telephone check-in; confirm medication compliance	Nurse or PCP
1 week	In-person PCP visit; assess treatment response	Primary Care Physician
4 weeks	Assess symptom resolution; repeat labs if needed	Primary Care Physician
1-3 months	Repeat CXR if immunocompromised or prolonged symptoms	PCP or Pulmonology

⚠️ Warning Signs - Seek Emergency Care If:

• Return fever (>38.5°C)
• Worsening shortness of breath
• Chest pain or hemoptysis
• Mental status changes
• Severe fatigue or syncope

📚 These criteria are for clinical guidance and should be integrated with clinical judgment and institutional protocols.

References: IDSA, ATS Guidelines | Blogger-Compatible Version (CSS-only collapsible sections)

LRTI DIAGNOSIS

PRCS (Protected Respiratory Catheter Specimen) - Protected Specimen Brush:

• Bronchoscopic technique with direct visualization
• Protected catheter design prevents upper airway contamination
• Quantitative culture: ≥10³-10⁴ CFU/mL diagnostic for VAP
• Higher specificity (~90%) but more invasive
• Requires expertise and equipment

Extation (Endotracheal Aspiration):

• Simple blind bedside procedure with suction catheter
• No visualization needed
• Higher diagnostic threshold: ≥10⁴-10⁵ CFU/mL
• Higher sensitivity (~70-90%) but lower specificity (~60%)
• Cost-effective and readily available 24/7                                                                                    
•  

 

Acute Kidney Injury

 AKI Management Algorithm (Step-by-Step)

---

Step 1: Diagnose AKI

• Criteria:
• SCr increase ≥0.3 mg/dL within 48h or ≥1.5× baseline.
• Urine output <0.5 mL/kg/h for ≥6h.
• Rule out pseudorenal failure (e.g., dehydration, obstruction).

---

Step 2: Stage AKI (KDIGO)

Stage	SCr Criteria	Urine Output Criteria
1	≥0.3 mg/dL or 1.5–1.9× baseline	<0.5 mL/kg/h for 6–12h
2	2.0–2.9× baseline	<0.5 mL/kg/h for ≥12h
3	≥3.0× baseline or ≥4.0 mg/dL	<0.3 mL/kg/h for ≥24h or anuria

---

Step 3: Identify the Cause

Prerenal (60%)

• History/Exam: Hypotension, dehydration, heart failure.
• Labs: FeNa <1%, urine osmolality >500 mOsm/kg.
• Management: Fluid resuscitation, optimize hemodynamics.

Intrinsic (35%)

• ATN: Acute Tubular Necrosis: Ischemia, toxins (aminoglycosides, contrast).
• Labs: FeNa >2%, granular casts.
• Management: Discontinue nephrotoxins, supportive care.
• AIN: Acute interstitial nephritis:  Drugs (penicillin, PPIs, NSAIDs).
• Labs: Eosinophils in urine, rash, fever.
• Management: Stop offending drugs, ± steroids.
• Glomerulonephritis/Vasculitis:
• Labs: Proteinuria, hematuria, low C3/C4.
• Management: Immunosuppression (steroids, cyclophosphamide).

Postrenal (5%)

• History/Exam: Obstruction (stones, BPH, tumors).
• Imaging: Renal ultrasound (hydronephrosis).
• Management: Catheterization, nephrostomy, or stenting.

---

Step 4: Immediate Management

• For All AKI:
• Discontinue nephrotoxins (NSAIDs, ACEi/ARBs, aminoglycosides).
• Optimize hemodynamics (fluids, vasopressors if needed).
• Monitor:
• SCr, BUN, electrolytes (K⁺, Na⁺, Ca²⁺, PO₄³⁻).
• Urine output (Foley catheter if oliguric).
• Fluid balance (strict I/O).
• Correct Electrolyte Imbalances:
• Hyperkalemia (K⁺ >6.5 mEq/L):
• Calcium gluconate (10 mL IV over 10 min).
• Insulin + glucose (10 units insulin + 50 mL D50).
• Albuterol nebulization (10–20 mg).
• Dialysis if refractory or ECG changes.
• Metabolic acidosis (pH <7.1): Bicarbonate.
• Fluid overload: Diuretics (if responsive) or RRT.

---

Step 5: Indications for RRT (Dialysis)

Start RRT if AEIOU criteria are met:

• Acidosis (pH <7.1, refractory).
• Electrolyte disturbances (K⁺ >6.5 mEq/L, refractory).
• Intoxication (dialyzable toxins: lithium, methanol, ethylene glycol).
• Overload (fluid overload refractory to diuretics).
• Uremia (BUN >100 mg/dL, pericarditis, encephalopathy, bleeding).

Modality Choice:

• Intermittent Hemodialysis (IHD): Stable patients.
• Continuous RRT (CRRT): Hemodynamically unstable (ICU).
• Peritoneal Dialysis (PD): If vascular access is difficult.

---

Step 6: Supportive Care

• Nutrition:
• Protein: 0.8–1.0 g/kg/day.
• Calories: 25–30 kcal/kg/day.
• Fluid Balance:
• Restrict fluids if oliguric (insensible losses + urine output).
• Infection Prophylaxis:
• Adjust antibiotic doses for renal function.

---

Step 7: Monitor and Follow-Up

• Daily:
• SCr, BUN, electrolytes, urine output, weight, fluid balance.
• Renal Ultrasound: If no improvement in 24–48h (rule out obstruction).
• Nephrology Consult:
• Stage 2–3 AKI.
• Unclear etiology.
• Need for RRT.

---

Step 8: Prognosis and Prevention

• Prognosis:
• Mortality: ~10–30% (higher in ICU, sepsis, Stage 3).
• Recovery: Prerenal AKI often reversible; ATN may take weeks.
• ~20–30% progress to CKD.
• Prevention:
• Avoid nephrotoxins.
• Hydrate before contrast procedures.
• Optimize hemodynamics in high-risk patients.

---

Quick Reference Table: AKI Causes and Management

Type	Causes	Diagnostic Clues	Management
Pre-renal	Hypovolemia, hypotension, HF	FeNa <1%, urine osmolality >500	Fluids, optimize hemodynamics
ATN	Ischemia, toxins (aminoglycosides)	FeNa >2%, granular casts	Discontinue nephrotoxins, supportive
AIN	Drugs (penicillin, PPIs, NSAIDs)	Eosinophils in urine, rash, fever	Stop drug, ± steroids
Glomerulonephritis	Immune-mediated (e.g., vasculitis)	Proteinuria, hematuria, low C3/C4	Immunosuppression (steroids, cyclophosphamide)
Post-renal	Obstruction (stones, BPH, tumors)	Hydronephrosis on ultrasound	Catheterization, nephrostomy, stenting

 

Maternal Sepsis

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Premature Rupture of Membranes

🏥 PPROM QUICK REFERENCE

Premature Preterm Rupture of Membrane - Bedside Card

2-3%

of all pregnancies affected

33%

of preterm births

10-32%

recurrence risk

24-37w

typical presentation

🔍 DIAGNOSIS

• Sterile speculum exam (GOLD STANDARD)
• Look for pooled fluid in posterior fornix
• Nitrazine test (alkaline = blue-green)
• Ferning test (salt crystals)
• Ultrasound (AFI assessment)
• PAMG-1 if equivocal

⚠ SCREEN FOR COMPLICATIONS

• Chorioamnionitis (fever + signs)
• Placental abruption (bleeding + pain)
• Cord prolapse (cord visible)
• Fetal distress (abnormal CTG)

Any complication → STAT DELIVERY

📍 MANAGEMENT BY GA

• Less than 22-24w: Previable (shared decision)
• 22-34w: EXPECTANT management
• 34-37w: Depends on GBS status
• 37w and above: Deliver (term reached)

💊 MEDICATIONS - ALL GA LESS THAN 34-35w

Corticosteroids

Betamethasone 12mg IM x2 at 24h apart

Antibiotics (latency)

Ampicillin + Macrolide x7-10 days

GBS prophylaxis (labor)

Penicillin G or Ampicillin IV

✓ MATERNAL SURVEILLANCE

• Daily temp monitoring
• Daily symptom check
• Weekly speculum exams (NO digital)
• Return if fever/pain/discharge/decreased FM
• Bed rest NOT recommended

✓ FETAL SURVEILLANCE

• Continuous CTG if greater than 24w viable
• Daily fetal movement counting
• Twice-weekly NST/CTG minimum
• Ultrasound q2-4 weeks
• Assess growth, AFI, placenta

⏱ IMMEDIATE STEPS

• Confirm diagnosis (sterile speculum)
• Vital signs + obstetric exam
• Fetal assessment (CTG if viable)
• Screen for complications
• CBC + cultures + GBS swab
• Ultrasound: confirm, assess GA, AFI
• START corticosteroids STAT

🏥 ADMISSION CRITERIA

• Any PPROM less than 34 weeks (typically)
• First 48-72 hours minimum
• Complications (fever, bleeding, distress)
• Unreliable or no home support
• GA less than 28 weeks (almost always)

🚨 RED FLAGS - DELIVER IMMEDIATELY

Chorioamnionitis:
Fever + tachycardia + tenderness + discharge

Abruption:
Bleeding + pain + shock signs

Cord Prolapse:
Cord visible through cervix

Fetal Distress:
Late decelerations + bradycardia

📋 DOCUMENTATION ESSENTIALS

Must include: Diagnosis method + results • Gestational age (LMP or US) • Red flag assessment • Complications screening • Medications given with times • Monitoring plan • Counseling and informed consent • Follow-up arranged

Version 1.0 | June 2026 | Swaraj Hospital and Research Institute, Bolangir

For complete details, refer to full PPROM Protocol Document

Swaraj Hospital & Research Institute

Protocol on Management of Severe Headache

Clinical Guidelines & Emergency Management Pathways

Version: 1.0

Effective Date: June 2026

Location: Bolangir

Department: Emergency & Neurology

Executive Summary Introduction Red Flags Assessment Investigations Management Treatment Referral

📋

Executive Summary

This protocol provides standardized guidelines for the assessment, investigation, and management of severe headache presentations at Swaraj Hospital & Research Institute. While most acute headaches are primary (benign) in nature, 15-25% of severe presentations indicate serious underlying pathology requiring urgent intervention including subarachnoid hemorrhage, meningitis, acute stroke, or space-occupying lesions.

Protocol Objectives

• Rapid identification of red-flag warning symptoms
• Appropriate use of diagnostic investigations
• Timely specialist referral
• Evidence-based pain management
• Clear admission and discharge criteria

01

Introduction & Definitions

Definition of Severe Headache

Severe headache is acute cranial pain of significant intensity (≥7/10 on visual analog scale) affecting the head or upper neck region, requiring urgent assessment to identify life-threatening causes and provide appropriate management.

Clinical Significance

• Headache is the 3rd most common ED presentation
• 85-90% are primary headaches (migraine, tension, cluster)
• 10-15% have secondary causes requiring intervention
• Misdiagnosis of dangerous causes leads to poor outcomes
• Early recognition and management reduce morbidity and mortality

Key Principles

1. High index of suspicion for dangerous causes
2. Rapid assessment minimizes delays
3. Appropriate imaging based on red flags
4. Clear referral pathways established

⚠

Red Flag Symptoms

ANY red flag present requires immediate investigation and likely admission. Do not discharge with reassurance alone.

⚡

Thunderclap Headache

Maximal intensity within 1-2 minutes; suggestive of SAH, dissection, RCVS. STAT imaging required.

🌡

Fever + Neck Stiffness

Classic meningitis triad; requires immediate LP and antibiotics within 60 minutes.

🧠

Focal Neurological Deficit

Weakness, aphasia, ataxia; indicates stroke or mass lesion. Emergency imaging.

👁

Visual Symptoms

Diplopia, visual field loss, photophobia with vision loss; suggests raised ICP or vascular event.

💭

Altered Consciousness

Confusion, disorientation, reduced LOC; emergency imaging and monitoring required.

❌

First/Worst Headache of Life

New onset severe, worst ever experienced; always investigate until proven benign.

Additional Risk Factors

• Immunocompromised patients
• Age >50 (increased risk of GCA, stroke)
• History of malignancy
• Pregnancy or postpartum period
• Anticoagulation therapy
• Recent head/neck trauma
• Sudden exertional onset

02

Initial Assessment & Clinical Evaluation

History Taking Components

Onset & Temporal Pattern

• Sudden vs gradual onset
• Progressive vs stable
• Frequency and duration
• Time of day when worst

Headache Characteristics

• Pain quality: throbbing, pressure, sharp, dull
• Severity: 0-10 scale
• Location: unilateral, bilateral, focal, diffuse
• Radiation pattern

Associated Features

• Fever, chills
• Nausea, vomiting
• Visual symptoms
• Weakness, numbness
• Confusion, behavioral changes
• Neck stiffness

Vital Signs Assessment

• Temperature: Fever suggests infection (meningitis, encephalitis)
• Blood Pressure: Hypertension may indicate emergency (ICH, eclampsia)
• Heart Rate & Rhythm: Tachycardia suggests systemic illness
• Respiratory Rate: Altered breathing suggests CNS involvement
• Oxygen Saturation: Hypoxia requires intervention

Neurological Examination (Minimum Standards)

Exam Component	What to Assess	Red Flag Finding
Level of Consciousness	Alert vs lethargic vs confused	Altered LOC or confusion
Pupils	Size, symmetry, reactivity to light	Unequal or fixed pupils
Visual Fields	Confrontation testing	Visual field defect
Motor Strength	Arm drift, leg strength (0-5 scale)	Asymmetric weakness
Cerebellar Signs	Gait, balance, coordination	Ataxia or dysmetria
Meningeal Signs	Neck stiffness, Kernig, Brudzinski	Any meningeal sign positive
Fundoscopy	Look for papilloedema	Papilloedema present

03

Diagnostic Investigations

Imaging Selection

CT Brain (Non-contrast)

First-line Imaging

Indications: All thunderclap headaches, first/worst headache, focal deficits, altered LOC, fever + meningeal signs
Timing: Within 30 minutes
Sensitivity: 95%+ for SAH in first 6 hours
Advantages: Fast, readily available, rules out hemorrhage and mass

CT Angiography (CTA)

Enhanced Vascular Imaging

Indications: SAH suspected, thunderclap with normal CT, arterial dissection suspected
Sensitivity: Excellent for aneurysm and arterial dissection
Timing: STAT if SAH suspected

MRI with MR Venogram

Advanced Imaging

Indications: Subacute/chronic progressive headache, suspected thrombosis, posterior fossa pathology
Advantages: Better tissue resolution, no radiation
Disadvantage: Slower, less accessible acutely

Lumbar Puncture (CSF Analysis)

Meningitis/Encephalitis Diagnosis

Indications: Meningitis strongly suspected, CSF pressure assessment
Timing: Within 60 minutes if bacterial meningitis
IMPORTANT: Perform CT first to rule out contraindications (mass, herniation)
Tests: Cell count, glucose, protein, culture, PCR, Gram stain

Blood Investigations

Test	Indication	What It Detects
CBC	Suspected infection	Elevated WBC suggests infection
ESR/CRP	Age >50 with headache	Inflammation (GCA, vasculitis)
Blood Cultures	Before antibiotics if sepsis	Bacteremia (meningitis)
PT/INR	If anticoagulated	Bleeding risk assessment
Virology PCR	Meningitis suspected	Viral pathogens

Investigation Decision Tree

1

Assess for Red Flags

Thunderclap, fever + neck stiffness, focal deficit, visual symptoms, altered LOC, first/worst headache?

2

If RED FLAGS present → STAT CT Brain

Complete within 30 minutes. Notify Neurology and prepare for possible ICU admission.

3

CT Normal? → Consider next step

If meningitis suspected → LP. If thunderclap → CTA. If improving → Consider discharge.

4

CT Abnormal → Treat per finding

SAH, ICH, mass, or other pathology identified. Consult appropriate specialist (Neurology, Neurosurgery).

04

Emergency Management Algorithm

1

Stabilization (First 10 minutes)

Establish IV access (two lines if severe), Oxygen (SpO₂ ≥94%), Cardiac monitor, NPO status, Quiet dark environment

2

Rapid Assessment for Red Flags

If red flags present: STAT CT/CTA, Notify Neurology, Request ICU bed. If negative: Proceed to Step 3.

3

Acute Pain Management

Paracetamol 1g IV/PO OR Ketorolac 30mg IV/IM. Avoid opioids (mask deterioration) and NSAIDs if hemorrhage suspected.

4

Supportive Care

Anti-emetics if nausea, IV fluids if dehydrated, dark/quiet room for migraine, temperature management if febrile.

5

Decision & Disposition

If imaging normal and red flags absent + pain controlled → Safe for discharge with return precautions.

Management of Specific Conditions

Suspected Subarachnoid Hemorrhage (SAH)

Immediate Actions:

• STAT CT, Neurology + Neurosurgery consult
• ICU admission, continuous neuro monitoring
• Nimodipine 60mg IV 4-hourly (vasospasm prevention)
• Target SBP <160, maintain oxygenation
• Avoid hypertension and hypoxia

Suspected Meningitis

STAT Antibiotic Therapy (Do not delay for LP)

• Ceftriaxone 2g IV 12-hourly
• Vancomycin 15-20mg/kg IV 8-12 hourly
• Ampicillin if >50 years or immunocompromised
• Dexamethasone 10mg IV with first antibiotic
• LP after CT to rule out contraindications
• ICU admission

Suspected Acute Stroke

Stroke Protocol:

• STAT CT/CTA, Neurology consult
• Activate stroke alert
• Consider thrombolysis if within therapeutic window
• ICU monitoring

05

Treatment Protocols

Primary Analgesics

Paracetamol (Acetaminophen)

1g IV or PO every 4-6 hours | Maximum 4g in 24 hours

Note: First-line, safe in pregnancy, avoid in severe hepatic disease

Ketorolac (NSAID)

30mg IV/IM single dose, then 10mg PO TID

Contraindications: Renal disease, GI bleed, pregnancy, hemorrhage suspected

Indomethacin

25-50mg PO/rectal TID for 7 days

Best for: Tension headache, cluster headache prophylaxis

Anti-emetics

Prochlorperazine

10mg IV/IM/PO every 6-8 hours

Ondansetron

4-8mg IV/PO every 8 hours

Migraine-Specific Therapy

Sumatriptan (Triptan)

6mg subcutaneous OR 50mg oral (only if migraine confirmed)

Propranolol (Prophylaxis)

40-80mg oral daily-BID (for recurrent migraine >2/month)

Amitriptyline (Prophylaxis)

10-75mg oral at bedtime (for chronic migraine)

Supportive Care Measures

• ✓ Dark, quiet room (minimizes migraine triggers)
• ✓ Head elevation 30 degrees
• ✓ Oxygen if SpO₂ <94%
• ✓ IV fluids if dehydrated
• ✓ Temperature control if febrile
• ✓ Position changes for comfort

Medications to AVOID

Do Not Use If:

• Opioids: Mask neurological deterioration, risk of dependence
• NSAIDs: Suspected hemorrhage (SAH, ICH, anticoagulated patient)
• Excess Analgesics: Risk of medication overuse headache (>10 days/month)

06

Admission, Discharge & Referral

ADMISSION CRITERIA

• Any red flag symptom present
• First/worst headache of life
• Progressive or unrelenting pain
• Fever + meningeal signs
• Focal neurological deficit
• Altered consciousness
• Abnormal imaging findings
• Failed outpatient management

SAFE DISCHARGE (ALL required)

• Complete neuro exam normal
• No red flag symptoms
• Imaging normal (if done)
• Pain controlled/improving
• Reliable patient with support
• Clear follow-up arranged
• Return precautions explained

NEUROLOGY REFERRAL

• Suspected SAH/ICH/stroke
• Space-occupying lesion
• Recurrent/chronic headache
• Migraine requiring prophylaxis
• Atypical features
• Undiagnosed after workup

Return Precautions for Discharged Patients

Advise Patient to Return Immediately If:

• Headache progressively worsens
• New weakness, numbness, or difficulty speaking
• Vision changes or eye pain
• Neck stiffness or fever develops
• Confusion or altered consciousness
• Seizures occur
• Headache different in character from usual

Documentation Requirements

Element	What to Document
Vital Signs	Temperature, BP, HR, RR, SpO₂ with time recorded
Pain Severity	0-10 scale, location, character, onset
Red Flag Assessment	Specific findings or explicitly "no red flags identified"
Neurological Exam	LOC, pupils, motor, cerebellar signs, meningeal signs
Imaging	Type, findings, time completed
Medications	Drug, dose, route, time, response
Final Diagnosis	Primary vs secondary, specific type
Disposition	Admitted to (ward/ICU), discharged, or referred

📚

References & Guidelines

1. Hainer BL, Matheson EM. Approach to acute headache in adults. Am Fam Physician. 2013;87(10):682-687.
2. Indian Council of Medical Research (ICMR). Standard Treatment Workflow for Management of Headache. Department of Health Research, Ministry of Health and Family Welfare, Government of India. 2024.
3. South Eastern Sydney Local Health District. Assessment and Management of Headaches in Adults within SESLHD Emergency Departments. SESLHDGL/060. January 2025.
4. Edvardsson B, Edvinsson L. Principles in evaluation of headache. Neurol Clin. 2019;37(4):745-760.
5. Orr SL, et al. 2025 Guideline Update to Acute Treatment of Migraine for Adults in the Emergency Department. American Headache Society. 2025.
6. International Headache Society. International Classification of Headache Disorders (ICHD-3). 3rd ed. 2024.

Disclaimer

This protocol is a clinical guideline based on best practices and available evidence. Individual clinical judgment and patient-specific factors must guide treatment decisions. Any deviations from this protocol should be documented with clinical reasoning.

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Protocol Version 1.0 | Effective Date: June 2026 | Next Review: June 2027

Swaraj Hospital & Research Institute, Bolangir | Department of Emergency Medicine & Neurology

This protocol is a guide for best practice. Distribution: Emergency Department, Neurology, Nursing Staff, Medical Library, Staff Portal