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tions hospitalization and immediate treatment of atrial fibrillation are required Urgent cardioversion is usually indicated in patients with shock or severe hypotension, pulmonary edema, or ongoing myocardial infarction or ischemia Although there exists a potential risk of thromboembolism with cardioversion if atrial fibrillation has been present for more than 48 hours, in hemodynamically unstable patients the need for immediate rate control outweighs that risk Electrical cardioversion is usually preferred in unstable patients An initial shock with 100 200 J is administered in synchrony with the R wave If sinus rhythm is not restored, an additional attempt with 360 J is indicated If this fails, cardioversion may be successful after loading with intravenous ibutilide (1 mg over 10 minutes, repeated in 10 minutes if necessary) or intravenous procainamide (500 1000 mg administered at a rate of 20 mg/min with careful monitoring of blood pressure) In more stable patients or those at particularly high risk for embolism (ie, underlying mitral stenosis, a history of prior embolism, or severe heart failure), a strategy of rate control is appropriate This is also true when the conditions that precipitated atrial fibrillation are likely to persist (such as following cardiac or noncardiac surgery, respiratory failure, or pericarditis) and when these conditions might resolve spontaneously over a period of hours to days (such as alcohol-induced atrial fibrillation, electrolyte or fluid imbalances, excessive exposure to theophylline or sympathomimetic agents, or some of the same previously cited conditions) The choice of agent is guided by the hemodynamic status of the patient, associated conditions, and the urgency of achieving rate control Although both hypotension and heart failure may improve when the ventricular rate is slowed, calcium channel blockers and blockers may themselves precipitate hemodynamic deterioration Digoxin is less risky, but even when used aggressively (05 mg intravenously over 30 minutes, followed by increments of 025 mg every 1 2 hours to a total dose of 1 15 mg over 24 hours in patients not previously receiving this agent), rate control is rather slow and may be inadequate, particularly in patients with sympathetic activation In the setting of myocardial infarction or ischemia, blockers are the preferred agent The most frequently used agents are either metoprolol (administered as a 5 mg intravenous bolus, repeated twice at intervals of 5 minutes and then given as needed by repeat boluses or orally at total daily doses of 50 400 mg) or, in very unstable patients, esmolol (05 mg/kg intravenously, repeated if necessary, followed by a titrated infusion of 005 02 mg/kg/min) If hypertension is present or -blockers are contraindicated, calcium channel blockers are immediately effective Diltiazem (20 mg bolus, repeated after 15 minutes if necessary, followed by a maintenance infusion of 5 15 mg/h) is the preferred calcium blocker if hypotension or LV dysfunction is present Otherwise, verapamil (5 10 mg intravenously over 2 3 minutes, repeated after 30 minutes if necessary) may be used Amiodarone, even when administered intravenously, has a relatively slow onset but is often a useful adjunct when rate control with the previously cited agents is incomplete or contraindicated or when cardioversion is planned in the near future However, amiodarone.

many types of intracranial masses (notable exceptions include lymphoma and toxoplasmosis in HIV-positive patients, herpes simplex encephalitis, and brain abscess) When appropriate, a contrast study can often be ordered to follow a normal noncontrast study A normal neuroimaging study does not sufficiently exclude subarachnoid hemorrhage and should be followed by lumbar puncture In patients for whom there is a high level of suspicion for subarachnoid hemorrhage or aneurysm, a normal CT and lumbar puncture should be followed by angiography within the next few days (provided the patient is medically stable) Lumbar puncture is also indicated to exclude infectious causes of acute headache, particularly in patients with fever or meningeal signs Cerebrospinal fluid tests should routinely include Gram stain, white blood cell count with differential, red blood cell count, glucose, total protein, and bacterial culture In appropriate patients, also consider testing cerebrospinal fluid for VDRL (syphilis), cryptococcal antigen (HIV-positive patients), acid-fast bacillus stain and culture, and complement fixation and culture for coccidioidomycosis Storage of an extra tube with 5 mL of cerebrospinal fluid is also prudent for conducting unanticipated tests in the immediate future Consultation with infectious disease experts regarding local availability of newer polymerase chain reaction tests for specific infectious pathogens (eg, herpes simplex 2) should also be considered in patients with evidence of central nervous system infection but no identifiable pathogen In addition to neuroimaging and lumbar puncture, additional diagnostic tests for exclusion of life-threatening causes of acute headache include erythrocyte sedimentation rate (temporal arteritis; endocarditis), urinalysis (malignant hypertension; preeclampsia), and sinus CT or x-ray (bacterial sinusitis, independently or as a cause of venous sinus thrombosis)

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Table 2 8 Summary likelihood ratios (LRs) for individual clinical features associated with migraine diagnosis

Clinical Feature Nausea Photophobia Phonophobia Exacerbation by physical activity LR + (95% CI) 19 (15 25) 58 (51 66) 52 (45 59) 37 (34 40) LR - (95% CI) 019 (018 020) 024 (023 026) 038 (036 040) 024 (023 026)

pattern involving scintillating scotoma followed by unilateral headache, photophobia, and nausea and vomiting (Table 2 8) It is evident that the presence of three or more of these features can establish the diagnosis of migraine (in the absence of other clinical features that warrant neuroimaging studies), and the presence of none or one of these features (provided it is not nausea) can help to rule out migraine

VBAK-LANDTX VBAK-STCEG_l VBKD-PERFK VBKD-ABSSC VBKD-BSTKD VBAK-KVGR1 through 5 Item Data VBAP-PSTYV RV45A-KWMENG VBAP-MATNR VBAP-MATWA VBAP-CHARG VBAP-PMATN VBAP-PRODH VBAP-MATKL VBAP-WERKS VBAP-VSTEL VBAP-ROUTE VBAP-LPRIO VBAP-KDMAT VBAP-MVGR1 through to 5 VBAP-POSNR Schedule Line VBEP-POSNR VBEP-ETENR VBEP-ETTYP RV45A-ETDAT VBEP-WMENG VBEP-BMENG VBEP-MBDAT VBEP-LDDAT VBEP-WADAT VBEP-TDDAT VBEP-VSTEl VBEP-BWART

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