# New EMT Unsure About Recent "Headache" Call



## wxemt (Feb 29, 2016)

Ok, so let me first start by saying the I am without a doubt still a fairly green EMT and in no way shape or form claim to know it all.  I recently ran a call with an older member and am a little unsure about why the call was ran the way it was.  Not saying it was wrong, just looking for some insight as I haven't been able to get much out of the AIC of the call.

Got called for a male in his early teens.  Hit his head about 8 hours prior while skiing.  My partner (AIC of the call, I was driving), started getting information from mom, while I got vitals and physical assessment.  Vitals all good ... 110/80, pulse 100, SP02 98% on room air.  Complains gradually developing of a 6/10 headache since hitting the back of his head during the fall.  Started about 2 hours after the accident.  Pupils PEARL, good PMS, AO, and no DCAP-BTLS where he whacked his head earlier.  He states no loss of consciousness and mom agrees.  Vomited earlier in the evening for no apparent reason\no recent illness and still nauseated.  I immediately started to suspect a possible concussion, even if just a mild one, given MOI, vomiting, and headache.

Mom doesn't want him to be transported, unless we felt it necessary.  To my surprise my partner stated that she didn't think it was necessary (even via POV).  Mom then asked what to do for headache and suggested Aspirin.  My partner, to my astonishment, agreed that Aspirin would be good to relieve headache.

Someone please tell where I am wrong on right in my thought process here.  Poor kid has the signs and MOI for a concussion and he doesn't need to checked out?  And then the Asprin.  Wouldn't taking something that inhibits platelet aggregation be contraindicated in possible TBI?  Even if it is just a very mild one (which we can't even confirm it is in the field).


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## Gurby (Feb 29, 2016)

Why do you think aspirin might be a bad idea here?


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## wxemt (Feb 29, 2016)

Possible bleeding/bruising of the brain.  Wouldn't aspirin possibly aggrevate that situation?


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## joshrunkle35 (Feb 29, 2016)

Early teens. Pulse 100. Did you retake it later? Is that normal for that person. Caused by anxiety? Just because it is WNL doesn't mean that it's normal...or it might be entirely normal for that patient, or the anxiety level of anyone who has a bunch of EMS suddenly in their home. I would've retaken pulse 10-15 min later. 

I would be perfectly fine recommending aspirin or anything similar. Ibuprofen, Aleve...

What was the kid's intake for the last 24 hours. Early teens: is it possible that he stayed up all night with friends eating pizza and mixing various types of sodas, skipped breakfast, ate a huge lunch and then went skiing and now has a headache? I would vomit without a head injury if I did that to my body. In the other hand, it could be a head injury, however, there don't appear to be any abnormal symptoms other than the vomiting and pulse. I'd re check pulse advise over the counter pain meds and recommend they call again if his condition changes.


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## Gurby (Feb 29, 2016)

I could be wrong, but aspirin seems real bad here?  Our main concern is that at this point we can't tell if this is dehydration/etc, a concussion, or a developing intracranial hemorrhage. 

Personally I would tell them to try not to take any medications for the headache... If it continues to get worse and gets to be unbearable, he should really go to the ED anyways.  Most (all?) of the NSAIDs have anti-platelet effects to some extent (Naproxen/Aleve is shown to have effects similar to aspirin, Ibuprofen maybe less so).  They could try acetaminophen but I would really recommend not. 

I would like to ask some other questions... Was he wearing a helmet?  What was mechanism (head vs ground from standing, head vs ground off of a jump, head vs tree, etc)?  Where is the headache located?  Is it continuing to get worse, what does it feel like?  Any blurry vision, double vision, photophobia, etc?

If the headache is bad enough that they're calling an ambulance, I'm going to recommend that they go to the ED.  I really don't think he needs an ambulance to transport him to the ED, but I push a little bit to try to get him to come with us just for the sake of CYA.  It looks pretty bad if he has a seizure 6 hours from now, Mom takes him to the ED and tells them "oh the nice ambulance drivers told us to just take some aspirin and wait to see if it got worse".


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## JohnTheEMT (Feb 29, 2016)

I would not advise the patient to take any type of medication. If the patient is complaining of a headache and vomiting it can be he has a head injury. Did you asked how he fell or what did he fell on to ?  I would of had mom take her son to the ER to get checked out. I ran numerous amount of calls for the exact same c/c for fighting or falling, some of those patients went to ICU because they had a brain bleed and some just had the normal headache .


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## wxemt (Feb 29, 2016)

Negative on the helmet.  He fell\"wiped out" on skis and hit the back of his head on the snow.  Headache was continuing to get worse.  Started about 2 hours after the fall.


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## Flying (Feb 29, 2016)

No aspirin, are you guys nuts!


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## Flying (Feb 29, 2016)

Talk about misused commas. To clarify, Aspirin is not justified in this situation (post-head trauma).
I believe that Gurby has the ideal recommendation. It's best to suspect an ongoing TBI/intracranial hemorrhage unless ruled out by the ED. Headache and recent vomiting ought to be examined given how unspecific they are as symptoms.

Pushing for a trip to the ED by POV at the least.


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## RScott (Feb 29, 2016)

The same thing happened to my daughter--bumped her head skiing and vomited a couple of hours later.  We called the ED and they told us in no uncertain terms to bring her in.  She was no longer in pain by the time we got to the ED.  The ED physician still recommended some scans because the combination of head trauma and vomiting.  She was clear.

I would think that at least a POV trip to the ED would have been warranted in your case.


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## CALEMT (Feb 29, 2016)

Headache and recent vomiting after a head injury are enough for me to push a trip to the ED. One additional thing that I would've asked is if your patient has had a history of concussion's or playing contact sports. Because chances of him having a concussion are far more likely if he's had one in the past. Also to mimic everyone else Aspirin is a bad idea in this situation.


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## Jim37F (Feb 29, 2016)

Without being there, it almost reads like your partner was treating this as a simple headache by itself, like they missed the recent head trauma part of the assessment. Since there was no transport I'm assuming there's no way to follow through with what happened to the patient afterwards  (e.g. did they eventually end up going to the hospital anyway and get checked out?) Hopefully QA/QI will see this..


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## Tigger (Mar 1, 2016)

This sounds like a typical concussion, which is not something that necessarily needs to be transported by ambulance. Concussions often have "worsening" symptoms that may develop over hours or days. Not something that necessarily needs to be evaluate at an ED if you have a half decent PCP, though it would be important to explain what sort of symptoms should precipitate a visit to an ED. Aspirin is maybe not the best idea, when I worked with hockey players we would use tylenol.


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## SpecialK (Mar 1, 2016)

The correct term for what he may have is *"brain injury".  *

Based on the information presented here I would recommend self care at home and a period of careful observation by mum.  He should see a doctor (but not necesarily in an ED) if his symptoms get worse.  

For analgesia I'd recommend he take regular paracetamol and ibuprofen following the instructions on the packet.


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## Akulahawk (Mar 1, 2016)

To me, the symptoms look primarily like that of a concussion. I'd be very wary about giving any aspirin or ibuprofen (or any NSAID for that matter) for a couple of days following this event without having a CT scan to show me that there's no bleed. Nausea and vomiting are very common in the post-concussion period. The fact that there was only one episode of vomiting early on is a bit encouraging. I would expect there would be some lingering nausea, a bit of a "fog" (even if alert & oriented) and the like. If treatment of the headache is necessary, I'd use Acetaminophen (paracetamol). 

While I do have some experience evaluating closed head injuries and concussions in particular, there have been some athletes in my personal experience that make me quite wary about them. Several of the athletes I have evaluated over the years have suffered rather severe concussions and signs/symptoms included headache, tinnitus, nausea, vomiting, blurry vision, positive Romberg, positive ataxia findings, partial loss of vision (in on case), inability to spell "world" backwards or do serial 7's from 100 past 2-3 steps, and quite often amnesia (retrograde type is quite common) Fortunately none of the athletes I evaluated actually suffered a bleed.


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## Gurby (Mar 1, 2016)

From a CYA/liability point of view, as EMT's and Paramedics, I think we have to encourage them to go to the ED, at least on paper.  In EMS, our job is to get people who are potentially sick to the hospital.  It's not really our job to separate sick from not sick - that's the hospital's job (at least in the litigation-happy USA).  It's a lot easier and doesn't open you up to liability to say "you could have something wrong, you should go to the hospital", as opposed to "you're probably fine, take some tylenol and sleep it off, call me back if x symptoms occur".

I often give a speech that goes something like, "professionally, I have to recommend that you come with us to the ED.  I'm not a doctor, and it's way above my pay grade to say that this isn't potentially something more serious or life threatening.  If you just drive yourself and something happens, my butt is on the line.  On the other hand, we can't force you to do anything, and personally, realistically, if it was me.... I'd probably go to an urgent care - they'll be able to do xyz, check you out and make sure it's not something serious.  But, again, officially, I'm supposed to tell you that you're going to die and need to come with us right away.  But it's really up to you.

I give them my honest opinion, but then remind them that I'm not a doctor and my opinion is worth pretty much what they paid for it (which at this point is nothing...).


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## Tigger (Mar 1, 2016)

Akulahawk said:


> To me, the symptoms look primarily like that of a concussion. I'd be very wary about giving any aspirin or ibuprofen (or any NSAID for that matter) for a couple of days following this event without having a CT scan to show me that there's no bleed. Nausea and vomiting are very common in the post-concussion period. The fact that there was only one episode of vomiting early on is a bit encouraging. I would expect there would be some lingering nausea, a bit of a "fog" (even if alert & oriented) and the like. If treatment of the headache is necessary, I'd use Acetaminophen (paracetamol).
> 
> While I do have some experience evaluating closed head injuries and concussions in particular, there have been some athletes in my personal experience that make me quite wary about them. Several of the athletes I have evaluated over the years have suffered rather severe concussions and signs/symptoms included headache, tinnitus, nausea, vomiting, blurry vision, positive Romberg, positive ataxia findings, partial loss of vision (in on case), inability to spell "world" backwards or do serial 7's from 100 past 2-3 steps, and quite often amnesia (retrograde type is quite common) Fortunately none of the athletes I evaluated actually suffered a bleed.





Akulahawk said:


> To me, the symptoms look primarily like that of a concussion. I'd be very wary about giving any aspirin or ibuprofen (or any NSAID for that matter) for a couple of days following this event without having a CT scan to show me that there's no bleed. Nausea and vomiting are very common in the post-concussion period. The fact that there was only one episode of vomiting early on is a bit encouraging. I would expect there would be some lingering nausea, a bit of a "fog" (even if alert & oriented) and the like. If treatment of the headache is necessary, I'd use Acetaminophen (paracetamol).
> 
> While I do have some experience evaluating closed head injuries and concussions in particular, there have been some athletes in my personal experience that make me quite wary about them. Several of the athletes I have evaluated over the years have suffered rather severe concussions and signs/symptoms included headache, tinnitus, nausea, vomiting, blurry vision, positive Romberg, positive ataxia findings, partial loss of vision (in on case), inability to spell "world" backwards or do serial 7's from 100 past 2-3 steps, and quite often amnesia (retrograde type is quite common) Fortunately none of the athletes I evaluated actually suffered a bleed.


Incidentally as far as I am aware there is no correlation between a concussion symptom score and a bleed. Indeed even vomiting and vision disturbances are not predictors of the "severity" of a concussion.


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## EpiEMS (Mar 1, 2016)

Tigger said:


> Incidentally as far as I am aware there is no correlation between a concussion symptom score and a bleed. Indeed even vomiting and vision disturbances are not predictors of the "severity" of a concussion.



Considering that there is a non-zero chance of a brain injury of some kind, I'd be pushing to transport (or at the very least, a POV transport). My medical direction would likely mandate an ALS provider attend, no less.

If that were my friend or family member, I'd drive them to the ED myself before I called 911, but the ED is definitely a good idea. PCPs don't have imaging, after all.


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## ERDoc (Mar 2, 2016)

If you look at the PECARN study, this kid fits into the CT vs Observation arm with a 0.9% chance of having a clinically important TBI.  Given the fact that he has continuing symptoms this far out, I would CT scan him.  It's most likely a concussion, which doesn't need an ER.  I would never recommend aspirin for kids.  I'd go with tylenol until there is a negative head CT.


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## NUEMT (Mar 16, 2016)

Gurby said:


> I could be wrong, but aspirin seems real bad here?  Our main concern is that at this point we can't tell if this is dehydration/etc, a concussion, or a developing intracranial hemorrhage.
> 
> Personally I would tell them to try not to take any medications for the headache... If it continues to get worse and gets to be unbearable, he should really go to the ED anyways.  Most (all?) of the NSAIDs have anti-platelet effects to some extent (Naproxen/Aleve is shown to have effects similar to aspirin, Ibuprofen maybe less so).  They could try acetaminophen but I would really recommend not.
> 
> ...




Gurby has hit this on the head.


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## NUEMT (Mar 16, 2016)

joshrunkle35 said:


> Early teens. Pulse 100. Did you retake it later? Is that normal for that person. Caused by anxiety? Just because it is WNL doesn't mean that it's normal...or it might be entirely normal for that patient, or the anxiety level of anyone who has a bunch of EMS suddenly in their home. I would've retaken pulse 10-15 min later.
> 
> I would be perfectly fine recommending aspirin or anything similar. Ibuprofen, Aleve...
> 
> What was the kid's intake for the last 24 hours. Early teens: is it possible that he stayed up all night with friends eating pizza and mixing various types of sodas, skipped breakfast, ate a huge lunch and then went skiing and now has a headache? I would vomit without a head injury if I did that to my body. In the other hand, it could be a head injury, however, there don't appear to be any abnormal symptoms other than the vomiting and pulse. I'd re check pulse advise over the counter pain meds and recommend they call again if his condition changes.




That is a lot to assume on intake.  Who cares what he ate?   He fell and hit his unprotected noggin on snow hard enough to ski on.  He then vomited.  They felt it necessary to call.  Points to subacute/developing symptoms to me.  No aspirin.  No advice regarding what to take.  I would never advise not taking in POV.  You have basically given that parent cause not to treat. And based on what...our mobile CT?  lol.


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## SpecialK (Mar 16, 2016)

NUEMT said:


> He fell and hit his unprotected noggin on snow hard enough to ski on.  He then vomited.  They felt it necessary to call.  Points to subacute/developing symptoms to me.  No aspirin.  No advice regarding what to take.  I would never advise not taking in POV.  You have basically given that parent cause not to treat. And based on what...our mobile CT?  lol.



It is eight hours post injury and he has no clinically obvious signs of expanding cerebral haematoma or severe traumatic brain injury.  What he does have a history, signs and symptoms consistent with minor traumatic brain injury (concussion).  

What he needs is observation.  In reality, he is probably better to be observed at home where mum can keep a close eye on him than in a busy emergency department where he is going to be checked by the nurse once an hour.

As for not treating him, not all patients are going to require treatment.  What they do require is a careful history taken and assessment performed, a reasonable diagnosis made (or in the absence of ability to make a clear diagnosis, a reasonable clinical impression formed) and a reasonable recommendation regarding referral and transport conveyed noting not all patients will require a recommendation for immediate referral elsewhere and if they do, not all will require ambulance transport.  

I would be quite happy to give him some oral paracetamol and ibuprofen for his pain, oral ondansetron for his nausea, give his mum advice regarding signs and symptoms to watch for and what to do if he doesn't get better or is they become more concerned.


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## COmedic17 (Mar 22, 2016)

NUEMT said:


> That is a lot to assume on intake.  Who cares what he ate?   He fell and hit his unprotected noggin on snow hard enough to ski on.  He then vomited.  They felt it necessary to call.  Points to subacute/developing symptoms to me.  No aspirin.  No advice regarding what to take.  I would never advise not taking in POV.  You have basically given that parent cause not to treat. And based on what...our mobile CT?  lol.


8 hours after the fact leads me to believe it's not a major bleed. Vomiting is also a sign of a concussion. There is literally nothing a ambulance is going to do. IF patient is stable AND aox4, I don't see a problem with mom transporting to the hospital or making the decision to monitor the patient herself.


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## EMS2PA (Mar 22, 2016)

ERDoc said:


> If you look at the PECARN study, this kid fits into the CT vs Observation arm with a 0.9% chance of having a clinically important TBI.  Given the fact that he has continuing symptoms this far out, I would CT scan him.  It's most likely a concussion, which doesn't need an ER.  I would never recommend aspirin for kids.  I'd go with tylenol until there is a negative head CT.



This is exactly what I was going to say. In my ED, if this patient came in, he'd buy himself a CT. The one thing we cannot rule out at this point, even though unlikely, is a subarachnoid hemorrhage. I've unfortunately seen the waxing and waning mental status present very subtlely , and family only really picked up on it after repeat questioning. 
This kid likely has a concussion, but in my EMS days I had no clue how to do a full neurological exam (and I'll admit, even as an ED provider, my neurological exam is still very basic, though much more thorough than when I was in EMS). While aspirin and NSAIDs are ok in a concussion, kids should not be given aspirin, and I'd be leery recommending NSAIDs if there was any concern for a bleed. In general, patients with a head injury that I send home, I recommend acetaminophen for the first 24-48h then NSAIDs after that. If they are having persistent headaches they need follow up.


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## Gurby (Mar 22, 2016)

EMS2PA said:


> This kid likely has a concussion, but in my EMS days I had no clue how to do a full neurological exam (and I'll admit, even as an ED provider, my neurological exam is still very basic, though much more thorough than when I was in EMS).



This is why I'm wary of us, as EMS providers, "recommending" anything but a trip to the hospital.  Our training focuses entirely on how to keep people alive in the short-term and get them quickly to definitive care.  When it comes to more subtle things like this, we don't know what we don't know.  I'll always give patients my honest opinion if they are thinking about refusing transport, but I always preface with "professionally, I have to recommend that you let us take you to the hospital."

This might not apply in other countries where the barrier to entry is a 4-year degree, and/or where you're less likely to get sued into oblivion for making a mistake.


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## conemt (Mar 22, 2016)

Gurby said:


> I'll always give patients my honest opinion if they are thinking about refusing transport, but I always preface with "professionally, I have to recommend that you let us take you to the hospital.



I was taught this same way in my EMT class. If a patient goes AMA, before we leave, we have to tell them what could possibly go wrong without listening to our advice.


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## Tigger (Mar 23, 2016)

Gurby said:


> This is why I'm wary of us, as EMS providers, "recommending" anything but a trip to the hospital.  Our training focuses entirely on how to keep people alive in the short-term and get them quickly to definitive care.  When it comes to more subtle things like this, we don't know what we don't know.  I'll always give patients my honest opinion if they are thinking about refusing transport, but I always preface with "professionally, I have to recommend that you let us take you to the hospital."
> 
> This might not apply in other countries where the barrier to entry is a 4-year degree, *and/or where you're less likely to get sued into oblivion for making a mistake.*


There's the issue.

I figure that our taxpayers support us and call us when they don't know what to do. We owe it to them to be honest with them and not just bully people into transport because we're afraid of liability.


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