New EMT Unsure About Recent "Headache" Call

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wxemt

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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).
 
Why do you think aspirin might be a bad idea here?
 
Possible bleeding/bruising of the brain. Wouldn't aspirin possibly aggrevate that situation?
 
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.
 
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".
 
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 .
 
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.
 
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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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.
 
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.
 
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..
 
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.
 
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.
 
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.
 
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...).
 
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.
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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.
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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.
 
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.
Click to expand...

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.
 
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.
 
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.

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".
Click to expand...


Gurby has hit this on the head.
 
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