Narcotics or sedating meds after concussion or head injury???

[RealityCheck]

Howdy folks

 

Wanted to tap all of your brains and inquire about current practice, warnings, precautions and general issues with concussion and head injury.

 

The ERs in my locale have shown a perpetual trend to give hydrocodone, flexeril, robaxin, fioricet, zofran, phenergan and other interesting drugs to folks RIGHT after being seen for concussion or head injury. The diagnoses in the ED chart include concussion, assault, contusion to face, head, neck strain, etc ad nauseum.

 

Imaging is hit and miss. Still way too many head CTs being done - probably for the lawyers or just to get the patient out of the ED. Poor reasoning in my opinion.

 

I may be severely old and out of date but I have some fair concerns about giving someone narcotics with a fresh head injury showing signs of headache, nausea, light sensitivity, poor balance, easy confusion on computative or memory testing.

 

The providers are MD, DO, PA and NP alike.

 

Concerns are multifocal.

 

Most of the time these folks have no scheduled follow up when they leave the ER.

The clinical notes show no discussion of masking symptoms, rebound headaches or altered mental status as side effects of narcotics.

 

When I get them a few days or even a week later (insert deep sigh) then I have to work through their rebound and persistent headaches.

 

So far, nothing bad has happened.

 

So, let's talk. Is this an outdated issue and narcotics are ok or is there a problem here.

 

I am completely interested in input from my colleagues.

[True Anomaly]

I can almost see in my mind's eye JMJ's head exploding while reading this....

 

In regards to actual head injuries/concussions with no objective evidence of significant injury (ie, if a head CT is done it is clean), I don't give opioids. Now, if there is a facial fracture or a concomitant fracture elsewhere like from a multi-system trauma, then I will in that case, but likely this isn't what you're talking about. In the situation you're talking about, I'm too concerned with rebound effects of opioids (I'm separating out opioids from the rest) and yes, to a certain extent the masking effects to prescribe them in that setting, but I was just taught that it was bad medicine- and I admittedly have a huge bias against the use of opioids for any injury no matter how mild.

 

You and I both know why some people choose to prescribe opioids and why others don't. The only thing that changes that is more and more research into a clinical question like this to hopefully show how how non-beneficial they are for a post-concussion patient.

 

As an aside, it disturbs me the number of people who believe that you should NEVER have pain, no matter what- so even after a car accident with headache or contusion or they banged their arm on the wall but it's not broken but OH MY GOD THE PAIN- there's no understanding that "yes, you have been injured, and guess what? IT HURTS. I'm sorry, but if you deal with the pain for a few days then your body will likely take care of itself and you'll be back to normal soon. If not, see your PCP".

[Acebecker]

No pain meds following concussion/head trauma other than Tylenol.  Most injuries get IBU in my clinic, but not head injuries.  Only fractures or painful abscesses get narcs. 

[winterallsummer]

CT head rules (Canadian for adults, PECARN for kids) to rule out CT, or if they fail it, obtain the CT.  For bad assault, I think some narcotics may be okay when benefits outweight risks.  In general I do not give opiates for HA for any reason.  Advil and follow up.

[GetMeOuttaThisMess]

Look at it from this perspective. You see pt and even get a head CT which is read as normal. Can pt have a delayed bleed that may not become apparent for even days? Yes. So pt goes home with precautions given to family/observer since pt can't monitor self. You give narcs. During the ensuing 48-72 hours pt has been taking narcotics. Pt is now noted to be hard to arouse. What question now arises? If APAP only given for HA it removes one of the two options, thus when pt is brought back in you immediately spin the head again. Couple of decades ago pt presented one week after getting bopped on the head by a dropped drill (construction worker at our facility). Lac to scalp w/o depression of skull->closed, no LOC so sent on his way. I see him the next weekend for suture removal. Has a HA, neuro intact. Spin head and there you go. Epidural hematoma. Put in house, observed for 24 hours, respin head next day, not enlarging, and out the door he went.

 

Sorry that it isn't a scientific study based post.

 

Sent from my iPad using Tapatalk

[rev ronin]

Of the listed meds, I do give Flexeril for muscle strain, because $4 list, non-narcotic sedation, patient satisfaction, and it just might help. I did for a cop who got rear ended in a non-work-related MVA just this week, but I also put him on sick leave for a week with mild to moderate concussion symptoms. Not interested in any of my brothers in blue working the streets with impaired snap decision making.

[RealityCheck]

Thank you all for the feedback.

I have looked for solid data to take to our ER group but haven't found any studies of substantial weight or within the past ten years.

 

My lady from Tuesday called today. Chomped through the Fioricet the ER gave her and ----- her headache persists. They spun her head on Saturday - negative and no focal changes in neuro exam. Damn rebounding headache. (They gave her hydros too)

 

I put her on complete rest, dark, cool room and no stimulus -- with an 18 month old ---- try to break the cycle. I feel for her but I didn't start this fire but get to look like the bad guy now and her head hurts. I get that.

 

I just wish the ER would listen when we give them feedback.

[rev ronin]

I just wish the ER would listen when we give them feedback.

Your feedback is irrelevant.  Press-Ganey is all that matters to the suits.

[Guest Paula]

Fioricet?  I haven't prescribed that in years and thought it fell out of favor for headaches.