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View Full Version : hmmmm, narcotics and a head injury



quicklime
04-08-2011, 08:45 PM
Say a guy has had a head injury, like a bottle over the head, and also a serious abdominal injury that involved some surgery and removal of a kidney.

He's in rough shape, all cut up, in the hospital. But he's also had this head injury, and been too out to test for severity.

Would they load him with narcotics, or is is a case of "sorry, suffer, dude" because of the worries about CNS depression? I know it would be a concern outside the hospital, but since he's in a bed and being monitored, would he get narcotics, or not?

Thanks,
Quick

sheadakota
04-08-2011, 09:13 PM
Well, he's going to have some CNS depression from the anesthesia adminstered during surgery, so that would be factored in while rating his responses. But a bottle over the head- hmm. I would say it depends on how neurolgical he was on admission and what the cat scan of his head shows.

If he has a bleed into his brain, then no he would not get pain meds. If he has a concussion than they would most likely get something for pain.

Basically if he is with it enough to complain of pain and is answering orientation questions correctly combined with no serious neuro s/s. he is with it enough to get pain meds-

The S/S I am talking about would be can he state his name, the date and another current question that everyone should know - most commonly- who is the president- or what month is this, what year- we will let day slide. His puplis need to be equal and reactive to light bilaterally and he needs to follow simple commands such as - open your eyes, give me a thumbs up- squeezing the hand is not acceptable as this can be a reflex.
If he consitantly passes all of these and his vital signs are all stable he gets the good stuff- The probelm is some neuro problems take 24 hours to show themselves after trauma- and most can not be seen on a monitor.

quicklime
04-08-2011, 10:59 PM
he came in unconscious from nearly bleeding out, spent a few days out (at least as written so far)....that's the problem. They can't ask, and a head injury isn't all that severe in the long run (his) but I'm not sure if they would err on the side of caution when the guy comes in unconscious with a big-assed hole in his back and a big-assed welt/cut on his head also...

sheadakota
04-08-2011, 11:29 PM
Yeah- if he is unconscious then nope no pain meds- not until he wakes up and starts asking for some- there are some non-narcotic meds they might give him though for perceived pain one would be the NSAID (non steroidal anti-inflamitory drug) Tordal- it can be given Iv or PO (by mouth)

ColoradoGuy
04-08-2011, 11:34 PM
Yeah- if he is unconscious then nope no pain meds- not until he wakes up and starts asking for some- there are some non-narcotic meds they might give him though for perceived pain one would be the NSAID (non steroidal anti-inflamitory drug) Tordal- it can be given Iv or PO (by mouth)

I agree. Generally, the only time we use pain killers and sedatives in unconscious head-injured patients is if they have increased pressure inside their heads and the drugs are part of a standard program to lower intracranial pressure. If we're in that mode, the patient's in a deep coma, partly drug-induced, and on a mechanical ventilator.

bellabar
04-10-2011, 05:21 AM
There is a whole philosophical debate around whether an unconscious person can feel pain, but in general, if a person is comatose they would get no pain meds. As they are waking up, they would get pain meds and narcotics might be a part of this. NSAIDs are used less commonly, because of a small but real risk of increased bleeding - neurosurgeons don't like any increased risk of bleeding if patients have a head injury.
Another option is epidural pain relief. It will give the patient pain relief to cover his abdominal wound, but keep his head relatively clear for neurological testing.

GeorgeK
04-10-2011, 09:24 PM
Toradol might seem nice, but after a nephrectomy you have to go light enough on it that it's not generally an effective method of pain control. You really want 2 healthy kidneys to handle it. Those patients usually did well on a PCA (Patient Controlled Analgesia). It has lock outs which you can tweak to lower dosages and frequencies depending upon the circumstances and you can put just about any med in them. Often that is morphine, but it could be demerol or dilaudid, whatever is best for that patient. If they are too out of it to press the button, then they don't get any. So, when you have someone in and out of consciousness, a short acting med in the PCA normally keeps them from ODing. You'd still have them on a Pulse Oximeter just in case.

Also the thing to remember about post op pain meds: The goal is not to have no pain. Pain is there for a reason, to keep you from overdoing it. Pain control is aimed at controlling the pain just well enough that the patient can do the things that they need to do to prevent other complications that would otherwise be caused by immobility due to pain, such as DVT's, Atelectasis and Pneumonia, also basic hygiene.