All posts by TheTraumaPro

Treating Headache After TBI

Most patients with mild traumatic brain injury (TBI) recover quickly and have few sequelae. Headache is common during the first few hours or days. But some patients experience significant and sometimes unrelenting headaches after their injury. How should we treat them? Are they the same as other common headaches?

There are several common types of headaches that are not related to brain injury, but many of these can begin after TBI. These include tension headaches from muscle tension or spasm, cervicogenic headaches from strains, sprains or more significant injury to the neck and cervical spine, musculoskeletal headaches from pain in bone or muscle in the head or neck, and headaches related to the TMJ and jaw.

But many patients experience significant headaches without any of these factors. Why? Sometimes it is due to blood in or around the brain, irritating the meninges. But often, there is nothing that we can detect using our current diagnostic technology. However, even if we can’t find a reason, the headache is very real and very concerning to the patient. 

I’ve seen practitioners treat post-TBI headaches with a variety of drugs ranging from acetominophen and NSAIDs to anti-seizure and psychotropic drugs. Unfortunately, there is little literature support for any of them. A review article published in 2012 found only one article with Class II data that showed no lasting effect from manipulation therapy. 

So what do we do? Here is an algorithm suggested by the review article:

  • Consider a workup to rule out intracranial pathology as a source of the headache
  • Categorize the headache. If it is one of the non-TBI types listed above, treat appropriately.
  • If the headache severely limits function, consider time-release opioids
  • For milder headache, consider adetominophen or NSAIDs
  • Treat any comorbidities that may contribute to headache
  • If the headache has migraine-type properties, treat as such
  • If the headache is associated with cervical spine pain, mobilize the neck as appropriate

Bottom line: There is very little guidance for treatment of headache purely associated with TBI. Time-honored drugs like opioids for severe pain and acetominophen and NSAIDs for mild to moderate pain help, but generally do not entirely relieve the pain. Only tincture of time will make things better. And it’s probably best to stay away from prescription drugs other than opioids recommended for the pain. They have not been shown to work, and there are plenty of side effects to worry about.

Related post:

  • Prescription drugs and side effects

Reference: Systematic review of interventions for post-traumatic headache. PM&R. 4(2):129-140, 2012.

Field Amputation: The Final Word

I’ve spent the last week writing about the nuances of field amputation. I’ve heard from a number of readers about who does it at their facility. Keep in mind that this is a very rarely performed procedure. The few times I’ve been called out in the field, the prehospital providers have conveniently managed to extricate the patient just prior to my arrival. Whew!

Various providers (prehospital, emergency physician, surgeon) may provide this “service” at various places around the world. In the US, it is usually a physician, and typically a surgeon. In my opinion, anyone can be trained to do a basic field amputation.

Much depends on local policies and procedures, training, and availability. Prehospital providers are on scene in most cases, so it makes sense that they could do a field amputation with appropriate training. Emergency physicians have more experience with airway management, sedation, and anesthesia, and can thus add value to the process. 

But again, in my opinion, a trauma surgeon is the best choice for performing this procedure. They have the technical skills, and are usually facile with anesthesia and sedation. But they also have a deep understanding of the anatomy involved, and the eventual reconstruction process. This allows them to tailor the amputation to optimize the eventual recovery from this operation. The surgeon does not necessarily have to resort to a guillotine type amputation. And they are better versed in performing amputations that involve the upper extremity, as well as more proximal amputations (shoulder, upper thigh). And if unexpected bleeding occurs that cannot be controlled by a tourniquet, they know what to do.

The only downside to using a physician is availability. There will always be extra time involved in getting them to the scene since they are typically hospital-based, whereas the prehospital providers are already present and are used to working in an austere environment. 

Bottom line: There is no cookbook for developing a field amputation policy and procedure. Look at your local resources, and the logistics imposed by environment, traffic, your hospital, and other factorss. Then look at my previous posts and figure out what works for you. And finally, make the process as simple as possible. Due to the very rare need for field amputation, you will need to periodically review the process and location of your packs so people don’t forget.

Field Amputation for Trauma, Part 4

We’ve covered all the prep for field amputation over the past 3 days. Now, it’s time to do it. What equipment is needed? There are two principles: figure it all out in advance, and keep it simple.

It is crucial that the trauma program design and assemble equipment and drug packs in advance, otherwise critical equipment may not make it to the field. The pack needs to be conveniently located, have fresh instruments and batteries for the equipment, and should have essential anesthetics included. A sample list is available here, and I encourage you to modify it to suit your needs.

Paralytics, sedatives and analgesics are essential. I prefer vecuronium, midazolam and fentanyl, but there are many other choices. I would discourage the use of propofol because it is difficult to titrate outside the hospital and may contribute to hypotension.

The patient must be intubated prior to starting the procedure. This airway may be difficult due to patient positioning, so be prepared to perform a surgical airway. Finally, don’t assume that your patient will be nicely positioned supine. Rescue workers may need to support the patient (or you) if he or she is in an awkward position.

Finally, don’t assume that you will accompany the patient (and possibly their limb) back to the hospital. Based on the specific aircraft used, there may not be room available. You may return by ground transportation or another aircraft. That’s why your backup plan needs to be well thought out!

Resources:

Field Amputation for Trauma, Part 3

We’ve discussed the numbers behind and indications for performing field amputation for trauma. Now it’s time to look at the logistics. There are two main considerations here: getting to the scene, and staying safe. The following presumes that the procedure will be done by a physician who is based at the trauma center. It will be different if performed by other trauma professionals.

Getting there includes an obvious problem: what happens when the physician leaves the hospital? During the daytime, others may be available, although they may have other responsibilities to keep them busy. At night it becomes more of an issue, as they may be the only surgeon or ED physician available for the hospital. And once involved in the field amputation process, they may be unavailable for hours.

The easiest solution is to utilize the backup trauma surgeon. All Level I and II centers must have one. There are two possibilities here: the in-house trauma surgeon leaves and the backup proceeds to the hospital for coverage (if in-house), or the backup surgeon is transported leaving the on-call surgeon to manage as usual.

The choice is up to the trauma center, but this is an issue that needs to be thought out in advance. The best solution takes geography into consideration. Since most transports to the scene will be made by helicopter, it is easier to use the trauma center’s helipad to pick up the on-call surgeon. If an in-house surgeon is not used, consideration must be given to the nearest safe landing zone and this may mean that an out-of-house surgeon would have to travel to the hospital for pick-up.

Once on scene, the physician must ascertain that the area of the incident is safe. This is important for the well being of the patient, the rescue crews and the patient. If the scene cannot be made safe, it is not possible to render care, even if the patient is in grave trouble.

Bottom line: Each trauma program must think through these details in advance and develop a policy for who goes to the scene and how they get there. And safety for all is of paramount importance.

Tomorrow I’ll discuss equipment and drugs needed for this procedure.

Field Amputation for Trauma, Part 2

Yesterday I discussed how uncommon field amputation is, despite all the potential drama. Today, I’ll review the indications for performing it.

There are basically four indications, two absolute and two relative:

  • Absolute #1: entrapped extremity with a lengthy extrication and a physiologically impaired patient who does not respond to fluids. In this case, there is occult blood loss into other areas that is killing your patient and they need to get out quickly for definitive management.
  • Absolute #2: entrapped extremity with a lengthy extrication and an unstable physical environment. Examples include entrapment in a structurally damaged building or a vehicle in danger of falling.
  • Relative #1: entrapped extremity with a lengthy extrication in a patient who was initially hypotensive but responded to IV fluids. It is possible to wait for additional extrication efforts, but vital signs must be monitored closely. At the first sign of recurrent hypotension, it’s time to amputate.
  • Relative #2: entrapped extremity and physiologically normal, but extrication may take many hours or may be impossible. Once again, there is time to wait and let rescue workers continue their efforts. However, the more time that passes, the less likely the extremity will ultimately be functional.

Obviously a lot of thought and judgment goes into making the decision amputate. It is helpful to have another physician to discuss the facts with, but as the treating trauma professional, the ultimate decision is yours.

Monday, I’ll talk about the logistics of getting to the scene of the potential field amputation.