Strange Headache

[medic32]

I was called out to intercept with a BLS service today for a 21 y/o female with a severe headache. The pt was at a small health clinic. She was riding with her friend and developed a sudden 10/10 headache over her left eye. She was pale and sweaty, and also had brain surgery 4 yrs ago due to a rupture of a vessel in her brain. She states that she was just riding along in the car when the symptoms began and due to the severity she went to this health clinic near the highway. I established an IV, O2 monitor, VS BP 126/64, HR 102, SPO2 100% RA. She was in obvious pn and distress and very anxious and uncomfortable. Following the IV and labs I administered 5mg of morphine and also 6.25mg of phenergan(NH protocol). She had no relief with the morphine so I gave her another 5 via the IV. This was given over roughly a 15 minute transport. Upon arrival to the ED she had no real changes and her pn. She does have a Hx of anxiety and takes prozac. On the way back to my station the EMT from the ambulance I intercepted with told me that he forgot to tell me that our pt was returning from a methadone treatment. Any thoughts on my treatment or what this girl has ?

[prncssmdc]

Possible seeker? Her BP is not elevated so either her ICP (if she has a bleed) has not yet come up AND/OR she does not really show (with her BP that she is in significant pain).

I do question the morphine admin. If she is suspected to have a brain bleed, morphine supposedly has some vasodilation qualities that could cause some issues. Not real familiar with the phenergan (sp) so I don't have much to say about that.

I'd say you have to lean more toward a brain bleed since she has a previous hx of such.

Slap the EMT you intercepted with and keep us posted if you find out her dx.

[FF/EMTP1317]

I also question the morphine administration. What were her pupils like? Did she have any nausea/vomiting? I'd be curious to find out how much methadone she had received. She could have received too much or too little.

[mike]

Does the pt have a history of Migraines?


I was called out to intercept with a BLS service today for a 21 y/o female with a severe headache. The pt was at a small health clinic. She was riding with her friend and developed a sudden 10/10 headache over her left eye. She was pale and sweaty, and also had brain surgery 4 yrs ago due to a rupture of a vessel in her brain. She states that she was just riding along in the car when the symptoms began and due to the severity she went to this health clinic near the highway. I established an IV, O2 monitor, VS BP 126/64, HR 102, SPO2 100% RA. She was in obvious pn and distress and very anxious and uncomfortable. Following the IV and labs I administered 5mg of morphine and also 6.25mg of phenergan(NH protocol). She had no relief with the morphine so I gave her another 5 via the IV. This was given over roughly a 15 minute transport. Upon arrival to the ED she had no real changes and her pn. She does have a Hx of anxiety and takes prozac. On the way back to my station the EMT from the ambulance I intercepted with told me that he forgot to tell me that our pt was returning from a methadone treatment. Any thoughts on my treatment or what this girl has ?

[CHASgirl6204]

Any altered mental status accompanied by nausea and vomiting?

[jdemaio]

Sounds like a seeker to me.

[Medic_QT]

Knowing the info you did, I would have treated her as if she had a possible bleed, because of the strong Hx and presentation (pallor, diaphoresis, obvious distress, slightly elevated HR, etc.). Early on there isn't enough for cushings triad/elevated ICP. Here, we just support ABC's, O2, IV, EKG, 12-lead, stroke assessment, if they're significant, start a twincath (dual lumen) if they're within the time limits for tpa administration. It's the hospital's job to find out if it's hemorrhagic.. We just do as much as we can to assist them.

Finding out that the patient was returning from methadone rx AFTER the run, I would have thwacked the EMT on the back of the head for leaving out that important tidbit of information. I would have thought she was a seeker if I'd known that.

Would I have treated her the same? Absolutely. But, we don't give pain meds for possible bleeds. If a patient has a hx of diagnosed migranes, photophobia, nausea, "yes this feels like all of my other migranes," we might give some morphine and zofran.

[medic32]

Just out of curiousity I visited the ED about my headache pt. She was found to not have any bleeding, She received 20 more of morphine in the ED followed by dilaudid with out much relief. She was discharged later in the day still c/o of a headache. The disharge report she is going to follow up with her neuro surgeon in a couple days. She also told me in the ambulance her surgery was to remove a non cancerous growth in her brain and that there were no complications with that. The ED told me that his fear is the growth may be returning and thats way she needed to follow up with the neuro surgeon.

[Sunburn]

I was gonna say. Sounded like you did a good job.