Advanced Medical Life Support

Chapter 12

Headache, Nausea, and Vomiting

Introduction
Headaches are usually benign, but they may have grave implications. They often occur along with nausea and vomiting.

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Topics
Headache
Nausea and Vomiting

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C ASE S TUDY
Situation
You are called to the scene for a patient who has passed out while playing basketball at the local gym. Upon your arrival, you find a 39-year-old male, supine in a pool of vomitus. The body and extremities are rigid and extended. He does not respond to verbal stimuli. Bystanders say the patient suddenly complained of a stiff neck and the worst headache of his life. He sat on the floor, vomited twice like a fire hose, and slowly became unresponsive.
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Headache
Severe or unusual headache is always important, especially if accompanied by changes in a patients mentation. Pain is best described in the patients own words.

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Anatomy & Physiology

Pain originates not in the brain but in facial muscles and tissues surrounding the brain, due to:
Contraction of muscles Distention & inflammation of blood vessels Irritation of nerves, especially in the meninges Elevated intracranial pressure
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Types of Headaches
Tension
Usually generalized. Caused by muscle spasms in head & scalp. Most common type in adolescents & adults. Stress is typical underlying etiology.

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Types of Headaches (continued)

Changes in cerebral blood flow Soft-tissue swelling & tenderness

Tension Vascular/migraine

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Types of Headaches (continued)

Tension Vascular/migraine Cluster
May originate in hypothalamus May arise from abnormal neurotransmission May occur as a cluster of headaches that awaken patient 2-3 times during the night, then do not recur for weeks or months
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Important to Note...
Tension and migraine headaches are the most common types. Other etiologies include:
Fever Hypoxemia Anemia Tumor Intracranial bleeding Oral contraceptives Nitrates Depression Hypertension Removal of CSF
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Patient Assessment
Identify & manage life-threats Note severity, changes, signs & symptoms Conduct scene size-up Initial assessment Is Patient Unconscious? History Postpone history-gathering, proceed rapid assessment. Physical Exam

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Important to Note...
Determining the significance of a headache often depends on careful documentation of changes in patient behaviors that might only be apparent to a single caregiver.

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Scene Size-up
Rule out trauma. Consider toxic inhalation. Remember your own safety! Search for scene clues!
(Odors, emesis basin or bucket, O2 tank, etc.)
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Initial Assessment
Goal: to identify immediate life-threats involving ABCs.
Obvious head trauma Also Vomitus note early: Posturing Changes in mentation Slurring of speech Neurologic deficits Abnormal breathing patterns

...All signs of intracranial pathology when seen in presence of headache

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Initial Assessment
Airway

A patient with an impaired mental status may not maintain an open airway.
Control airway aggressively. Be prepared to suction at any time.

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Initial Assessment
Breathing

Abnormal breathing patterns should suggest ICP.

Cheyne-Stokes Biots respirations Central neurogenic hyperventilation
Suspect ICP? Dont hesitate.
Intubate & oxygenate unconscious patient without delay. (Consider hyperventilation.)
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Initial Assessment
Circulation

Assess circulatory status of patient.

Pulse may be elevated in response to pain. Bradycardia suggests ICP. Fever suggests headache as a result of infection.

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Telltale Headaches
Headaches can indicate serious disorders:
Hypoxia Poisoning (i.e., CO, cyanide, many other substances) Stroke Postictal state Anemia Metabolic imbalance (i.e., diabetes, uremia) Tumor Head trauma 12-18

Important to Note...
Any patient with a history of headache whose mentation or ABCs are impaired warrants a rapid medical assessment, appropriate intervention, and then prompt transport.
Assessment of mentation and ABCs should continue en route, to identify further changes.

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Focused History & Physical Exam

Headache

If patient is responsive and can provide information, first gather history & then conduct a focused physical exam. If patient is unresponsive, conduct rapid medical assessment before getting information from bystanders.
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Focused History
Does the patient suffer chronic headaches? If so, ask:
How long have you had headaches? Have they changed, and if so, how? How often do they occur? How long do they last? Where do they usually hurt? What do they feel like?

(continued) 12-21

Focused History (continued)

Ask the chronic sufferer (continued):
How fast do headaches reach worst intensity? Other complaints during headache? Does anything seem to trigger them? Any warning signs prior to onset? What makes them worse or better? When did the headache pattern change?
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Headache History Tips

Sudden onset suggests serious trouble. Throbbing suggests vascular etiology. Provocation by pressure-inducing activity suggests pressure-related etiology.

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Focused History (continued)

OPQRST Questions
O nset P alliation/Provocation Q uality R adiation S everity T ime

Suddenness of onset? Accompanying symptoms?

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Focused History (continued)

OPQRST Questions
O P Q R S T nset alliation/Provocation uality adiation everity ime

May be aggravated by rapid movement or certain foods. Side-effects of medications involved? Known related disorders?

Response to pain meds?

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Focused History (continued)

OPQRST Questions
O nset P alliation/Provocation Q uality R adiation S everity T ime

Try to determine what the pain feels like. Concentrate on patients descriptive terms.

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Focused History (continued)

OPQRST Questions
O nset P alliation/Provocation Q uality R adiation/location S everity T ime

Where is the pain?

One-sided or bilateral?

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Focused History (continued)

OPQRST Questions
O nset P alliation/Provocation Q uality R adiation S everity T ime

How bad is the pain? Try 10-scale, but dont badger patient. Severe pain may not reflect a grave etiology.
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Focused History (continued)

OPQRST Questions
O nset P alliation/Provocation Q uality R adiation S everity T ime

When did the headache come on? Was it preceded or accompanied by other sensations or symptoms? Duration of the headache?
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Important to Note...
Altered mental status is a significant sign in the presence of headache. It is always considered ominous until proven otherwise.

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Focused Physical Exam

Inspect and palpate head for trauma. Inspect neck for evidence of injury.

Check eyes for abnormalities of appearance or function. Check motor & sensory function of extremities (especially motor function).
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Focused Physical Exam (continued)

Monitor the ABCs.
Be alert for hypertension. Watch respiratory pattern, rate & depth. Expect elevated pulse in response to pain. Elevated respiratory rate suggests hypoxia. Fever suggests infection.

Check blood glucose level.

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Focused Physical Exam

Continually monitor mentation, ABCs. Reassess vitals & note trends.

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Not Just a Headache...

Ominous Signs in the Presence of Headache Neurologic dysfunction or seizures Change in mentation or behavior Abrupt onset Worsening on exertion Fever or stiff neck Change in quality of a chronic headache BP (especially with emesis)
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Important to Note...
Possible serious etiologies of headache:
Intracranial tumor Subarachnoid hemorrhage Intracerebral hemorrhage Subdural hematoma Meningitis Preeclampsia Hypertension Depression Carbon monoxide or other toxic inhalation Loss of cerebrospinal fluid Fever Hypoxemia Anemia Stress

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Differential Diagnosis
Subarachnoid Hemorrhage
Results from ruptured (berry) aneurysm Sudden onset of worst headache of (my) life Most common between ages of 20-40 Reaches maximum intensity within minutes. C/o generalized pain, stiff neck, tachypnea, photophobia, diaphoresis, tachycardia Coma typical, bradycardia, apnea & death Keys: control airway, oxygenate, transport.
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Differential Diagnosis
Intracerebral Hemorrhage
Bleeding produces a clot somewhere in the brain that compresses surrounding tissue Chronic hypertension is common predecessor Severe pain that gradually worsens Neurologic deficit more disturbing for patient than headache pain Manage ABCs, oxygenate, transport.
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Differential Diagnosis
Intracranial Mass
Pain due to distortion of intracranial contents by an evolving mass Pain is chronic, present upon awakening Provoked by activity Manage ABCs, oxygenate, transport.

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Differential Diagnosis
Subdural Hematoma
Usually follows trauma, which may not have seemed significant to patient Expanding mass impairs neurologic function ICP produces confusion & stupor Chronic hematoma occurs at least 2 weeks after injury, with transient headache Manage ABCs, oxygenate, transport.
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Differential Diagnosis
Migraine Headache
Chronic vascular headaches affecting young adults, ranging from moderate to profound intensity and accompanied by a variety of transient sensory & motor disturbances Usually unilateral Often preceded by an aura & accompanied by nausea, vomiting Predisposition is hereditary
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Differential Diagnosis
Tension Headache
Caused by muscle contraction in neck, head Most common No aura Usually bilateral May consider analgesics

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Differential Diagnosis
Meningitis
Caused by infectious meningeal inflammation Generalized headache, fever, nausea, vomiting, photophobia, chills & nuchal rigidity Take conservative BSI precautions. Some forms of meningitis are contagious. Manage ABCs, oxygenate & transport.

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Differential Diagnosis
Preeclampsia (Toxemia of Pregnancy)
Third-trimester complication of pregnancy, featuring hypertension, proteinuria & excessive edema Generalized headache, visual disturbances & seizures common Control ABCs, oxygenate, insert IV. Handle gently & quietly to avoid seizures. Quiet transport in subdued lighting
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Differential Diagnosis
Carbon Monoxide Poisoning
Headache, nausea, vomiting, altered mental status, tinnitus, chest pain, disorientation, and seizures Control ABCs, hyperoxygenate, transport.

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Nausea & Vomiting

In prehospital environment, these complaints may or may not suggest a serious underlying etiology. But they often occur along with headache.

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Nausea & Vomiting (continued)

Stimulation of the vomiting center can arise from:
Irritation or infection in gastrointestinal viscera Stimulation of inner ear by motion or infection Disorders of higher central nervous system Stimulation of CNS chemoreceptors, by:
drugs uremia radiation therapy hypoxia poisons acidosis

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Nausea & Vomiting (continued)

Patient Assessment
Focus: identify & manage life-threats (such as airway obstruction)

Scene Size-up
Note: buckets, vomitus on bed clothes, evidence of meal or drugs

Initial Assessment (Control ABCs)

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Important to Note...
When taking a history where vomiting is the complaint, use the relevant parts of the OPQRST format.

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Focused History & Physical Exam

Nausea & Vomiting

History
Use the OPQRST format to develop an understanding of the onset, nature, severity and quality of the vomiting. Also consider associated symptoms such as pain, neurologic disturbances and ObGyn history (in female patients).
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Focused History & Physical Exam

Nausea & Vomiting

Physical exam
Conscious patient: Focused Physical Exam Unconscious patient: Rapid Medical Assessment
Overall appearance (posture, affect, nutritional state, etc.) Breath sounds & odors Evidence of distention, tenderness, rigidity Skin rashes Relative temperature
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Focused History & Physical Exam

Nausea & Vomiting

Vital signs: be alert!

Postural hypotension Tachypnea Respiratory pattern disturbances (i.e., Kussmauls respirations) Fever

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Focused History & Physical Exam

Nausea & Vomiting

Ongoing Assessment
Monitor ABCs, watch for trends.

Management priorities
Concentrate on preventing aspiration; consider antiemetics.

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Important to Note...
Possible serious etiologies associated with nausea & vomiting
intracranial pressure Stroke Intracranial mass Hypertensive crisis Acute myocardial infarction Pericarditis Drugs Increased ocular pressure Gastrointestinal disorders Diabetic ketoacidosis Ovarian cyst or torsion Pelvic inflammatory disease Pregnancy Endometriosis Testicular torsion, disorders Pneumonia Spinal fracture Electrolyte imbalance
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Treatment Pathway for Headache/Nausea/Vomiting

Scene Size-up Note environmental clues to rule out trauma or toxins Initial Assessment Assess neuro status, control ABCs & determine need for early transport

Focused History & Physical Exam

Obtain SAMPLE history Perform physical exam Obtain vitals Obtain blood glucose level

(continued)

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Treatment Pathway for Headache/Nausea/Vomiting (continued)

General Management Priorities:
Continue to support ABCs Hyperventilate w/ 100% O2 Insert IV of NS Avoid glucose if high ICP anticipated ECG/ manage dysrhythmias Consider antihypertensives if diastolic BP >130 Antiemetics for persistent vomiting Transport in LLR position if no spinal injuries

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C A S E S T U D Y F O L L O W-U P
Situation
You are called to the scene for a patient who has passed out while playing basketball at the local gym. Upon your arrival, you find a 39-year-old male, supine in a pool of vomitus. He does not respond verbally, and he appears to be in a decerebrate posture. You note that he is gurgling with every respiration. Bystanders say the patient suddenly complained of a stiff neck and the worst headache of his life. He sat on the floor, vomited twice like a fire hose, and slowly became unresponsive.
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C A S E S T U D Y F O L L O W-U P
Situation
History
Bystanders agree that patient did not strike his head, but that instead he sat down in the middle of the floor, lay down on the floor, and got real stiff after complaining of headache and a stiff neck. No one seems to know anything about his past medical history.
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C A S E S T U D Y F O L L O W-U P
Assessment & Treatment
Patient is unresponsive to deep pain. Respirations are 30 per minute & shallow; radial pulse is 50, strong & regular. Neck is rigid, pupils widely dilated & sluggish. Plantar reflexes bilaterally abnormal. BP = 178/84; ECG reveals sinus brady @ 52, & pulse ox reads 98%. Skin is normal in temp. but slightly diaphoretic. Impression: spontaneous (subarachnoid) intracranial bleed.

Rx: suction airway aggressively, intubate the trachea, & ventilate via BVM w/ O2 @ high concentration.
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C A S E S T U D Y F O L L O W-U P
Assessment & Treatment Outcome
Patient transported promptly, with ventilations continued en route & no change in status noted. Subarachnoid hemorrhage confirmed at hospital; prognosis for recovery listed as uncertain.

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