Mike asked:
>Q. When is a head injury significant enough to be classifed as
>contraindicated for Entonox and Nubain administration.
I think Entonox is only contra-indicated if there is a closed air space,
i.e. a skull fracture that has allowed air to enter the cranium but not
to equalise pressure rapidly to the outside world. This would be quite
rare, and I guess the patient would be quite sick with more obvious
signs of significant head trauma. The concern in your case would be a
basal skull # (cribiform plate say) with air into frontal fossa, partly
sealed by flap of dura etc. (You see how contrived the injury would have
to be). Post-neuro-surgery would be more of a problem, with small air
spaces left under a well-closed wound. I'm not sure how much of this
theoretical risk would be translated into a real practical risk. There
is a small risk of respiratory suppression with entonox, but as it is so
short-acting, the resp depression is self-limiting.

As far as nubain (and presumably any opioid analgesic) is concerned, the
risk is mainly respiratory depression. Certainly the worry is head-
injured people being admitted for observation who could deteriorate due
to respiratory depression, CO2 retention, and raised intra-cranial
pressure, after administration of sedative doses of opioids. This
problem can be cicumvented by regular (like very 5 minutes) observation
of RR after opioids until no further sedation is likely. It is a sad
reflection on hospital "acute" ward nursing skill mix and numbers that
such obs are unlikely to be performed. Until there are bedside "CO2
meters" as convenient and non-invasive as Pulse oximeters, there is no
Hi-Tech substitute for measuring the Resp Rate (and depth).

I wouldn't worry too much about opioid-induced pupil constriction
masking blown pupils due to hemisphere herniation, this is a late sign
of rising intra-cranial pressure, and (hopefully) earlier warning signs
would be picked up by regular obs (see above) and necessary action taken
long before pupils blew. Your kid sounds far too well to have a brain
problem.

As for choice of opioid: You know I'm not Nubain's greatest fan, but it
presumably has theoretical advantages over more traditional poppy-juice
derivatives due to the mixed antagonist-agonist profile. This is the
reason you use Nubain on the white taxis (no offence) rather than
morphine. The cyclomorph administered by SIMCAS might be expected to
cause more resp depression (and more analgesia?) than nubain.
Incidentally, the cyclizine in cyclomorph would be expected to raise BP,
also not ideal if any suspicion of significant head injury. We tend to
use Codeine Phosphate if we have any real concerns about head injury, as
it supposedly causes less pupil constriction and less repiratory
depression. Sadly it also seems to give less analgesia.

In hospital, if a distressed patient needs more than codeine phos, I
can't see anything wrong with giving morphine etc., as long as you are
prepared to watch the patient like a hawk and are ready to tube/vent
them stat if needed. The consequences of having a trauma victim, perhaps
with a neck injury, thrashing around in agony for the want of some
analgesia outweigh the potential risks.

In summary: you must firstly do what you believe is right for your
patient (and be prepared to justify your actions to others later if you
go against advice or protocols) and secondly you must do what your work
based trainer suggests (or have I got 1st and 2nd wrong way round?). If
that was my kid (God forbid), I would like to think they were made as
comfortable as possible, and then watched very closely for any signs of
deterioration.

Strictly between you, me and the list, what would you have done if your
WBT hadn't got involved? (Email me personally if you prefer).

Follow-up question:
You say that full c-spine protocols were followed. Could your SIMCAS
colleague have taken responsibility for confirming your suspicions that
there was no neck injury and let the child escape the dreaded surf-board
and hard collar, or did you dump her in A&E trussed up in those
frightening contraptions?
===========================================================================
Goat
(e-mail: [log in to unmask])
Sussex, U.K.
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To err is human, to forgive is not management policy
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