What medication can be given to a 42-year-old male (M) with a laceration and pain after a fall, normal neurologic physical examination (Neuro PE), and pending plain cranial computed tomography (CT) scan for pain management?

Pain Management for Head Trauma Patient Awaiting CT

For a 42-year-old male with a scalp laceration and normal neurologic examination awaiting cranial CT, give oral acetaminophen 650-1000 mg immediately, as it provides effective analgesia without masking neurologic changes or increasing bleeding risk. 1

Why Acetaminophen is the Optimal Choice

Acetaminophen is the preferred first-line analgesic because it does not interfere with neurologic assessment, has no antiplatelet effects, and provides adequate pain relief for soft tissue injuries. 2, 1

• Acetaminophen is recommended as first-line pharmacologic treatment for mild to moderate pain, providing comparable pain relief to NSAIDs without gastrointestinal or bleeding risks 2
• The standard adult dose is 650-1000 mg orally, with a maximum daily dose of 4000 mg 1
• Pain relief typically begins within 30-60 minutes of oral administration 1

Why to Avoid NSAIDs in This Context

NSAIDs should be avoided in head trauma patients prior to CT imaging because they increase bleeding risk through platelet inhibition, which could worsen intracranial hemorrhage if present. 2

• NSAIDs carry significant risks including gastrointestinal bleeding, platelet dysfunction, and potential drug interactions 2
• While topical NSAIDs are excellent for isolated musculoskeletal injuries, they are inappropriate for scalp lacerations with potential intracranial injury 3
• The antiplatelet effects of NSAIDs persist for days and could complicate neurosurgical intervention if needed 2

Why to Avoid Opioids

Opioids must be avoided because they alter mental status and pupillary responses, making neurologic examination unreliable and potentially masking signs of deterioration. 2, 3

• Opioids cause sedation that interferes with Glasgow Coma Scale assessment, which is critical for detecting neurologic deterioration 2
• Opioids provide similar pain relief to NSAIDs but cause significantly more side effects 3
• The risk of masking evolving intracranial pathology outweighs any analgesic benefit 2

Critical Monitoring During Transport

Serial neurologic examinations are more important than the initial CT scan, as intracranial hemorrhage can evolve over hours even with an initially normal CT. 2, 4, 5

• A normal initial CT scan does not exclude delayed intracranial hemorrhage, which can develop within 24 hours 4, 5
• Patients with normal CT but abnormal neurologic examination (GCS <15) require documented observations every 30 minutes until GCS 15 is achieved 2
• The risk of deterioration with both normal CT and normal neurologic examination is very low (0.006%) 2

Additional Pain Management for the Laceration

For the laceration itself, consider topical lidocaine-adrenaline-tetracaine (LAT) combination if available, as it provides needle-free anesthesia for wound repair. 6

• LAT combination provides effective anesthesia without injection pain 6
• If additional anesthesia is needed during repair, buffered lidocaine injected slowly reduces injection pain 6
• Laceration repair can be safely performed after CT confirms no intracranial injury requiring immediate intervention 6

Key Contraindications to Remember

Do not give acetaminophen if the patient has taken any other acetaminophen-containing products in the past 4-6 hours or has known liver disease. 1

• Maximum daily dose is 4000 mg from all sources combined 1
• Many over-the-counter cold and pain medications contain acetaminophen 1
• Ask specifically about recent acetaminophen use before administering 1

Common Pitfall to Avoid

The most dangerous error is giving sedating medications (opioids, benzodiazepines) that mask neurologic deterioration, as evolving epidural hematomas can present with lucid intervals followed by rapid decompensation. 5, 7 A patient who appears stable can deteriorate within hours, and altered mental status from medications prevents early detection of this life-threatening complication. 2, 5