Minor Head Trauma


General Information
  1. Defined by GCS  > 14


 

History

  1. Ask both patient and any witnesses
    • Witnesses can be CRUCIAL
      • Patient may be comatose/ obtunded
      • Patient may be confused
      • Patient may have had loss of consciousness (LOC)
    • Ask about
      • Loss of consciousness
        • Greater chance of serious neurological injury
      • Mechanism of injury
        • May have prognostic value
      • Prior head injuries
        • Especially prior concussions
      • Drug/ alcohol use
        • May affect mental status assessment
        • May affect bleeding potential (chronic ETOH)
      • Medications
        • Anticoagulant use is worrisome
      • Also consider
        • Psychiatric disease
        • Premorbid history of headaches

Physical findings

  1. Most common complaint is headache
  2. Also complain of transient amnesia, disorientation, or confusion
  3. Neurological exam
    • Serial GCS measurements
    • Look for external trauma
      • Scalp lacerations
      • Basilar skull fx signs
        • Hemotympanum
        • Raccoon eyes
        • Battle's sign (takes 8 - 12 hrs)
        • CSF otorrhea/ rhinorrhea
    • Eyes
      • Pupillary reaction
        • Check direct and consensual light reactions
        • Unilateral dilated pupil: consider impending herniation
      • Intranuclear opthalmoplegia: possible brainstem injury
      • Retinal hemorrhages, detachment
      • Papilledema
    • Ears
      • Check for hemotympanum and blood in canal
      • Check for CSF otorrhea
    • Check for anosmia - nerves sheared at cribiform plate
      • IF CSF rhinorrhea with this: HIGH risk of ascending meningitis infection
    • Check for motor weakness, check reflexes
      • Focal findings indicate pathology
        • Localized brain contusion
        • Impending herniation
        • Spinal injuries
    • Check for gross sensory deficits
    • Bedside mental status
      • Assess consciousness, orientation, and attention
      • Aphasia indicates local pathology (unless pre-existing)
    • RE-EVALUATE FREQUENTLY! PATIENTS' CONDITION CAN CHANGE RAPIDLY!!!

 

Radiologic imaging

  1. Head CT scanning: Yes or No?
    • Can be based on risk level
    • High-risk findings - usually need CT scan
      • Focal neurologic findings
      • Asymmetric pupils
      • Skull fracture
      • Multiple trauma
      • Serious, painful, distracting injuries
      • External signs of trauma
      • Initial Glasgow Coma Scale score of 13
      • Loss of consciousness (> 2 min)
      • Posttraumatic confusion/ amnesia (> 20 min)
      • Progressively worsening headache
      • Vomiting
      • Posttraumatic seizure
      • History of bleeding disorder/ anticoagulation
      • Recent ingestion of intoxicants
      • Unreliable/ unknown history of injury
      • Suspected child abuse
      • Age > 60 yo, < 2 yo
    • Low-risk findings - probably do NOT need CT scan
      • Asymptomatic at exam
      • No other injuries
      • No focality on examination
      • Normal pupils
      • No change in consciousness
      • Intact orientation/ memory
      • Initial Glasgow Coma Scale score of 14–15
      • Accurate history
      • Trivial mechanism
      • Injury > 24 hr ago
      • Reliable home observers
    • Decision tools:
      • New Orleans Head CT criteria
      • Canadian Head CT rule
  2. Skull X-rays
    • Generally have been replaced by CT scan
    • Indications
      • Scalp laceration (to bone or > 5 cm)
      • Violent mechanism of injury
      • Persisting headache and/ or vomiting
      • Significant maxillofacial injuries

 

Disposition

  1. If condition stable and radiologic findings unremarkable
    • Discharge with head injury instructions
      • Adult observation x 36 hr
      • Acetaminophen only for pain (NO ASA/ NSAID x36hrs)
      • Return for any neurological changes
    • Follow-up with private physician
    • If patient returns, look for delayed complications of minor head trauma
  2. Consider admission if
    • Possible drug or alcohol use
    • Epilepsy
    • Attempted suicide
    • Preexisting neurological conditions
      • Parkinson's disease
      • Alzheimer's disease
    • Bleeding potential
      • Patient on warfarin
      • Patient with coagulation disorder
    • Lack of responsible adult to supervise
    • Any uncertainty in diagnosis