1.03 Minor Head Trauma (“Concussion”)

agk’s Library of Common Simple Emergencies

Presentation

A patient is brought to the ED after suffering a blow to the head. There may or may not be a laceration, scalp hematoma, headache, transient sleepiness and/or nausea, but there was NO loss of consciousness, amnesia for the injury or preceding events, seizure, neurological changes, or disorientation. The patient or family may express concern about a “mild concussion,” the possibility of a skull fracture, or a rapidly developing scalp hematoma or “goose egg.”

What to do:

• Corroborate and record the history from witnesses. Ascertain why the patient was injured (was there a seizure or sudden weakness?) and rule out particularly dangerous types of head trauma. (A blow by a brick or hammer is more likely to produce a depressed skull fracture.)
• Perform and record a physical examination of the head, looking for signs of a skull fracture, such as hemotympanum or bony depression, and examine the neck for spasm, bony tenderness, rage of motion, and other signs of associated injury.
• Perform and record a neurological examination, with special attention to mental status, cranial nerves, strength, and deep tendon reflexes to all four limbs.
• If the history or physical examination suggests there could be a clinically significant intracranial injury, obtain a non-contrast computed tomogram (CT) scan of the head. Criteria for obtaining a CT scan include: documented loss of consciousness, amnesia, cerebrospinal fluid leaking from nose or ear, blood behind the tympanic membrane or over the mastoid (Battle’s sign), stupor, coma, or any focal neurological sign.
• If the history or physical examination suggests there could be a clinically significant skull fracture, obtain skull x rays. Criteria for obtaining skull x rays include: a blow by a heavy object, suspected skull penetration and palpable depression.
• If there is no clinical indication for CT scan or skull films, explain to the patient and concerned family and friends why x-ray images are not being ordered. Many patients expect x rays, but will gladly forego them once you explain they are of little value.
• Explain to the patient and responsible family or friends that the more important possible sequelae of head trauma are not diagnosed with x rays, but by noting certain signs and symptoms as they occur later. Make sure that they understand and are given written instructions that any abnormal behavior, increasing drowsiness or difficulty in rousing the patient, headache, neck stiffness, vomiting, visual problems, weakness, or seizures are signals to return to the ED immediately.

What not to do:

• Do not skimp on the neurological examination or its documentation.
• Do not be reassured by negative skull films, which do not rule out intracranial bleeding or edema.

Discussion

The risks of late neurological sequelae (subdural hematoma, seizure disorder, meningitis, post concussion syndrome, etc.) make good followup essential after any head trauma; but the vast majority of patients without findings on initial examination do well. It is probably unwise to describe to the patient all of the subtle possible long-term effects of head trauma, because many may be induced by suggestion. Concentrate on making sure all understand the danger signs to watch for over the next few days. A large scalp hematoma may have a soft central area which mimics a depression in the skull when palpated directly, but allows palpation of the underlying skull when pushed to one side. Cold packs may be recommended to reduce the swelling, and the patient may be reassured that the hematoma will resolve over days to weeks. Patients with minor head injuries who meet the criteria for a CT scan but who have a normal scan and neurological examination may be safely discharged from the ED.

References:

• Shackford SR, Wald SL, Ross SE, et al: The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma 1992;33:385-394.
• Mitchell KA, Fallat ME, Raque GH, et al: Evaluation of minor head injury in children. J Ped Surg 1994;29:851-854.
• Staffeld L, Levitt A, Simon, et al: Identification of ethanol-intoxicated patients with minor head trauma requiring computed tomography scans. Acad Emerg Med 1993:1:227-234.

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