1.03 Minor Head Trauma ("Concussion")
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agk's Library of Common Simple Emergencies


Presentation 
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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 con- 
cussion," 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 exam- 
   ination, 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 neurolog- 
   ical 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 instr- 
   uctions that any abnormal behavior, increas- 
   ing 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:
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- 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 
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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 under- 
lying 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 neuro- 
logical examination may be safely discharged 
from the ED.

References:
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- 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: Ident- 
   ification of ethanol-intoxicated patients 
   with minor head trauma requiring computed 
   tomography scans. *Acad Emerg Med* 1993: 
   1:227-234.

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