1. Minor Head Trauma ("Concussion")
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

2. 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.