Head Trauma / Mild TBI

Key considerations: Epidural hematoma, Subdural hematoma, Traumatic subarachnoid hemorrhage

Cannot miss

GCS <15
Loss of consciousness >5 minutes
Post-traumatic seizure
Focal neurological deficit
Signs of basilar skull fracture (raccoon eyes, Battle sign, hemotympanum, CSF leak)
Anticoagulant use
Age >65 with head trauma
Vomiting ≥2 episodes
Dangerous mechanism (fall >5 stairs, MVC, pedestrian struck)
Worsening headache

history: Mechanism of injury: fall height, MVC speed, assault, sports; Loss of consciousness: duration; Amnesia: retrograde and anterograde; Symptoms: headache, nausea, vomiting, dizziness, confusion; Anticoagulant or antiplatelet medications; Prior head injuries / concussions; Alcohol or drug intoxication at time of injury; exam: GCS scoring: Eyes + Verbal + Motor; Scalp: lacerations, hematomas, step-offs (depressed fracture); Eyes: pupil reactivity and symmetry, tracking; Ears: hemotympanum, CSF otorrhea (basilar skull fracture); Nose: CSF rhinorrhea; Neck: C-spine tenderness (assume concurrent C-spine injury); Neurological: focal deficits, cerebellar signs, cranial nerves; labs: BMP; Coagulation studies: PT/INR (if anticoagulated); Type and screen if significant hemorrhage suspected; Blood alcohol level and drug screen as indicated; imaging: CT head non-contrast: apply Canadian CT Head Rule or NEXUS Head CT criteria to determine need; Canadian CT Head Rule: GCS <15 at 2hrs, suspected open/depressed skull fracture, signs of basilar fracture, vomiting ≥2, age ≥65, amnesia >30min before impact, dangerous mechanism; CT C-spine: must be performed with head CT if C-spine not cleared clinically; If anticoagulated: lower threshold for CT — scan all anticoagulated patients with head trauma; bedside: GCS assessment; Pupil reactivity check; C-spine assessment per NEXUS or Canadian C-Spine Rule

immediate: ABC assessment with C-spine immobilization; GCS assessment and document; CT head if any Canadian CT Head Rule criteria met; If GCS ≤8: intubate and protect airway; general: Concussion (GCS 15, normal CT): observation, discharge with head injury instructions; Anticoagulation reversal if intracranial hemorrhage found; Serial neurological checks; Avoid re-injury: no contact sports until cleared; specific: diagnosis: Epidural Hematoma; steps: Neurosurgery consult — emergent craniotomy if symptomatic; Classic presentation: lucid interval followed by rapid deterioration; Usually middle meningeal artery (temporal bone fracture); Time-critical surgical emergency; diagnosis: Subdural Hematoma; steps: Neurosurgery consult; Acute (<72 hours): surgical evacuation if >10mm thickness or midline shift >5mm or neurological decline; Reverse anticoagulation; Chronic subdural in elderly may present with insidious confusion; diagnosis: Concussion / Mild TBI; steps: CT head if Canadian CT Head Rule criteria met; If CT negative: discharge with written head injury instructions; Return precautions: worsening headache, vomiting, confusion, seizure, weakness, clear fluid from nose/ears; Cognitive and physical rest for 24-48 hours, then gradual return to activity; No driving, alcohol, or sedating medications for 24 hours; PCP follow-up in 1-2 weeks, sooner if symptoms persist

admit: Any intracranial hemorrhage; GCS <15 that does not improve; Skull fracture; Anticoagulated patient with intracranial hemorrhage; Neurological decline during observation; Unsafe social situation / unreliable observation at home; discharge: GCS 15, normal CT (or no indication for CT per validated rules); Alert and oriented, no focal deficits; Reliable observer at home for 24 hours; Written head injury instructions provided; Follow-up arranged; consults: Neurosurgery: all intracranial hemorrhage, depressed skull fracture; Trauma surgery: multi-system trauma; Social work: non-accidental trauma concerns, elder abuse

Canadian CT Head Rule: 100% sensitivity for neurosurgical intervention — if all criteria negative in GCS 13-15, CT can be safely avoided
Anticoagulated patients with head trauma: scan ALL of them — even with GCS 15 and minor mechanism. Delayed hemorrhage is common
Epidural hematoma "lucid interval": patient may initially look well, then deteriorate rapidly — the classic talk-and-die presentation
Return-to-play protocol after concussion: minimum 24 hours of physical and cognitive rest, then gradual stepwise return
Elderly patients on anticoagulants are at extremely high risk for subdural hematoma — even from minor falls

Canadian CT Head Rule (Stiell et al.), CDC mTBI Guidelines, Eastern Association for Surgery of Trauma (EAST) TBI Guidelines. Last reviewed: 2024-11-01