In a patient with blunt head trauma and an associated scalp injury, what is the recommended evaluation and management, including neurological exam, imaging criteria, wound care, tetanus prophylaxis, antibiotics, analgesia, and discharge instructions?

Management of Blunt Head Trauma with Scalp Injury

In patients with blunt head trauma and scalp injury, perform a focused neurological examination with GCS assessment, obtain noncontrast head CT if clinical decision rules indicate imaging (GCS 13-15 with risk factors, or any GCS 9-12 or lower), control scalp hemorrhage with direct pressure and wound closure, administer tetanus prophylaxis per immunization status, avoid routine antibiotics for simple lacerations, provide adequate analgesia, and discharge with strict return precautions if imaging is negative and neurological exam is normal.

Neurological Examination

Assess the Glasgow Coma Scale (GCS) immediately, as this determines the entire management pathway 1, 2:

• GCS 13-15 (Mild): Apply clinical decision rules (2008 ACEP Clinical Policy) to determine imaging necessity
• GCS 9-12 (Moderate): CT imaging is mandatory
• GCS 3-8 (Severe): CT imaging is mandatory with neurosurgical consultation

Document specific findings including:

• Loss of consciousness duration
• Post-traumatic amnesia
• Focal neurological deficits
• Signs of skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF leak)

Critical pitfall: Patients on anticoagulants (warfarin, NOACs) or antiplatelet agents (clopidogrel, ticagrelor) have a much lower threshold for imaging regardless of GCS, as they have 3.9% versus 1.5% risk of intracranial injury compared to non-anticoagulated patients 2.

Imaging Criteria

Noncontrast head CT is the only appropriate initial imaging modality 1:

Indications for CT in mild head trauma (GCS 13-15):

• Age >60 years
• Anticoagulation or antiplatelet therapy (excluding aspirin alone)
• Dangerous mechanism of injury
• Vomiting
• Post-traumatic seizure
• Suspected skull fracture
• Neurological deficit

Mandatory CT imaging:

• GCS 9-12 or lower
• Penetrating injury
• Suspected intracranial arterial or venous injury

Do not obtain skull radiographs, MRI, or MRA for initial evaluation - these have been replaced by CT which is more sensitive for neurosurgical lesions 1.

Repeat Imaging Considerations

For patients on anticoagulants/antiplatelet agents with negative initial CT: The evidence shows delayed intracranial hemorrhage is very rare (0.6% for warfarin, 0% for clopidogrel) 2. A single negative CT scan is adequate for safe discharge in patients with normal neurological examination, even on anticoagulation, without routine repeat imaging or prolonged observation 2. However, if GCS remains <15 after 24 hours despite negative initial CT, consider repeat CT or MRI 1.

Scalp Wound Management

Control hemorrhage immediately - scalp wounds bleed profusely due to rich vascular supply and can cause significant blood loss leading to hemodynamic instability 3:

Hemorrhage control:

• Apply direct pressure
• Raney clips or hemostatic clamps for temporary control
• Identify and ligate bleeding vessels if necessary
• The superficial temporal artery is most commonly injured in blunt trauma 4

Wound closure:

• Irrigate thoroughly with normal saline
• Debride devitalized tissue
• Close in layers if deep (galea, then skin)
• Use absorbable sutures for galea, non-absorbable for skin
• Consider staples for scalp lacerations (faster, equally effective)

Critical pitfall: Examine for underlying skull fracture by palpation and imaging. Large, boggy, non-frontal scalp hematomas are associated with higher odds of intracranial injury (OR 9.9) 5. Do not assume ruling out skull fracture eliminates intracranial injury risk - 49% of patients with scalp hematoma and intracranial injury had no skull fracture 5.

Tetanus Prophylaxis

Administer based on wound characteristics and immunization history 6, 7:

High-risk wounds (most scalp injuries qualify):

• Contaminated wounds
• Puncture wounds
• Wounds with devitalized tissue
• Wounds >6 hours old

Tetanus vaccination protocol:

• Complete primary series (<3 doses or unknown): Give Td/Tdap + tetanus immunoglobulin (TIG) 250 units IM
• Complete series, last dose >10 years: Give Td/Tdap booster
• Complete series, last dose 5-10 years with high-risk wound: Give Td/Tdap booster
• Complete series, last dose <5 years: No prophylaxis needed

Note: While HTIG failure is theoretically possible 6, proper administration remains the standard of care for passive immunization.

Antibiotic Therapy

Routine prophylactic antibiotics are NOT indicated for simple scalp lacerations 3.

Consider antibiotics only for:

• Grossly contaminated wounds
• Wounds with significant devitalized tissue
• Delayed presentation (>12-24 hours)
• Immunocompromised patients
• Penetrating injuries with retained foreign bodies

If antibiotics are indicated, cover skin flora (Staphylococcus aureus, Streptococcus species). First-generation cephalosporins (cephalexin) are typically adequate.

Rare but serious complication: Scalp necrotizing fasciitis can occur even without obvious skin changes. Suspect if foul-smelling discharge, subcutaneous emphysema on CT, or systemic signs of infection develop 8. This requires emergency surgical debridement.

Analgesia

Provide adequate pain control:

• Mild-moderate pain: Acetaminophen 650-1000mg PO q6h or ibuprofen 400-600mg PO q6h
• Moderate-severe pain: Consider short course of opioids (oxycodone 5-10mg PO q4-6h PRN)
• Local anesthesia: Lidocaine 1% with epinephrine for wound closure (avoid epinephrine in flap-based wounds with questionable perfusion)

Avoid NSAIDs in patients with intracranial hemorrhage or at high risk for bleeding.

Discharge Instructions

Patients can be safely discharged if 1:

• Normal neurological examination (GCS 15)
• Negative head CT (if obtained)
• No other injuries requiring admission
• Reliable patient or caregiver available

Return precautions (provide written instructions):

• Worsening headache
• Repeated vomiting
• Increasing confusion or difficulty awakening
• Seizures
• Weakness or numbness
• Vision changes
• Clear or bloody drainage from nose/ears
• Neck stiffness

The risk of deterioration with normal CT and normal neurological exam is extremely low (0.006%) 1, making discharge appropriate even without continuous observation.

Follow-up:

• Wound check in 24-48 hours if high-risk wound
• Suture/staple removal in 7-10 days
• Primary care follow-up in 1-2 weeks
• Neurosurgery follow-up only if intracranial pathology identified

For patients on anticoagulation with negative CT and normal exam: Discharge is safe without routine observation or repeat imaging 2. The delayed hemorrhage rate is 0.3% in older adults, with only one case occurring in an anticoagulated patient at 5 days post-injury.