Diagnosis: Mild Traumatic Brain Injury (Concussion) with Scalp Laceration
This patient has sustained a mild traumatic brain injury (mTBI/concussion) with an associated 5 cm occipital scalp laceration. The mechanism (fall with direct occipital impact), altered mental state (dizziness), and significant scalp laceration all meet diagnostic criteria for mTBI and warrant immediate head CT imaging 1.
Clinical Reasoning
Why This is Mild TBI
The patient meets established diagnostic criteria for mTBI based on:
- Direct blunt trauma to the head from ground impact 1
- Alteration in mental state (dizziness qualifies as feeling dazed/disoriented) 1
- Conscious with presumed GCS 14-15 (conscious but symptomatic) 1
- Presentation within 24 hours of injury 1
The Centers for Disease Control and Prevention definition specifically includes "any period of observed or self-reported transient confusion, disorientation, or impaired consciousness" - dizziness after head trauma qualifies 1.
Critical Management Decision: Head CT is Mandatory
This patient requires non-contrast head CT immediately based on multiple high-risk features 1:
Level A Recommendation criteria present:
- Physical evidence of trauma above the clavicle (5 cm scalp laceration) 1
- Vomiting or headache (dizziness often accompanies these symptoms) 1
Additional concerning features:
- Occipital impact location - posterior fossa injuries can be particularly dangerous
- Large scalp laceration (5 cm) - associated with 20% rate of intracranial injury in mild TBI patients 2
- Symptomatic (dizziness) - indicates neurological dysfunction 3, 4
Why CT Cannot Be Deferred
The scalp laceration alone is a critical factor. Research demonstrates that patients with mild TBI (GCS 15) and scalp lacerations have intracranial injuries in approximately 20% of cases, including skull base fractures (7.4%), linear skull fractures (7.4%), brain contusions (3.2%), and subdural hematomas (1.1%) 2. The 5 cm length indicates significant force transmission.
Common pitfall to avoid: Do not be falsely reassured by the patient being conscious and conversant. Up to 15% of patients with GCS 15 have acute intracranial lesions on CT, and approximately 1% require neurosurgical intervention 1. The GCS alone is insufficient for risk stratification in mild TBI 1.
Differential Considerations for the Dizziness
While the primary diagnosis is mTBI, the dizziness specifically may represent 4:
- Labyrinthine concussion (inner ear injury from impact)
- Benign paroxysmal positional vertigo (BPPV from otolith displacement)
- Vestibular nerve injury
- Direct neurological dysfunction from the brain injury itself
- Cervical injury (must be evaluated given fall mechanism)
Immediate Management Algorithm
Stabilize and assess: Ensure cervical spine precautions until cleared, given fall mechanism and occipital impact 5
Obtain non-contrast head CT immediately - do not delay 1, 6, 7
Serial neurological assessments: Monitor GCS, pupillary response, focal deficits - deterioration indicates need for neurosurgical consultation 1
Wound management: The 5 cm laceration requires irrigation, exploration for foreign bodies/skull fracture, and closure
Disposition depends on CT results:
- If CT shows intracranial injury: Admission for observation, neurosurgical consultation 1
- If CT negative AND neurological exam normal: May consider discharge with strict return precautions and responsible adult supervision 6, 7
- If persistent symptoms despite negative CT: Consider admission for observation or extended ED monitoring 8
Critical Red Flags Requiring Immediate Neurosurgical Consultation
- Deteriorating GCS
- New focal neurological deficits
- Persistent vomiting
- Severe or worsening headache
- Any intracranial hemorrhage or skull fracture on CT
- Signs of basilar skull fracture (Battle's sign, raccoon eyes, CSF leak)
The combination of mechanism, scalp injury, and symptoms places this patient at substantial risk for clinically significant intracranial injury that requires identification through CT imaging 1, 2.