What is the appropriate management for a patient who has hit her head on a door?

Management of a Patient Who Hit Her Head on a Door

For a patient who has hit her head on a door, assessment should focus on evaluating for signs of traumatic brain injury using the Glasgow Coma Scale (GCS), pupillary size and reactivity, and monitoring for development of concerning symptoms, with documentation of these findings in the medical record.

Initial Assessment

Neurological Evaluation

• Assess severity using Glasgow Coma Scale (GCS) 1
  • Document all three components: Eye-Verbal-Motor responses
  • Pay particular attention to the motor component which remains robust even in sedated patients
• Evaluate pupillary size and reactivity 1
• Document baseline neurological status 1

Key Historical Information to Document

• Mechanism of injury (hit head on door)
• Time of injury
• Presence or absence of:
  • Loss of consciousness
  • Amnesia (before or after the injury)
  • Vomiting
  • Headache (especially if diffuse)
  • Sensory deficits or muscle weakness
  • Tingling in extremities

Risk Stratification

Based on the 2023 American College of Emergency Physicians (ACEP) guidelines 1, patients can be classified as:

Low-Risk Mild Head Injury

• GCS of 15
• No history of loss of consciousness
• No amnesia
• No vomiting
• No diffuse headache
• Risk of intracranial hematoma requiring surgical evacuation <0.1% 2

Medium-Risk Mild Head Injury

• GCS of 15 with one or more of:
  • Loss of consciousness
  • Amnesia
  • Vomiting
  • Diffuse headache
• Risk of intracranial hematoma requiring surgical evacuation 1-3% 2

High-Risk Mild Head Injury

• GCS of 14-15 with:
  • Skull fracture and/or neurological deficits
  • Risk factors: coagulopathy, drug/alcohol consumption, previous neurosurgical procedures, pre-trauma epilepsy, age >60 years
• Risk of intracranial hematoma requiring surgical evacuation 6-10% 2

Neuroimaging Decision

When to Obtain Head CT

According to the 2023 ACEP guidelines 1, CT is indicated for patients with:

• Any high-risk factors:
  • Failure to reach GCS 15 within 2 hours of injury
  • Suspected open skull fracture
  • Signs of basal skull fracture
  • Vomiting more than once
  • Age >64 years
• Medium-risk factors may warrant CT based on clinical judgment

When CT is Not Required

• Low-risk patients without concerning symptoms can be discharged with written instructions 2
• Conventional neuroimaging is typically normal in concussive injuries 1

Documentation Requirements

Document the following in the medical record:

• Detailed neurological assessment including GCS score 1
• Pupillary size and reactivity 1
• Presence or absence of risk factors
• Serial assessments if the patient remains under observation
• Timing of assessments 3
• Any interventions performed
• Discharge instructions provided

Discharge Instructions

For patients who can be safely discharged:

• Warning signs that require return to medical care:
  • Worsening headache
  • Repeated vomiting
  • Increasing drowsiness or confusion
  • Seizure
  • Visual disturbances
  • Weakness or numbness in limbs
• Rest recommendations
• Gradual return to normal activities
• Follow-up instructions

Special Considerations

Anticoagulant/Antiplatelet Medications

• Patients on these medications require more cautious evaluation 1
• May need CT even with minor symptoms

Burn Blisters (if present from friction)

• Cover loosely with sterile dressing but leave blisters intact 1

Follow-up Care

• Arrange appropriate follow-up for patients with persistent symptoms
• Consider referral for post-concussive syndrome if symptoms persist beyond expected recovery time 1

Pitfalls to Avoid

• Do not dismiss minor head injuries, as they can occasionally lead to serious complications
• Avoid terms like "ding" or "bell rung" as they minimize the injury 1
• Do not rely solely on initial presentation, as symptoms may evolve over time
• Ensure proper documentation of all assessments and findings for medical-legal purposes
• Do not discharge patients with concerning symptoms without appropriate evaluation

Remember that proper assessment and documentation of head injuries, even seemingly minor ones, is crucial for patient safety and appropriate medical care.