What is the appropriate management for a 44-year-old male with a head injury from a fall?

Management of Head Injury in a 44-Year-Old Male

A non-contrast head CT scan is the most appropriate initial imaging study for this 44-year-old male who fell and hit his head, and should be performed immediately along with cervical spine imaging.

Initial Assessment and Management

Immediate Actions

• Establish and maintain airway, breathing, and circulation
• Assess Glasgow Coma Scale (GCS) score
• Perform focused neurological examination
• Start IV fluids as planned
• Order appropriate laboratory studies:
  • Complete blood count
  • Basic metabolic panel
  • Coagulation studies
  • Blood alcohol level (if suspected)
  • Toxicology screen (if suspected)

Imaging

• Non-contrast head CT is the first-line imaging modality for acute head trauma 1
• Cervical spine CT should be performed concurrently to rule out associated cervical spine injury
• Multiplanar reformatted images increase diagnostic accuracy and can affect management plans 1

Clinical Decision Rules for Head CT

The American College of Emergency Physicians (ACEP) 2008 Clinical Policy provides guidance on when to obtain head CT in patients with head trauma 1:

Level A Recommendation (Strong)

Head CT is indicated in patients with head trauma with loss of consciousness (LOC) or post-traumatic amnesia (PTA) if any of the following are present:

• Headache
• Vomiting
• Age >60 years
• Drug or alcohol intoxication
• Short-term memory deficits
• Physical evidence of trauma above the clavicle
• Post-traumatic seizure
• GCS score <15
• Focal neurologic deficit
• Coagulopathy

Level B Recommendation (Moderate)

Head CT should be considered in patients with head trauma without LOC or PTA if any of the following are present:

• Focal neurologic deficit
• Vomiting
• Severe headache
• Age ≥65 years
• Signs of basilar skull fracture
• GCS score <15
• Coagulopathy
• Dangerous mechanism of injury (e.g., fall from height >3 feet)

Management Based on CT Findings

If CT is Normal

• Monitor neurological status
• Provide appropriate pain management
• Consider discharge if neurologically stable with reliable follow-up and no other concerns

If CT Shows Abnormalities

• Consult neurosurgery for any significant findings
• Admit for observation and monitoring
• Consider repeat imaging in 6-24 hours for patients with intracranial hemorrhage
• For patients on anticoagulants with normal initial CT, the risk of delayed intracranial hemorrhage is low (0.6% for warfarin) 1

Special Considerations

Severe TBI (GCS ≤8)

• Transfer to a specialized center with neurosurgical facilities as soon as possible 1
• Early intubation and ventilation to maintain adequate oxygenation and prevent secondary brain injury
• Target normocapnia (EtCO2 30-35 mmHg) 1

Follow-up Imaging

• Repeat head CT is indicated for patients with:
  • New or progressive neurologic deficits 1
  • Initial positive findings with clinical deterioration 1
• Patients with small intracranial hemorrhage (<10 mL) and normal neurologic examination may not require routine repeat imaging 1

Common Pitfalls to Avoid

1. Delayed imaging: Do not delay obtaining a head CT in a patient with significant head trauma
2. Incomplete evaluation: Always consider cervical spine injury in patients with head trauma
3. Premature discharge: Ensure adequate observation period and reliable follow-up
4. Missing associated injuries: Thoroughly evaluate for other traumatic injuries
5. Inadequate monitoring: Maintain vigilance for neurological deterioration even with initially normal imaging

By following this evidence-based approach, you can optimize outcomes for this patient with head trauma while minimizing the risk of missing significant intracranial injuries.