What are the immediate recommendations for a patient with a blunt head injury in concussion without loss of consciousness (LOC)?

Immediate Management of Blunt Head Injury with Concussion Without Loss of Consciousness

For patients with blunt head injury and concussion without loss of consciousness, immediate neurological evaluation including assessment of pupils, Glasgow Coma Scale (GCS), and monitoring for specific symptoms is recommended, with consideration for CT imaging based on risk factors. 1

Initial Assessment

Neurological Evaluation

• Check GCS score (should be 14-15 in concussion without LOC)
• Assess pupils for size, symmetry, and reactivity
• Evaluate for focal neurologic deficits
• Document presence of posttraumatic amnesia or disorientation 1, 2

Key Symptoms to Assess

• Headache (particularly if severe)
• Vomiting
• Dizziness and balance problems
• Visual disturbances
• Sensitivity to light and noise
• Confusion or disorientation
• Memory problems
• Difficulty concentrating 2

Imaging Decisions

CT Scan Indications (Level B Recommendation)

CT imaging should be considered in patients with blunt head trauma without LOC if ANY of the following are present:

• Focal neurologic deficit
• Vomiting
• Severe headache
• Age ≥65 years
• Physical signs of basilar skull fracture
• GCS score <15
• Coagulopathy (including anticoagulant/antiplatelet use)
• Dangerous mechanism of injury (fall >3 feet/5 stairs, ejection from vehicle, pedestrian struck) 1

Special Considerations for Anticoagulated Patients

• Patients on warfarin have 1.88 times higher risk of significant intracranial injury
• Patients on combined aspirin and clopidogrel have 2.88 times higher risk
• Lower threshold for imaging in these patients 3

Red Flags Requiring Immediate Medical Attention

• Worsening headache
• Repeated vomiting
• Seizures
• Altered mental status
• Visual changes
• Skull deformities
• Increased drowsiness or confusion
• Development of focal neurological deficits 2

Initial Management

Immediate Steps

1. Remove from activity/potential for additional injury
2. Assess for red flags requiring emergency intervention
3. Perform neurological evaluation as outlined above
4. Determine need for CT imaging based on risk factors
5. Recommend physical and cognitive rest for 24-48 hours 2

Patient Education

• Explain common post-concussive symptoms
• Provide clear return instructions for worsening symptoms
• Discuss expected recovery timeline (typically days to weeks)
• Advise against activities that risk additional head injury until fully recovered 2

Follow-Up Recommendations

• Schedule follow-up within 24-72 hours to reassess symptoms
• Consider referral to concussion specialist if symptoms persist beyond 2-3 weeks 2

Return to Normal Activities

Graduated Return Protocol

For athletes or active individuals, implement a 5-stage return protocol:

1. Light aerobic exercise (after 24-48 hours of rest)
2. Sport/activity-specific exercise
3. Non-contact training drills
4. Full-contact practice (if applicable)
5. Return to competition/full activity

Progress to next stage only if asymptomatic for 24 hours; if symptoms recur, return to previous stage 2

Common Pitfalls to Avoid

• Failing to recognize concussion in patients without LOC
• Missing red flags that indicate more serious injury
• Allowing premature return to activities with risk of head injury
• Inadequate follow-up for persistent symptoms
• Not considering special populations (elderly, anticoagulated patients) who have higher risk 1, 2

Remember that concussion can occur without loss of consciousness, and proper management in the acute phase can significantly impact recovery outcomes and prevent complications such as prolonged post-concussive syndrome 2.