How should a 26-year-old female with no past medical history be managed after a fall down stairs with possible head trauma, presenting with persistent mild headache and left arm pain 24 hours later, currently taking Tylenol (acetaminophen)?

Management of a 26-Year-Old Female After a Fall with Possible Head Trauma

The patient should be evaluated in an emergency department for assessment of possible mild traumatic brain injury (mTBI) and left arm injury, as persistent headache 24 hours after a fall with possible head trauma requires medical evaluation to rule out intracranial pathology.

Initial Assessment and Triage

• The patient's presentation of persistent mild headache 24 hours after a fall down stairs with possible head trauma warrants immediate medical evaluation, even without loss of consciousness or other neurological symptoms 1
• The combination of a fall mechanism, possible head impact, and persistent headache meets criteria for evaluation of potential mild traumatic brain injury 1
• Left arm pain should also be assessed for possible fracture or soft tissue injury 1

Neurological Evaluation

• A thorough neurological examination should be performed to assess for signs of intracranial injury 1
• Specific attention should be paid to:
  • Mental status and cognitive function
  • Cranial nerve examination
  • Motor and sensory function
  • Balance and coordination
  • Signs of basilar skull fracture (periorbital ecchymosis, retroauricular ecchymosis, hemotympanum, CSF rhinorrhea/otorrhea) 1

Neuroimaging

• A non-contrast head CT scan is indicated in this patient with persistent headache after trauma, even without loss of consciousness 1
• The American College of Emergency Physicians guidelines recommend neuroimaging for patients with headache after head trauma 1
• CT imaging of the left arm may also be necessary depending on physical examination findings 1

Management Plan

If Neuroimaging is Negative:

• Patient can be discharged home with appropriate instructions if neurological examination is normal and CT is negative 1
• Acetaminophen can be continued for pain management, but patient should be advised to stop if:
  • Pain worsens or lasts more than 10 days
  • New symptoms develop
  • Redness or swelling appears 2
• NSAIDs may be considered as an alternative or adjunct for headache management 1, 3
• Patient should avoid using other medications containing acetaminophen to prevent overdose 2

Discharge Instructions:

• Written and verbal instructions should be provided at a sixth to seventh-grade reading level 1
• Patient should be instructed to return to the ED immediately if experiencing:
  • Worsening headache
  • Repeated vomiting
  • Confusion or memory problems
  • Focal neurological deficits
  • Increased sleepiness
  • Seizures 1
• Home observation with frequent waking is not necessary or recommended 1
• Patient should refrain from strenuous mental or physical activity until symptom-free 1
• Follow-up with primary care provider within 1-2 weeks should be arranged 1, 3

If Neuroimaging Shows Abnormalities:

• Management will depend on specific findings and may require neurosurgical consultation 1
• For intracranial hemorrhage, management may include:
  • Admission for observation
  • Neurosurgical intervention for significant mass effect
  • Blood pressure control
  • Reversal of anticoagulation if applicable 1

Special Considerations

• Persistent headache after head trauma may indicate postconcussive syndrome if it continues beyond 3 weeks 1
• Medication overuse headache should be considered if the patient has been using analgesics frequently 1, 3
• The patient should be advised that most mild traumatic brain injuries resolve within days to weeks, but some symptoms may persist longer 1, 3
• Referral to a headache specialist should be considered if symptoms persist beyond 3-4 weeks 1, 4

Common Pitfalls to Avoid

• Failing to obtain neuroimaging in a patient with persistent headache after trauma 1
• Relying solely on the absence of loss of consciousness to rule out significant head injury 1, 5
• Prescribing opioids for headache management, which should be avoided 1, 4
• Dismissing persistent headache as "just a concussion" without proper evaluation 1, 3
• Failing to provide clear return precautions and follow-up instructions 1