What is the course of treatment for a 34-year-old male with a reported loss of consciousness, Glasgow Coma Scale (GCS) 15, Alert and Oriented (AO) x4, a 1-inch laceration to the occipital region, complaining of blurry vision, headache, ataxia, and nausea, with a history of unknown heroin use?

Management of Traumatic Brain Injury with Loss of Consciousness and Post-Traumatic Symptoms

The patient requires immediate transport to a hospital with neurosurgical capabilities, with prehospital management focusing on airway protection, maintaining systolic blood pressure above 110 mmHg, and preventing secondary brain injury. 1

Prehospital Management

• Perform rapid neurological assessment using Glasgow Coma Scale (GCS), pupillary size/reactivity, and motor response to establish baseline 1
• Secure airway and provide supplemental oxygen to maintain SaO₂ > 95% to prevent hypoxemia, which is associated with poor neurological outcomes 1
• Establish IV access and maintain systolic blood pressure > 110 mmHg to ensure adequate cerebral perfusion 1
• Immobilize cervical spine as a precaution despite denial of neck pain, as cervical spine injuries commonly accompany head trauma 2
• Control bleeding from occipital laceration with direct pressure and sterile dressing 1
• Monitor vital signs and neurological status every 5 minutes until arrival at hospital 1
• Provide early notification to receiving facility about patient's condition to allow preparation of specialized equipment 2

Hospital Management

Immediate Assessment and Stabilization

• Continue neurological monitoring using complete GCS assessment and pupillary examination 1
• Obtain non-contrast head CT scan without delay to identify potential intracranial injuries 1
• Assess for signs of increased intracranial pressure (headache, nausea, blurry vision) 1
• Evaluate for signs of postconcussive syndrome using standardized assessment tools 1
• Consider toxicology screening given history of heroin use, although current pupils are 3mm 3

Diagnostic Workup

• Perform complete head CT scan with inframillimetric sections to identify primary brain lesions 1
• Consider CT-angiography if risk factors for vascular injury are present (occipital trauma) 1
• Evaluate for retrograde and anterograde amnesia by asking about events before and after injury 1
• Document all symptoms using a postconcussion symptom scale (headache, nausea, vomiting, balance problems, dizziness, visual problems) 1
• Monitor for signs of deterioration that may indicate need for neurosurgical intervention 1

Treatment Plan

• Provide analgesia for headache while monitoring for changes in neurological status 1
• Administer antiemetics for nausea and vomiting 1
• Maintain normocapnia if mechanical ventilation is required, as hypocapnia can cause cerebral vasoconstriction 1
• Avoid hypotensive agents if sedation is needed 1
• Consider external ventricular drainage if intracranial hypertension develops despite medical management 1

Disposition and Follow-up

• Admit for observation if CT scan shows intracranial injury or if symptoms persist despite normal imaging 1
• If CT is normal but symptoms persist, consider observation for 24 hours to monitor for delayed deterioration 1
• Provide detailed discharge instructions written at sixth to seventh-grade level if discharged 1
• Instruct patient to return immediately for worsening headache, repeated vomiting, increased sleepiness, confusion, or focal neurological deficits 1
• Arrange follow-up to monitor for persistent postconcussive symptoms (headache, dizziness, visual problems, cognitive difficulties) 1

Special Considerations

• The reported 15-minute loss of consciousness is concerning and warrants thorough evaluation, as LOC occurs in less than 10% of concussions but may indicate more serious injury 1
• The combination of blurry vision, headache, ataxia, and nausea following head trauma with LOC suggests possible intracranial injury requiring imaging 1
• History of heroin use requires careful monitoring for respiratory depression and potential drug interactions with medications used for treatment 3
• Mental fogginess may predict slower recovery from concussion 1
• The patient's ability to walk a mile unassisted is reassuring but does not rule out significant intracranial pathology 4