What is the plan of care for a patient presenting to primary care for emergency room follow-up after a motor vehicle accident?

Management of Patients Presenting to Primary Care for Emergency Room Follow-up After a Motor Vehicle Accident

For patients presenting to primary care for emergency room follow-up after a motor vehicle accident, a comprehensive evaluation should be performed focusing on physical injuries, pain management, psychological impact, and functional status assessment to ensure optimal recovery and prevent long-term complications. 1

Initial Assessment

• Perform a thorough reassessment of injuries identified in the emergency department, reviewing ED documentation to ensure continuity of care 1
• Evaluate for missed injuries, particularly mild traumatic brain injury (mTBI), which is commonly overlooked in the emergency setting 2
• Screen for postconcussion symptoms using a validated tool such as the Rivermead Post-Concussion Symptoms Questionnaire, especially in patients reporting headache, memory issues, or concentration problems 2
• Assess pain levels using standardized pain scales and document location, character, and severity of pain 3
• Review vital signs and physical examination with particular attention to areas of injury identified in the ED 1

Pain Management

• Implement a multimodal analgesic approach to minimize side effects, particularly in elderly patients 1
• Consider acetaminophen as first-line therapy for mild to moderate pain, administered regularly rather than as needed 1
• Use NSAIDs with caution, especially in older patients or those with renal, GI, or cardiac risk factors 3
• For moderate to severe pain, short-term opioid analgesics may be appropriate with clear instructions on proper use, side effects, and safe storage 3
• Provide written instructions regarding medication dosing, timing, and potential side effects 3

Psychological Assessment

• Screen for post-traumatic stress disorder (PTSD) symptoms, as approximately 10% of MVA victims develop PTSD even after minor accidents 4
• Assess for anxiety related to travel, which affects approximately 25% of MVA victims and can persist for years 4
• Evaluate for signs of depression, as prior major depression is a significant risk factor for developing PTSD after an MVA 5
• Consider early referral to mental health services for patients showing signs of significant psychological distress 4

Imaging and Further Diagnostic Testing

• Review imaging studies performed in the ED and determine if additional imaging is warranted based on persistent or new symptoms 6
• Consider CT maxillofacial without contrast for patients with facial injuries that may have been incompletely evaluated 6
• For patients with persistent headache, dizziness, or cognitive symptoms, consider neuroimaging if not previously performed to evaluate for mTBI 2

Return to Activities

• Provide clear guidance on return to work, school, and daily activities based on injury severity and job requirements 3
• Address driving restrictions as appropriate, considering both physical limitations and potential psychological impact 3
• For patients with residual deficits that might affect driving, consider referral to adaptive driving programs 3
• Discuss legal requirements regarding driving after injury, which vary by state 3

Follow-up Planning

• Schedule appropriate follow-up visits based on injury severity and recovery trajectory 1
• Arrange specialist referrals as needed (orthopedics, neurology, physical therapy, etc.) 1
• Consider early physical therapy for musculoskeletal injuries to prevent chronic pain development 1
• Provide clear instructions on warning signs that should prompt immediate medical attention 3

Special Considerations for Elderly Patients

• Recognize that elderly patients struck by vehicles have higher mortality rates and require more vigilant follow-up 1
• Assess for frailty and consider its impact on recovery and rehabilitation needs 1
• Be particularly cautious with medication management, considering age-related changes in pharmacokinetics 1
• Evaluate fall risk and implement prevention strategies as appropriate 1

Prevention of Long-term Complications

• Implement early venous thromboembolism prophylaxis for patients with reduced mobility 1
• Monitor for signs of post-traumatic headache, which can become chronic if not adequately addressed 2
• Address sleep disturbances promptly, as they can exacerbate pain and slow recovery 4
• Consider the impact of ongoing litigation on recovery, which may be associated with prolonged symptoms 4

Patient Education

• Provide written instructions regarding expected recovery course and when to seek additional care 3
• Educate patients about the potential for delayed onset of symptoms, particularly with mTBI and PTSD 2, 4
• Discuss the importance of completing prescribed therapy and rehabilitation programs 1
• Emphasize that most patients with minor injuries have good outcomes when appropriate follow-up care is received 7

Common Pitfalls to Avoid

• Failing to recognize mild traumatic brain injury, which is frequently missed in the emergency department setting 2
• Underestimating the psychological impact of MVAs, even those involving seemingly minor injuries 4
• Inadequate pain management leading to chronic pain syndromes 3
• Lack of clear communication about activity restrictions and return-to-work guidelines 1
• Insufficient follow-up for elderly patients who have less physiologic reserve and higher complication rates 1