What is the appropriate management for blunt trauma to the head?

Management of Blunt Head Trauma

Initial CT scanning is strongly indicated for all patients with blunt head trauma who are on anticoagulant therapy, have altered mental status (GCS <15), or demonstrate focal neurologic deficits, regardless of the severity of the mechanism or presence of symptoms. 1, 2

Initial Assessment and Imaging

• A non-contrast head CT scan is the gold standard for initial evaluation of blunt head trauma in adults with concerning features 2
• Patients with GCS score of 14 or less, altered mental status, or signs of basilar skull fracture should undergo immediate CT imaging due to approximately 4.3% risk of clinically important traumatic brain injury 2
• Patients on anticoagulants (warfarin, NOACs) or antiplatelet agents (clopidogrel, ticagrelor) have higher risk of intracranial hemorrhage and should receive CT imaging even with minor trauma 1, 2
• Plain film radiographs have no role in the assessment of acute traumatic brain injury as they cannot reliably detect intracranial injuries 2

Risk Stratification

• High-risk features requiring immediate CT imaging:

  • GCS score <15 or other signs of altered mental status 2
  • Focal neurologic deficits 2
  • Signs of basilar or palpable skull fracture 2
  • Anticoagulant or antiplatelet medication use 1, 2
  • Age >60 years with loss of consciousness or amnesia 1
  • Severe mechanism of injury 2

• Moderate-risk features where CT should be considered:

  • Temporary loss of consciousness 2
  • Post-traumatic amnesia 2
  • Persistent headache or vomiting 1
  • History of coagulopathy 2

Management Based on Initial CT Findings

Negative Initial CT Scan

• For patients not on anticoagulants with a negative initial CT and normal neurological examination:

  • May be safely discharged with appropriate head injury instructions 2
  • No routine repeat imaging is necessary 2

• For patients on anticoagulants or antiplatelet agents with a negative initial CT:

  • The risk of delayed intracranial hemorrhage is low (0.6-6%) 1
  • ACEP guidelines support that these patients do not routinely require admission or observation if they have normal neurological examination 1
  • Clear discharge instructions should include symptoms of delayed hemorrhage 1
  • Consider brief observation (4-6 hours) before discharge for high-risk patients (age >80, history of LOC) 1

Positive Initial CT Scan

• Patients with intracranial hemorrhage on initial CT require:
  • Neurosurgical consultation 1
  • Consideration of anticoagulation reversal if applicable 1
  • For patients on warfarin with ICH, immediate reversal of anticoagulation is indicated 2
  • Follow-up imaging within 24 hours to assess for hemorrhage progression 1
  • Patients on anticoagulants have a 3-fold increased risk of bleeding progression (26% vs 9%) 1

Special Considerations

• Anticoagulated patients: Factor Xa inhibitors like apixaban have a lower incidence of ICH compared to vitamin K antagonists (2.6% vs 10.2%), but still higher than patients without anticoagulation 1, 2
• Delayed hemorrhage: In patients on warfarin with initially negative CT scans, delayed ICH occurs in approximately 0.6% of cases, with rare need for neurosurgical intervention 2
• Missed injuries: Up to 13.6% of blunt trauma patients may have undiagnosed injuries, with 40% having clinical implications, highlighting the importance of repeated clinical assessments 3

Common Pitfalls to Avoid

• Failing to obtain CT imaging for patients on anticoagulants after head trauma, even if the mechanism seems minor 1
• Unnecessary repeat imaging in stable patients with negative initial CT and normal neurological examination 1
• Overlooking the need for neurosurgical consultation in patients with positive CT findings 1
• Neglecting to provide clear discharge instructions regarding warning signs of delayed hemorrhage 1
• Underestimating the risk of delayed hemorrhage in elderly patients on anticoagulation 2