What is the assessment and management plan for a patient who fell and hit their head without losing level of consciousness (LOC)?

Assessment and Management of Head Trauma Without Loss of Consciousness

For a patient who fell and hit their head without losing consciousness, perform a focused neurological examination and assess for specific high-risk features that mandate CT imaging, as the absence of loss of consciousness does NOT exclude clinically significant intracranial injury. 1, 2

Initial Clinical Assessment

Immediately evaluate for the following high-risk features that indicate need for neuroimaging, regardless of the absence of loss of consciousness:

• GCS score of 14 (even without LOC) 2, 3
• Repeated vomiting (more than one episode) 2, 3
• Severe or persistent headache 2, 3, 4
• Signs of basilar skull fracture (hemotympanum, Battle's sign, raccoon eyes, CSF otorrhea/rhinorrhea) 2, 3
• Focal neurological deficits 2, 3
• Age ≥65 years 2, 3
• Coagulopathy or anticoagulant use (warfarin, NOACs, heparin) 1, 2
• Dangerous mechanism of injury (fall from height >3 feet, pedestrian struck, high-speed motor vehicle collision) 2, 3
• Post-traumatic amnesia (even without LOC) 1, 2
• Palpable skull fracture or significant scalp hematoma 2, 5

Critical Evidence Supporting Imaging Without LOC

The absence of loss of consciousness provides false reassurance. Studies demonstrate that 1.8-4.9% of patients with mild TBI without LOC develop intracranial lesions, and 0.3-0.6% require neurosurgical intervention. 2, 3 The need for neurosurgical intervention is similar (0.4% vs 0.5%) between patients with and without LOC. 2

Neuroimaging Decision

Obtain non-contrast head CT immediately if ANY of the above high-risk features are present. 1, 2, 3, 4 The American College of Emergency Physicians guidelines explicitly state that CT imaging is indicated based on risk factors, independent of LOC status. 1, 2

Do NOT rely solely on clinical decision rules (Canadian CT Head Rule, New Orleans Criteria) as these were originally validated in patients WITH LOC or amnesia. 2, 3

Special Populations Requiring Enhanced Vigilance

Patients on Anticoagulation

• If initial CT is negative but patient is on warfarin or NOACs: Consider 24-hour observation with repeat CT at 20-24 hours post-injury, as delayed hemorrhage occurs in 1.4-4.5% of anticoagulated patients. 1
• If observation is not feasible: Ensure reliable follow-up and provide explicit return precautions, though this is less safe than observation. 1

Seizure Patients

• Patients with head injury from fall caused by seizure have 90.9% incidence of intracranial hematoma (vs 39.8% in other fall mechanisms), with 81.8% requiring surgical evacuation. 6
• Do NOT attribute decreased consciousness or focal deficits to the seizure itself until CT excludes mass lesion. 6

Disposition Based on CT Results

If CT is Negative:

• Discharge home with detailed return precautions if patient has reliable follow-up and no ongoing symptoms 4
• Provide written instructions to return immediately for: worsening headache, vomiting, confusion, weakness, vision changes, seizures, or difficulty walking 4
• Prescribe acetaminophen for pain (avoid opioids and NSAIDs in acute phase) 4
• Schedule follow-up within 24-48 hours for symptom reassessment 1, 4

If CT Shows Abnormalities:

• Obtain immediate neurosurgical consultation 4
• Admit for observation with serial neurological examinations 1, 4
• Reverse anticoagulation if applicable and hemorrhage is present 4
• Consider repeat imaging in 12-24 hours to assess for expansion 1, 4

Monitoring Protocol for Observation

Serial neurological examinations every 2-4 hours for first 24 hours, assessing: 1

• GCS score
• Pupillary size and reactivity
• Motor strength
• Vital signs (blood pressure, heart rate, respiratory rate)

Repeat CT imaging is indicated if: 1

• Neurological deterioration occurs
• New or worsening symptoms develop
• Patient is anticoagulated (routine repeat at 24 hours)

Common Pitfalls to Avoid

• Never assume absence of LOC means low risk – 3-13% of patients with GCS 15 and no LOC have acute intracranial lesions on CT 2, 3
• Do not discharge anticoagulated patients without imaging or observation period 1
• Do not attribute symptoms to "just a concussion" without excluding structural injury first 2, 3
• Avoid prescribing opioids for headache management in this population 4

Follow-Up Considerations

If symptoms persist beyond 3-4 weeks, consider referral to headache specialist or concussion clinic for evaluation of post-concussive syndrome. 4 However, ensure structural pathology was adequately excluded initially before attributing symptoms to functional causes.