What are the patient education guidelines for a patient who has experienced a fall with a head injury and no loss of consciousness (LOC)?

Patient Education for Fall with Head Injury and No Loss of Consciousness

Immediate Assessment and Decision for Imaging

Patients who fall and hit their head without loss of consciousness should undergo CT imaging if they have any of the following high-risk features: focal neurologic deficit, vomiting, severe headache, age ≥65 years, physical signs of basilar skull fracture, GCS <15, coagulopathy, or dangerous mechanism of injury (fall >3 feet or 5 stairs). 1

Key Risk Factors Requiring CT Scan

Even without loss of consciousness, the following warrant immediate head CT 1:

• Focal neurologic deficits (weakness, numbness, vision changes)
• Vomiting (even a single episode increases risk)
• Severe headache (not mild discomfort)
• Age ≥65 years (older adults have higher risk of intracranial injury from seemingly minor falls) 1
• Physical signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF leak)
• GCS score <15 (any confusion or disorientation)
• Coagulopathy or anticoagulation use (warfarin, clopidogrel, aspirin, heparin) 1
• Dangerous mechanism (fall from >3 feet or >5 stairs, pedestrian struck, motor vehicle ejection) 1

Critical Point About Anticoagulation

Patients on anticoagulants (warfarin, clopidogrel, aspirin) who hit their head are at extremely high risk for delayed intracranial hemorrhage and rapid deterioration, even with normal initial presentation. 1 These patients require:

• Immediate CT imaging regardless of symptoms 1
• Extended observation period (minimum 24 hours) 1
• Consideration for hospital admission if CT shows any abnormality 1
• Lower threshold for repeat imaging if any symptoms develop 1

Warning Signs Requiring Immediate Return to Emergency Department

Educate patients to return immediately if they develop 2, 3:

• Worsening or severe headache that doesn't improve with over-the-counter pain medication
• Repeated vomiting (more than one episode)
• Confusion, disorientation, or difficulty recognizing people/places
• Slurred speech or difficulty speaking
• Weakness or numbness in arms, legs, or face
• Vision changes (double vision, blurred vision, loss of vision)
• Seizures or convulsions
• Unequal pupil size
• Clear or bloody fluid draining from nose or ears
• Increasing drowsiness or difficulty staying awake
• Loss of consciousness at any point after the initial injury
• Behavioral changes (unusual irritability, restlessness, or personality changes)

Observation Period and Activity Restrictions

First 24-48 Hours 2, 3

• Someone should check on the patient every 2-3 hours during the first 24 hours, including waking them from sleep
• Avoid alcohol completely for at least 48 hours (masks symptoms and increases bleeding risk)
• Avoid driving for at least 24 hours or until cleared by physician
• No contact sports or activities with fall risk for at least one week
• Limit screen time (phones, computers, TV) as this can worsen headache and cognitive symptoms

Medication Safety 1

• Avoid aspirin, ibuprofen, and other NSAIDs for 48 hours (increases bleeding risk)
• Acetaminophen (Tylenol) is preferred for headache management
• Do not take sleeping pills or sedatives unless specifically prescribed (can mask deterioration)

Special Considerations for Older Adults (≥65 Years)

Ground-level falls in older adults can cause serious intracranial injury even without loss of consciousness. 1 Older patients require:

• Lower threshold for CT imaging (age ≥65 is itself an indication for CT) 1
• Extended observation period due to higher risk of delayed bleeding 1
• Careful blood pressure monitoring (systolic BP <110 mmHg may represent shock in this age group) 1
• Review of all medications especially anticoagulants and antiplatelet agents 1
• Home safety assessment before discharge to prevent repeat falls 1

When Discharge is Safe

Patients can be safely discharged home without imaging if ALL of the following are true 2, 3:

• No loss of consciousness at any point
• GCS score of 15 (fully alert and oriented)
• No vomiting
• No severe headache (mild headache acceptable)
• Age <65 years
• No anticoagulation or bleeding disorder
• No focal neurologic deficits
• No signs of skull fracture
• Low-energy mechanism (not a dangerous fall)
• Reliable caregiver available for observation

Follow-Up Care

• Return for routine follow-up in 3-5 days if symptoms persist 2, 3
• Gradual return to normal activities over 1-2 weeks as symptoms resolve
• Cognitive rest initially (limit work, school, reading, screen time) then gradual resumption
• No return to contact sports until completely symptom-free and cleared by physician

Common Pitfall to Avoid

The absence of loss of consciousness does NOT mean the injury is minor. Studies show that 4.9% of patients without loss of consciousness or amnesia still have intracranial injury, and 0.5% require neurosurgery. 1 The presence of other risk factors (especially age ≥65, anticoagulation, vomiting, or severe headache) mandates imaging and close observation regardless of consciousness status.