What is the appropriate workup for a patient (pt) who has fainted and hit their head?

Workup for Patient Who Fainted and Hit Head

A patient who has fainted and hit their head requires immediate assessment for both traumatic brain injury and the underlying cause of syncope, with urgent non-contrast CT head imaging being the cornerstone of evaluation for anyone with altered mental status, neurological deficits, or high-risk features.

Immediate Clinical Assessment

Primary Survey and Stabilization

• Assess airway, breathing, and circulation first - ensure adequate oxygenation (SpO2 ≥95%) and blood pressure (systolic BP >110 mmHg, MAP ≥80 mmHg if head injury suspected) 1, 2
• Perform rapid neurological examination including Glasgow Coma Scale (GCS) with all three components (Eye-Verbal-Motor), pupillary size and reactivity, and motor response 1, 2
• Check for signs of increased intracranial pressure including deteriorating consciousness, pupillary changes, or focal neurological deficits 1
• Assess for orthostatic hypotension by measuring blood pressure supine and standing (if safe to do so) as a potential cause of syncope 1

Key Historical Elements to Obtain

• Circumstances of the fall: Was there true loss of consciousness vs. mechanical trip? Any prodromal symptoms (lightheadedness, palpitations, chest pain)? 1
• Time spent on floor/ground - prolonged time down suggests more severe injury or inability to get up 1
• Witness account of the event, including any seizure-like activity 1
• Medication review - particularly vasodilators, diuretics, antipsychotics, sedative/hypnotics, and anticoagulants 1
• Past medical history - cardiac disease, prior syncope, seizures, diabetes, Parkinson's disease 1

Imaging Studies

CT Head (Non-Contrast) - First-Line Imaging

Obtain urgent non-contrast CT head for any of the following 1, 3:

• GCS ≤13 or any altered mental status 1
• Loss of consciousness (even if transient) 3
• Post-traumatic amnesia 3
• Repeated vomiting (≥2 episodes) 3
• Neurological deficits on examination 3
• Signs of skull fracture (palpable step-off, significant scalp hematoma, Battle's sign, raccoon eyes, hemotympanum, CSF otorrhea/rhinorrhea) 3
• Seizure activity 3
• Coagulopathy or anticoagulant therapy 3
• Age >65 years with any concerning features 1

CT head can be deferred only in very low-risk patients with: no loss of consciousness, no vomiting or amnesia, completely normal neurological examination, and minimal scalp swelling 3. However, given the syncope component, most patients warrant imaging.

Additional Imaging Considerations

• CT cervical spine if neck pain, midline tenderness, or high-risk mechanism 1
• CT maxillofacial if facial trauma or suspected skull base fracture 1
• Chest X-ray if concern for cardiopulmonary cause of syncope 1

Laboratory and Diagnostic Workup

Essential Laboratory Tests

• Complete blood count - assess for anemia as cause of syncope 2
• Basic metabolic panel - check glucose, electrolytes (hyponatremia, hypokalemia can cause syncope) 2
• Coagulation studies (PT/INR, aPTT) - especially if on anticoagulation or abnormal CT 2
• Troponin and ECG - critical to evaluate for cardiac causes of syncope 1
• Blood gas analysis if altered mental status or respiratory concerns 1

Cardiac Evaluation for Syncope

• 12-lead ECG on all patients - look for arrhythmias, heart block, prolonged QT, Brugada pattern, signs of ischemia 1
• Continuous cardiac monitoring during ED stay 1
• Consider echocardiography if structural heart disease suspected 1

Risk Stratification and Monitoring

High-Risk Features Requiring Admission 1, 3

• Neurological: GCS <15, focal deficits, persistent altered mental status, seizure
• CT findings: Any intracranial hemorrhage, skull fracture, significant brain injury
• Cardiac: Abnormal ECG, chest pain, dyspnea, signs of heart failure
• Recurrent syncope or inability to ambulate safely
• Elderly patients (>65 years) with multiple risk factors
• Anticoagulation therapy even with normal initial CT (may need repeat imaging at 24 hours)

Observation Protocol for Moderate-Risk Patients

• Serial neurological examinations every 15-30 minutes for first 2 hours, then hourly for 4-12 hours 1
• Repeat CT head if neurological deterioration (GCS drop ≥2 points or motor score drop ≥1 point) 1
• Gait assessment before discharge - patient must be able to rise from bed, turn, and ambulate steadily 1

Common Pitfalls to Avoid

• Do not attribute head injury solely to mechanical fall without investigating syncope cause - "if a healthy 20-year-old wouldn't have fallen in this situation, investigate why this patient did" 1
• Do not discharge patients on anticoagulation with normal initial CT without considering delayed hemorrhage risk and need for repeat imaging 3
• Do not miss cardiac causes - syncope with head trauma requires ECG and cardiac workup, not just head CT 1
• Do not overlook orthostatic hypotension - check orthostatic vital signs when safe 1
• Do not send home patients who cannot ambulate safely or pass "get up and go test" 1
• Do not delay imaging in elderly patients - they have higher risk of intracranial injury even with seemingly minor mechanisms 1, 3

Disposition Decisions

Admit if 1, 3:

• Any abnormal CT findings
• Persistent neurological symptoms
• Cardiac cause of syncope identified or suspected
• Inability to ensure safe home environment
• Anticoagulation with head trauma (even if initial CT normal)

Discharge with close follow-up if 1, 3:

• Normal CT head
• Normal neurological examination
• Benign syncope cause identified (vasovagal, situational)
• Normal cardiac workup
• Able to ambulate safely
• Reliable home situation with supervision
• Clear return precautions provided