When should a patient be seen after a head injury?

When Should a Patient Be Seen After Bumping Their Head?

Any patient with a head injury should be evaluated immediately in an emergency department if they have any high-risk features, including loss of consciousness, amnesia, persistent headache, vomiting, age over 60-65 years, anticoagulant or antiplatelet use, neurologic deficits, signs of skull fracture, or dangerous mechanism of injury. 1

Immediate Emergency Department Evaluation Required

Patients require urgent ED assessment if they present with any of the following high-risk criteria:

High-Risk Clinical Features

• GCS score less than 15 within 2 hours of injury 1
• Any loss of consciousness or post-traumatic amnesia 1
• Persistent or worsening headache 1, 2
• Vomiting (especially if more than once) 1
• Age greater than 60-65 years 1
• Neurologic deficits (focal weakness, sensory changes, abnormal mental status) 1
• Signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF leak) 1
• Suspected open or depressed skull fracture 1
• Post-traumatic seizure 1
• Dangerous mechanism of injury (pedestrian struck by vehicle, fall from height, high-speed motor vehicle collision) 1

Medication-Related High Risk

• Any anticoagulant use (warfarin, NOACs like apixaban, rivaroxaban, dabigatran) 1, 3
• Antiplatelet agents (clopidogrel, ticagrelor) - excluding aspirin alone 1, 3
• Known coagulopathy 1, 4

These patients require immediate CT imaging of the head without contrast, as they have 100% sensitivity for identifying patients requiring neurosurgical intervention when using validated decision rules. 1

Moderate-Risk Features Requiring Prompt Evaluation

Patients with the following features should be seen within 24 hours even if initially appearing well:

• Physical evidence of trauma above the clavicles (significant scalp hematoma, facial trauma) 1
• Drug or alcohol intoxication at time of injury 1, 5
• Deficits in short-term memory 1
• Single episode of vomiting 4
• Significant subgaleal swelling 4

Patients Who May Not Require Immediate Evaluation

Only patients meeting ALL of the following criteria may potentially avoid immediate ED evaluation: 4

• No history of loss of consciousness
• No amnesia for the event
• No vomiting
• Normal neurologic examination
• Minimal or no subgaleal swelling
• Not on anticoagulants or antiplatelet agents
• Age under 60 years
• No dangerous mechanism of injury

However, even these low-risk patients should be given clear return precautions and monitored by a responsible adult for 24 hours. 3, 6, 2

Critical Timing Considerations

Delayed Deterioration Risk

• 18% of patients who deteriorate after head injury do so between days 2-7 6
• Delayed intracranial hemorrhage can occur even with initially normal presentation 1, 3, 6
• Patients on anticoagulants have 0.6-6% risk of delayed hemorrhage even with negative initial CT 1, 3

When Symptoms Develop Later

Any patient who develops new or worsening symptoms after head injury requires immediate ED evaluation, regardless of initial presentation: 6, 2

• Worsening or persistent headache beyond 24 hours
• New onset of vomiting or dizziness
• Confusion or altered mental status
• Focal neurologic deficits
• Increased sleepiness or difficulty arousing
• Seizures

Common Pitfalls to Avoid

• Never rely on absence of loss of consciousness alone to rule out significant injury - 3.5% of patients without LOC or amnesia still had intracranial lesions 1, 5
• Never discharge anticoagulated patients without CT imaging, even with minor mechanisms 1, 3
• Never assume elderly patients (>60-65 years) are low-risk - they have significantly higher rates of intracranial injury 1
• Never overlook dangerous mechanisms of injury (pedestrian vs vehicle, falls from height) as these independently predict intracranial injury 1, 4
• Never fail to provide written discharge instructions about warning signs requiring immediate return 3, 6, 2

Special Population: Anticoagulated Patients

All patients on anticoagulants or antiplatelet agents (except aspirin alone) require immediate ED evaluation and CT imaging after any head trauma, regardless of how minor the mechanism appears. 1, 3

• Risk of intracranial hemorrhage is 3.9% in warfarin patients vs 1.5% in non-anticoagulated patients 1
• NOACs have 2.6% ICH rate vs 10.2% for vitamin K antagonists, but both are higher than non-anticoagulated patients 1, 3
• Bleeding progression occurs in 26% of anticoagulated patients vs 9% of non-anticoagulated patients 3