What are the immediate steps to take if a 13-year-old patient hits their head, including assessment of red flags and physical evaluation?

Immediate Assessment and Red Flags for Head Injury in a 13-Year-Old

Any 13-year-old who hits their head must be immediately removed from activity and assessed for red flags that require emergency activation, including loss of consciousness, worsening headache, repeated vomiting, altered mental status, seizures, visual changes, or signs of skull fracture. 1

Critical Red Flags Requiring Emergency Medical Services Activation

The following signs and symptoms mandate immediate EMS activation and emergency department evaluation 1, 2:

• Loss of consciousness (even brief) 1, 2
• Worsening or severe headache 1, 2
• Repeated vomiting (more than once) 1, 2
• Altered mental status (confusion, disorientation, difficulty recognizing people/places) 1, 2
• Seizure activity 1, 2
• Visual changes 1
• Neck pain or suspected cervical spine injury 2
• Signs of skull fracture (swelling, deformities of the scalp, Battle's sign, raccoon eyes, hemotympanum, CSF otorrhea/rhinorrhea) 1

High-Risk Features for Intracranial Injury (PECARN Criteria for Ages 2+)

For children ≥2 years old, the following indicate approximately 4.3% risk of clinically important intracranial injury and warrant CT imaging 1:

• Glasgow Coma Scale score of 14 1
• Other signs of altered mental status (agitation, somnolence, repetitive questioning, slow response to verbal communication) 1
• Signs of basilar skull fracture (as listed above) 1

Structured Physical Assessment Protocol

Immediate Monitoring (First 5 Minutes)

Document the following serially every 5 minutes from time of injury 2:

• Time of injury 2
• Serial vital signs (watch for bradycardia, which can indicate increased intracranial pressure) 2
• Level of consciousness 2

Cognitive Evaluation

Assess the following domains systematically 2:

• Orientation questions (person, place, time, situation) 2
• Immediate memory testing (repeat word lists) 2
• Delayed memory testing (recall after 5 minutes) 2
• Concentration assessment (digit span backwards, months in reverse order) 2

Neurological Examination

Perform focused assessment for 2:

• Balance problems (unsteady gait, poor coordination) 2
• Focal neurologic deficits (weakness, sensory changes, cranial nerve abnormalities) 2
• Pupillary response (asymmetry, sluggish reaction) 2

Symptom Checklist

Use a standardized graded symptom checklist to assess 2, 3:

• Headache or pressure in head 1, 2
• Dizziness or feeling "dinged," stunned, or dazed 2
• Nausea 2
• Balance problems 2
• Sensitivity to light or noise 2
• Feeling slowed down or "in a fog" 2

Immediate Management Decisions

Mandatory Removal from Activity

ANY single symptom or sign warrants immediate removal from play/activity 2. The patient must NOT return to activity that day, regardless of symptom resolution 1, 2.

Observation Requirements

• Never leave the patient alone after suspected concussion 2
• Monitor for several hours for deterioration 2
• Provide written instructions to patient and family about warning signs requiring emergency evaluation 2

Follow-up Arrangements

Arrange follow-up with a healthcare professional trained in concussion management within 24-48 hours, even if symptoms appear mild 1, 2.

Critical Pitfalls to Avoid

Loss of consciousness occurs in less than 10% of concussions, and its absence does NOT rule out concussion 2. Many clinicians mistakenly believe that absence of LOC means no significant injury—this is incorrect and dangerous.

Do NOT allow "playing through" symptoms. Even if symptoms seem to resolve quickly, the patient requires formal medical evaluation before returning to any activity with risk of reinjury 1, 2.

Beware of the "talk and deteriorate" phenomenon. Patients with epidural hematomas may have a lucid interval before rapid deterioration 1. This is why serial monitoring and written discharge instructions are critical.