What is the recommended management for a 60-year-old woman with a head injury from hitting a concrete wall, presenting with frontal headache, difficulty concentrating, general soreness, and injuries to her left elbow and shoulder, but no loss of consciousness (LOC), neck pain, or focal neurological deficits?

Management of 60-Year-Old Woman with Mild Head Trauma

Immediate Recommendation

This patient should undergo a non-contrast head CT scan based on her age (60 years) and frontal headache, despite the absence of loss of consciousness, as these are established risk factors for intracranial injury in mild traumatic brain injury. 1, 2

Clinical Decision-Making Algorithm

Step 1: Assess Need for CT Imaging

This patient meets Level B criteria for head CT based on the 2008 ACEP guidelines, which recommend CT imaging for head trauma patients without loss of consciousness or post-traumatic amnesia if they have: 1

• Age ≥60 years (this patient is 60) 1, 2
• Severe headache (frontal headache present) 1, 2

The Canadian CT Head Rule similarly identifies age ≥65 years as a high-risk criterion, though this patient is just below that threshold. 3 However, the New Orleans Criteria specifically include age >60 years as an indication for CT, which applies directly to this case. 2, 4

Step 2: Evaluate Additional Risk Factors Present

Beyond age and headache, assess for other concerning features that would strengthen the indication for imaging: 1

• Difficulty with concentration suggests possible cognitive impairment, though not meeting criteria for short-term memory deficit 1
• "Foggy sensation" represents altered mental status, which warrants closer evaluation 4
• Mechanism of injury (concrete wall impact) represents significant force 3

Step 3: Rule Out Contraindications to Safe Discharge

Critical exclusions that would mandate imaging regardless of other factors: 1, 2

• Anticoagulation therapy (warfarin, NOACs) - inquire specifically 1
• Antiplatelet agents beyond aspirin (clopidogrel, ticagrelor) - inquire specifically 1
• Coagulopathy or bleeding disorders 1, 3
• Previous neurosurgical procedures 2

Management of Musculoskeletal Injuries

Left Elbow and Shoulder Assessment

Perform focused physical examination of the left upper extremity to exclude fractures or significant soft tissue injury: 5

• Palpate for bony tenderness, deformity, or crepitus
• Assess active and passive range of motion (already noted as preserved) 5
• Test motor strength in all muscle groups (already noted as intact)
• Evaluate neurovascular status distally

Consider plain radiographs of the elbow and shoulder if: 6

• Point tenderness over bony structures
• Significant mechanism suggests possible fracture
• Patient age increases fracture risk

The preserved strength and range of motion are reassuring, but do not exclude fracture in the setting of significant trauma. 5

Cervical Spine Evaluation

The absence of neck pain is reassuring, but given the mechanism (head striking concrete wall), maintain clinical vigilance: 1

• The 2018 guidelines recommend cervical CT for moderate-to-severe TBI, but this patient's mild presentation without neck pain makes cervical imaging less urgent 1
• If any midline cervical tenderness develops, obtain cervical spine imaging 1

Post-CT Management Pathways

If CT is Negative

Patients with mild TBI and negative head CT can be safely discharged without admission or prolonged observation: 2

• Multiple large prospective studies demonstrate that none of 1,170 patients with negative CT and 24-hour observation experienced neurologic deterioration 2
• A Class I trial of 1,292 mild TBI patients with negative CT found zero complications requiring surgery at 3-month follow-up 2

Discharge instructions must include: 2

• Written and verbal return precautions for: memory problems, confusion, abnormal behavior, increased sleepiness, loss of consciousness 2
• Instructions written at 6th-7th grade reading level with ≥12-point font 2
• Do NOT recommend frequent waking or pupil checks at home (no evidence of benefit) 2

Postconcussive symptom education (mandatory): 2

• Dizziness and balance problems
• Nausea and vision problems
• Sensitivity to noise and light
• Depression, mood swings, anxiety, irritability
• Sleep disturbances

Follow-up recommendations: 2

• Referral to TBI specialist if symptoms persist beyond 3 weeks 2
• Injury prevention counseling (seatbelt, alcohol, helmet safety) 2

If CT Shows Abnormalities

Any positive finding requires: 1

• Neurosurgical consultation for lesions requiring intervention 1
• Admission for observation if intracranial hemorrhage present 1
• Serial neurologic examinations (every 15-30 minutes initially, then hourly) 1
• Correction of systemic factors: maintain mean arterial pressure ≥80 mmHg, avoid hypoxemia (SaO2 <90%) 1

Critical Pitfalls to Avoid

Do not skip CT imaging based solely on absence of loss of consciousness - the 2008 ACEP guidelines explicitly provide Level B recommendations for CT in patients WITHOUT LOC when other risk factors are present. 1 This patient's age (60 years) and headache meet these criteria. 1, 2

Do not discharge without comprehensive written instructions - verbal instructions alone are insufficient, and the literature demonstrates improved outcomes with structured, written discharge education. 2

Do not assume musculoskeletal injuries are minor without examination - "general soreness" after significant trauma warrants systematic evaluation to exclude occult fractures, particularly in a 60-year-old patient. 5

Do not overlook medication history - failure to identify anticoagulation or antiplatelet therapy (beyond aspirin) represents a critical error, as these patients have 3.9% risk of intracranial hemorrhage versus 1.5% in non-anticoagulated patients. 1, 3