What are the treatment and management options for a traumatic head injury with a hematoma after hitting a vehicle?

Management of Traumatic Head Injury with Scalp Hematoma After Vehicle Collision

For a purple bump (scalp hematoma) after hitting the head on a vehicle, immediate assessment for underlying brain injury is the priority, followed by local wound care if imaging is normal and no concerning symptoms are present.

Immediate Assessment and Red Flags

The critical first step is determining whether this represents isolated scalp trauma or indicates underlying traumatic brain injury (TBI). Even seemingly minor head trauma can result in delayed intracranial hemorrhage, particularly in elderly patients 1.

Neurological Evaluation Required

• Assess level of consciousness immediately - any alteration in mental status, confusion, or loss of consciousness at the scene mandates urgent brain imaging 2, 3
• Check for focal neurological deficits including pupillary reactivity, motor weakness, or abnormal posturing, as these predict severe underlying injury 2, 3
• Evaluate for signs of skull fracture - palpable step-off, Battle's sign (mastoid ecchymosis), raccoon eyes (periorbital ecchymosis), or CSF rhinorrhea/otorrhea all require immediate CT imaging 2
• Document mechanism of injury - high-speed motor vehicle accidents carry significantly higher risk of irreversible brain damage compared to simple blows or falls 4

Hemodynamic Priorities

• Maintain systolic blood pressure >110 mmHg from first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcomes in head trauma 2, 3, 5
• Use vasopressors (phenylephrine or norepinephrine) immediately if hypotensive rather than waiting for fluid resuscitation, which has delayed hemodynamic effects 2, 3, 5

Imaging Strategy

When to Obtain CT Scan

Obtain non-contrast brain CT immediately without delay if any of the following are present 2, 3, 5:

• Any alteration in consciousness or Glasgow Coma Scale <15
• Focal neurological deficits
• Persistent vomiting (>2 episodes)
• Severe or worsening headache
• Age >65 years (higher risk of delayed chronic subdural hematoma) 1
• Anticoagulant or antiplatelet medication use
• Suspected skull fracture on examination
• High-energy mechanism (motor vehicle collision at regulatory speeds can cause severe injury) 6

Technical Specifications

• Use inframillimetric sections reconstructed with thickness >1mm, visualized with double fenestration (central nervous system and bone windows) to detect both parenchymal injury and skull fractures 2, 3
• Include cervical spine imaging in the same study, as neck injury commonly coexists with head trauma in vehicle collisions 2, 7

Management Based on Findings

If CT Shows Intracranial Pathology

• Transfer immediately to neurosurgical center - do not delay for "stabilization" at non-neurosurgical facility, as mortality is lower in specialized centers even for patients not requiring surgery 2, 3, 5
• Maintain systolic BP >110 mmHg continuously using vasopressors as needed 2, 3, 5
• Avoid hypotonic solutions such as Ringer's lactate in patients with head trauma; use isotonic crystalloids instead 2
• Establish airway control with endotracheal intubation if Glasgow Coma Scale ≤8, with continuous end-tidal CO2 monitoring to maintain normal PaCO2 (avoid hypocapnia which causes cerebral vasoconstriction) 2, 3, 5

If CT is Normal and Patient Neurologically Intact

Local management of scalp hematoma includes:

• Apply ice to the area for 15-20 minutes every 2-3 hours for the first 24-48 hours to reduce swelling and pain
• Elevate head of bed 30 degrees to promote venous drainage and reduce swelling
• Provide analgesia with acetaminophen; avoid NSAIDs in the first 24 hours due to theoretical bleeding risk
• Observe for 12-24 hours if any concerning features were present initially (even with normal CT), as delayed deterioration can occur 1

Critical Discharge Instructions and Follow-Up

Return Precautions (Must Provide Even if Initial CT Normal)

Instruct patient to return immediately for 1:

• Worsening or severe headache
• Repeated vomiting
• Increasing confusion or difficulty staying awake
• Weakness, numbness, or difficulty walking (unsteady gait is NOT typical of simple concussion and suggests intracranial pathology) 1
• Seizure activity
• Clear fluid draining from nose or ears

Special Consideration for Delayed Presentation

• Chronic subdural hematoma can develop up to 2 months after seemingly minor trauma with initially normal CT, particularly in elderly patients 1
• Symptoms may be subtle and overlap with post-concussion syndrome (headache, dizziness), but ataxia and unsteady gait should prompt repeat imaging 1
• Lower threshold for repeat CT if symptoms persist beyond 2 weeks or new symptoms develop 1

Common Pitfalls to Avoid

• Never assume a "simple bump" is benign based on external appearance alone - scalp hematomas can coexist with life-threatening intracranial hemorrhage 2, 3
• Never delay vasopressor use while attempting fluid resuscitation in hypotensive head trauma patients - this increases mortality 2, 3, 5
• Never attribute persistent dizziness and gait instability to "post-concussion syndrome" without repeat imaging - these symptoms are atypical and suggest structural pathology 1
• Never use hypotonic fluids (Ringer's lactate) in head trauma patients - use isotonic crystalloids only 2