What are the guidelines for urgent care triage of head injuries?

Head Injury Triage in Urgent Care: A Four-Step Algorithmic Approach

All head-injured patients presenting to urgent care should be systematically evaluated using the CDC's four-step field triage algorithm, with immediate transport to a trauma center for those meeting Step One (physiologic) or Step Two (anatomic) criteria. 1

Step One: Physiologic Criteria (Immediate Trauma Center Transport)

Transport immediately to a trauma center if ANY of the following are present:

• Glasgow Coma Scale ≤13 1
• Systolic blood pressure <90 mmHg 1
• Respiratory rate <10 or >29 breaths per minute, OR need for ventilatory support 1

These physiologic criteria identify the most critically injured patients who require the highest level of trauma care available. 1

Step Two: Anatomic Criteria for Head Injuries (Immediate Trauma Center Transport)

Transport immediately to a trauma center if ANY of the following head-specific injuries are identified:

• Open or depressed skull fracture 1
• Penetrating injuries to the head 1
• Paralysis (indicating potential spinal cord or severe neurologic injury) 1

Critical pitfall: Surface examination alone cannot adequately assess the extent of underlying injury in penetrating head trauma—these injuries place vital neurologic systems at immediate risk and require rapid neurosurgical capabilities. 1

Step Three: Mechanism of Injury (Transport to Appropriate Trauma Center)

Even without obvious physiologic or anatomic findings, transport to a trauma center if the mechanism suggests high-energy impact:

• Falls >20 feet in adults 1
• Falls >10 feet in children (or 2-3 times the child's height) 1
• High-risk auto crash with intrusion >12 inches (occupant site) or >18 inches (any site), including roof intrusion 1
• Ejection from vehicle (partial or complete) 1
• Death in same passenger compartment 1
• Auto vs. pedestrian/bicyclist thrown, run over, or impact >20 mph 1
• Motorcycle crash >20 mph 1

These patients may be transported to the closest appropriate trauma center, which need not be the highest-level facility depending on local protocols. 1

Step Four: Special Considerations for Head Injury (Contact Medical Control)

Patients on anticoagulation or with bleeding disorders who sustain head injury are at HIGH RISK for rapid deterioration and require urgent evaluation even with normal initial presentation. 1, 2

Additional high-risk factors requiring medical control consultation:

• Age >55 years (injury/death risk increases significantly; systolic BP <110 may represent shock after age 65) 1
• Age >65 years with ground-level falls (low-impact mechanisms can result in severe injury in older adults) 1
• Pregnancy >20 weeks 1, 2
• EMS provider judgment when clinical concern exists despite not meeting other criteria 1

Critical Management Principles

When in doubt, transport to a trauma center. 1 This guiding principle should override hesitation when triage criteria are borderline or clinical judgment suggests concern.

Physiologic Monitoring Requirements

For patients with altered consciousness (GCS <15), continuous monitoring must include:

• Neurologic status with serial GCS assessments 3
• Vital signs including blood pressure, heart rate, respiratory rate, and oxygen saturation 4
• Airway patency and ventilatory adequacy (airway establishment is the first priority before any other intervention) 5, 6

Common Pitfalls to Avoid

Do not rely on normal initial presentation in anticoagulated patients—these individuals can deteriorate rapidly hours after injury despite initially reassuring examination. 1, 2

Do not dismiss ground-level falls in elderly patients (>65 years)—age-related physiologic changes mean that mechanisms causing minimal injury in younger patients can be life-threatening in older adults. 1

Do not delay transport to obtain imaging at urgent care—patients meeting Step One or Step Two criteria require immediate transport to facilities with neurosurgical capabilities, not preliminary CT scanning at non-trauma centers. 1

Do not use systolic BP <90 mmHg as the sole shock indicator in elderly patients—after age 65, systolic BP <110 mmHg may represent shock and warrants trauma center evaluation. 1

Documentation Requirements Before Transfer

Essential data elements to communicate during transfer include:

• Glasgow Coma Scale score at presentation and any changes 4
• Mechanism of injury with specific details (fall height, crash velocity, intrusion measurements) 4
• Anticoagulation status if applicable 2, 4
• Time intervals from injury to presentation and from presentation to transfer 4
• Initial vital signs and any interventions performed 4

Pediatric-Specific Considerations

Children require preferential triage to pediatric-capable trauma centers when available. 1 The fall height threshold is lower (>10 feet vs. >20 feet in adults), and respiratory rate criteria differ for infants <1 year (upper limit >29 breaths/minute maintained to increase sensitivity). 1