How should head injuries be managed in the urgent care setting?

Management of Head Injuries in the Urgent Care Setting

In the urgent care setting, patients with mild traumatic brain injury (GCS 14-15) should undergo non-contrast head CT if they present with any of the following risk factors: loss of consciousness, post-traumatic amnesia, vomiting, age >60 years, headache, drug/alcohol intoxication, focal neurological deficit, short-term memory deficit, physical trauma above the clavicle, post-traumatic seizure, or coagulopathy. 1, 2

Initial Assessment and Risk Stratification

The urgent care approach to head injuries must focus on rapidly identifying patients who require CT imaging versus those who can be safely discharged. The key is systematic risk stratification based on validated clinical criteria.

High-Risk Patients Requiring Immediate CT Imaging

Patients presenting with any of the following factors warrant non-contrast head CT 1, 2:

• Loss of consciousness or post-traumatic amnesia - These are fundamental indicators, though neither alone is sufficiently sensitive to exclude all at-risk patients 1, 2
• Vomiting (especially >1 episode) - Strong predictor of intracranial injury 1
• Age >60-65 years - Significantly increases risk of intracranial pathology 1, 2
• Focal neurological deficit - Indicates structural injury requiring identification 1, 2
• Severe headache - Not just mild discomfort 1
• GCS score <15 - Any deviation from perfect score 1, 2
• Signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF otorrhea/rhinorrhea) 1, 2
• Post-traumatic seizure 1, 2
• Coagulopathy or anticoagulant/antiplatelet therapy - Lower threshold for imaging in these patients 1, 2
• Drug or alcohol intoxication - Impairs clinical assessment 1, 2
• Short-term memory deficits 1, 2
• Physical evidence of significant trauma above the clavicle 1, 2

Patients Without Loss of Consciousness or Amnesia

Even patients without loss of consciousness or post-traumatic amnesia should receive CT imaging if they have focal neurological deficit, vomiting, severe headache, age ≥65 years, signs of basilar skull fracture, GCS <15, coagulopathy, or dangerous mechanism of injury (ejection from vehicle, pedestrian struck, fall >3 feet or 5 stairs) 1.

Critical Clinical Context

Up to 15% of patients with GCS 15 will have an acute lesion on head CT, though less than 1% require neurosurgical intervention 1, 2. This underscores why clinical decision rules are essential - they prevent both over-imaging and missed injuries.

Patients Safe for Discharge Without Imaging

Patients with NO loss of consciousness, NO vomiting or amnesia, normal neurological examination, and minimal or no subgaleal swelling can be safely discharged without imaging 3. These patients require:

• Clear discharge instructions with warning signs 3
• Responsible adult supervision 3
• Instructions to return if symptoms develop 3

Common Pitfalls to Avoid

• Do not rely on skull radiographs - They are not sensitive enough for screening and negative findings can be misleading 2
• Do not dismiss patients based solely on mechanism - Clinical factors trump mechanism alone 2
• Do not assume absence of loss of consciousness excludes injury - Other risk factors still mandate imaging 2
• Lower your threshold significantly for elderly patients and those on anticoagulation - These populations have substantially higher risk 1, 2

When to Transfer vs. Manage in Urgent Care

Immediate transfer to emergency department is required for:

• Any patient requiring CT imaging who cannot be scanned at your facility 4
• GCS <15 1
• Deteriorating neurological status 5, 6
• Suspected intracranial hemorrhage on CT 5, 6
• Patients requiring neurosurgical consultation 5, 6

Rapid transport to a trauma center capable of neurosurgical services is essential because definitive management of head-injured patients is not possible in urgent care settings 4.

Documentation Requirements

Document the following for every head injury patient 3:

• Exact mechanism of injury
• Presence or absence of loss of consciousness and duration
• Presence or absence of amnesia (retrograde and anterograde)
• Number of vomiting episodes
• Complete neurological examination including GCS
• All risk factors assessed
• Rationale for imaging decision or discharge