What are the immediate steps for a patient with a brief loss of consciousness (LOC) after hitting their head, considering factors such as age, medical history, including anticoagulant therapy, and mechanism of injury?

Immediate Management of Brief Loss of Consciousness After Head Trauma

For any patient with brief loss of consciousness (LOC) after hitting their head, obtain a noncontrast head CT scan immediately—this is the standard of care regardless of current neurological status. 1

Initial Assessment and CT Imaging Decision

CT imaging is mandatory when LOC has occurred, as loss of consciousness is itself a high-risk criterion that cannot exclude intracranial injury even with a Glasgow Coma Scale (GCS) score of 15. 1

Key Clinical Factors That Strengthen the Need for Immediate CT:

• Age ≥60-65 years – This dramatically increases risk (odds ratio 19.2 for intracranial injury) and warrants imaging even with minimal symptoms 1, 2, 3
• Anticoagulation or antiplatelet therapy (warfarin, NOACs, clopidogrel, ticagrelor) – These patients have 2-4 times higher risk of significant intracranial hemorrhage (3.9% vs 1.5% in non-anticoagulated patients) and require CT regardless of mechanism severity 1, 2
• GCS score of 14 (not 15) at any point during evaluation 1
• Post-traumatic amnesia of any duration 1
• Vomiting (especially if repeated) 1
• Severe or worsening headache 1, 4
• Focal neurological deficits 1
• Physical signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF leak) 1
• Dangerous mechanism of injury (motor vehicle accident, fall >3 feet/5 stairs, pedestrian struck, assault) 1, 4

Special Populations Requiring Lower Threshold for Imaging

Anticoagulated Patients

All patients on anticoagulants or antiplatelet agents (excluding aspirin monotherapy) require immediate head CT after any head trauma with LOC. 1, 2

• Warfarin increases intracranial hemorrhage risk to 3.9% vs 1.5% baseline 1
• NOACs have lower risk than warfarin (2.6% vs 10.2%) but still significantly elevated 1
• Clopidogrel and dual antiplatelet therapy carry similar high risk 1
• Aspirin monotherapy alone does not require routine repeat imaging but initial CT is still indicated with LOC 1

Elderly Patients (≥65 years)

Age ≥65 years combined with LOC mandates CT imaging due to substantially elevated baseline risk for intracranial injury, even with seemingly minor mechanisms. 2, 4, 3

Post-CT Management Algorithm

If Initial CT Shows NO Hemorrhage:

For patients NOT on anticoagulants/antiplatelet agents:

• Discharge is safe if GCS remains 15, neurological exam is normal, and reliable caregiver is available for home observation 1, 4
• No routine repeat imaging or hospital admission is needed 1
• Provide clear written discharge instructions about warning signs 1, 4

For patients ON anticoagulants/antiplatelet agents (warfarin, NOACs, clopidogrel):

• Discharge without repeat imaging is acceptable if initial CT is negative, GCS is 15, and neurological exam is normal 1
• Delayed intracranial hemorrhage occurs in only 0.6% of warfarin patients and 0% of clopidogrel patients with negative initial CT 1
• Routine observation or repeat CT is NOT supported by evidence for neurologically intact patients with negative initial scan 1

If Initial CT Shows Intracranial Hemorrhage:

• Immediate neurosurgical consultation 1, 2
• Hold anticoagulation and consider reversal agents (andexanet alfa for apixaban/rivaroxaban, prothrombin complex concentrate for warfarin) 2
• Obtain repeat CT within 6-24 hours as anticoagulated patients have 3-fold increased risk of hemorrhage progression (26% vs 9%) 2, 3
• Hospital admission for neurological monitoring 1, 2

Discharge Instructions and Warning Signs

Patients discharged after negative CT must return immediately for any of the following: 1, 4

• Worsening or severe headache not relieved by acetaminophen
• Repeated vomiting
• Confusion, disorientation, or difficulty recognizing people/places
• Slurred speech or difficulty speaking
• Weakness or numbness in extremities or face
• Vision changes or unequal pupils
• Seizures
• Increasing drowsiness or difficulty staying awake
• Any loss of consciousness after the initial injury
• Clear or bloody fluid from nose or ears

Observation Protocol at Home:

• Someone should check on the patient every 2-3 hours for the first 24 hours, including waking them from sleep 4
• Avoid alcohol for 48 hours 4
• Avoid driving for 24 hours or until cleared by physician 4
• Use acetaminophen (not NSAIDs or aspirin) for headache in first 48 hours 4
• Limit screen time as this worsens symptoms 4

Common Pitfalls to Avoid

• Never skip CT imaging in a patient with documented LOC, even if they are now neurologically normal with GCS 15 1
• Do not rely on absence of amnesia or brief duration of LOC to exclude intracranial injury—studies show these factors are insufficiently sensitive 1
• Do not perform routine repeat imaging in stable patients with negative initial CT, as this increases costs and radiation without changing outcomes 1
• Do not unnecessarily admit anticoagulated patients with negative CT and normal exam for observation—delayed hemorrhage requiring intervention is extremely rare (0.6%) 1
• Do not forget to assess fall risk and anticoagulation indication in elderly patients before discharge 2, 4, 3
• Optimal CT timing is ≥5 hours post-injury for lesion detection, but do not delay imaging if high-risk features are present 3