What should be done for a 15-year-old female who hit her head and lost consciousness?

Immediate Management of a 15-Year-Old Female with Head Injury and Loss of Consciousness

This patient requires immediate emergency department evaluation with consideration for non-contrast head CT imaging based on high-risk clinical features. Loss of consciousness following head trauma in an adolescent mandates urgent medical assessment to rule out intracranial injury, which occurs in approximately 4-8% of such cases 1.

Immediate Actions Required

Emergency Department Transport and Initial Assessment

• Activate emergency medical services (EMS) immediately - any adolescent with loss of consciousness after head trauma requires professional medical evaluation and should not be transported by private vehicle 1.
• The patient must be kept still and monitored continuously during transport, as approximately 18% of patients who deteriorate after head injury do so between days 2-7 2.
• Upon ED arrival, perform rapid assessment including Glasgow Coma Scale (GCS) score, vital signs, and brief neurological examination 1.

Critical Red Flags Requiring Immediate CT Imaging

The following high-risk features mandate urgent non-contrast head CT 1, 3:

• Any loss of consciousness (this patient meets this criterion)
• GCS score <15 at 2 hours post-injury
• Severe or worsening headache
• Repeated vomiting
• Signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF otorrhea/rhinorrhea)
• Focal neurological deficits
• Palpable skull fracture
• Altered mental status or confusion

Neuroimaging Decision-Making

CT head without contrast is the imaging modality of choice for this patient 1, 3. The decision algorithm is:

• High-risk patients (GCS ≤14, altered mental status, signs of skull fracture, focal deficits, or loss of consciousness with additional risk factors): CT is indicated with 4.4-16% risk of clinically important traumatic brain injury 2, 3.
• For adolescents ≥2 years with isolated brief loss of consciousness but GCS=15 and no other risk factors, observation with possible CT may be considered based on clinical judgment 1, 3.
• Do not obtain routine skull radiographs - up to 50% of intracranial injuries occur without fracture, and radiographs miss many fractures that CT would detect 2, 3.
• MRI has no role in acute evaluation - it is impractical, requires sedation, and provides no advantage over CT for detecting acute hemorrhage or fractures 1, 2.

Mandatory Restrictions and Monitoring

Immediate Activity Restrictions

The patient must immediately cease all activities and await medical evaluation 1. Specifically:

• No driving, cycling, or use of mechanical machinery until cleared by a healthcare provider 1.
• Complete removal from sports participation - the patient cannot return to play the same day under any circumstances 1.
• No physical exertion until medically cleared 1.

Critical Warning Signs for Deterioration

Instruct caregivers to return immediately to the ED if any of the following develop 2:

• Worsening or severe headache
• Repeated vomiting (especially multiple episodes)
• Increasing confusion or disorientation
• Unusual drowsiness or difficulty waking
• Seizures
• Weakness, numbness, or slurred speech
• Unequal pupil size
• Significant behavior changes

Disposition and Follow-Up

If CT is Normal and Patient is Neurologically Intact

• The patient can be safely discharged home with comprehensive written instructions if CT shows no intracranial injury and neurological examination is normal 1.
• Provide detailed discharge instructions using standardized tools (such as CDC's modified ACE Care Plan), which significantly improve follow-up compliance (32% to 61%) and parental recall of instructions 4.
• Schedule follow-up within 24-48 hours with primary care provider or concussion specialist 1, 4.
• Expect gradual symptom resolution over 1-2 weeks; persistent symptoms beyond 2 weeks warrant specialist referral 1, 3.

If CT Shows Intracranial Injury

• Immediate neurosurgical consultation is required 1.
• Hospital admission for observation and serial neurological assessments 3.
• Less than 1% of mild TBI patients require neurosurgical intervention, but those with positive CT findings need close monitoring 1.

Common Pitfalls to Avoid

• Never minimize the injury using terms like "ding" or "getting your bell rung" - these trivialize potentially serious brain injury 1.
• Do not allow same-day return to activity even if the patient "feels fine" - this significantly increases risk of second impact syndrome 1.
• Do not delay imaging when high-risk features are present - clinical gestalt alone misses significant injuries 1, 3.
• Do not discharge without written instructions - verbal instructions alone result in poor compliance and increased risk of complications 4.