Emergency Department Management of School-Age Boy with Brief Loss of Consciousness After Head Collision
Immediate Imaging is Mandatory
Any documented loss of consciousness after head trauma mandates immediate non-contrast head CT scan, regardless of current neurological status or GCS score of 15. 1
- Loss of consciousness is a high-risk criterion that cannot exclude intracranial injury even when the child appears completely normal on examination 1
- CT imaging must be obtained before any discharge decision, as LOC alone increases the risk of clinically important traumatic brain injury from 0.5% to 2.5% 2
- The American College of Radiology explicitly requires CT for any patient with witnessed LOC after head trauma 1
Why Normal Exam Does Not Eliminate Need for CT
- Approximately 5.6% of patients with LOC but no constitutional signs or symptoms still have intracranial injury on CT 3
- Children with isolated LOC (no other risk factors) still have a 0.5% risk of clinically important traumatic brain injury requiring intervention 2
- Never skip CT imaging based solely on normal neurological examination when LOC has been documented 1
Post-CT Discharge Criteria (Assuming Negative CT)
If the head CT is negative, the child can be safely discharged home without observation admission or repeat imaging, provided all of the following criteria are met: 1
- GCS remains 15 throughout ED evaluation 1
- Neurological examination remains completely normal 1
- Reliable caregiver is available for home observation 1
- No anticoagulant or antiplatelet therapy (not applicable to most school-age children) 1
Observation Period in ED
- Brief observation period of several hours in the ED is reasonable to monitor for any deterioration before discharge 4
- Serial neurological examinations during this period help detect any evolving symptoms 4
- However, routine hospital admission for observation is not necessary if CT is negative and exam remains normal 1
No Repeat Imaging Required
Routine repeat CT scanning or hospital admission for observation is not supported by evidence in neurologically intact patients with negative initial CT. 1
- Delayed intracranial hemorrhage requiring intervention is extremely rare in children without anticoagulation 1
- Repeat imaging increases costs and radiation exposure without changing outcomes 1
Critical Discharge Instructions
Parents must be instructed to return immediately for any of the following warning signs: 1
- Worsening or severe headache 1
- Repeated vomiting 1
- Confusion, disorientation, or difficulty recognizing people/places 1
- Slurred speech or difficulty speaking 1
- Weakness or numbness in extremities or face 1
- Vision changes or unequal pupils 1
- Seizures 1
- Increasing drowsiness or difficulty staying awake 1
- Any additional loss of consciousness 1
- Clear or bloody fluid from nose or ears 1
Home Monitoring Protocol
- Someone should check on the child every 2-3 hours for the first 24 hours, including waking them from sleep 1
- Avoid alcohol (if age-appropriate concern) for 48 hours 1
- Use acetaminophen (not NSADs or aspirin) for headache in first 48 hours 1
- Limit screen time as this worsens concussion symptoms 1
Common Pitfalls to Avoid
- Never assume brief duration of LOC (<10 minutes) eliminates need for CT - even very brief LOC requires imaging 1, 2
- Do not rely on absence of post-traumatic amnesia to skip imaging when LOC occurred 1
- Do not perform routine repeat imaging in stable patients with negative initial CT 1
- Do not discharge without clear return precautions and reliable home supervision 1
Sport-Related Concussion Considerations
- This child should be removed from all athletic activities immediately 4
- No return to play on the same day, even if symptoms resolve 4
- Graduated return-to-play protocol should be coordinated with primary care physician after symptom resolution 4
- Conventional neuroimaging (CT/MRI) is typically normal in concussive injury and contributes little to ongoing concussion management after initial ED evaluation 4