An 8-year-old boy who fell face‑first onto hard linoleum, now with transient grogginess, irritability, photophobia, headache, vomiting, a negative head CT and a normal neurologic exam, and who has received ondansetron (Zofran) and ibuprofen (Advil), what additional emergency department and home interventions are recommended for his presumed concussion?

Management of Presumed Concussion in an 8-Year-Old with Negative CT

This child requires close neurological monitoring in the ED for at least 4-6 hours with serial neurological examinations, comprehensive discharge education with written instructions, and strict return precautions—but no additional imaging or medications are needed at this time given the negative CT and normal neurological exam. 1

Continued Emergency Department Management

Serial Neurological Assessment

• Perform neurological examinations every 30-60 minutes while in the ED to detect any secondary deterioration, focusing on Glasgow Coma Scale (particularly motor response), pupillary size and reactivity, and level of alertness 1
• The child's initial grogginess and current sleeping represent concerning features that warrant extended observation despite the negative CT 1
• Any decrease of 2 or more points in GCS or new focal neurological deficits would require repeat CT imaging 1

Observation Period

• Maintain ED observation for a minimum of 4-6 hours from the time of injury before considering discharge, as extended clinical observation can safely reduce unnecessary imaging and detect delayed deterioration 1
• The child's vomiting, photophobia, and altered mental status (grogginess, difficulty waking) place him at moderate risk despite negative imaging 1

Medication Management

• Continue symptomatic treatment with ondansetron for persistent vomiting as already administered 2, 3
• Acetaminophen is preferred over ibuprofen for headache management in the acute post-injury period (first 24-48 hours) due to theoretical concerns about NSAIDs potentiating intracranial bleeding, though evidence of actual harm is lacking 4, 5
• After 48 hours, ibuprofen can be used safely and may be more effective for persistent headaches 5

Discharge Instructions and Home Management

Immediate Post-Injury Rest Protocol

• Mandate complete physical and cognitive rest for 24-48 hours, meaning no school, screen time, reading, or physical activity 4, 1
• After this initial rest period, begin gradual return to light activities as tolerated without symptom provocation 4, 1
• Avoid strict prolonged rest beyond 48 hours, as evidence shows this may be detrimental to recovery 4

Critical Return Precautions

Instruct caregivers to return immediately or call 911 for:

• Persistent or worsening vomiting (more than 2-3 episodes) 4, 6
• Increasing drowsiness or difficulty waking the child 4, 6
• Seizure activity 6
• Severe or worsening headache despite medication 4, 6
• Excessive irritability or significant behavior changes 4
• Unsteady walking or coordination problems 4
• Visual changes or unequal pupil size 4, 6
• Any new focal neurological symptoms 1

Monitoring at Home

• Wake the child every 2-3 hours during the first night to assess responsiveness and neurological status 4
• Parents should be able to arouse the child to full consciousness and have him answer simple questions appropriately 4

Follow-Up Care

• Schedule follow-up with primary care physician within 24-48 hours for reassessment and ongoing concussion management 2, 1
• Consider referral to a sports concussion clinic if symptoms persist beyond 7-10 days, as most children recover within this timeframe 4, 2
• Approximately 80-90% of children recover within one month, though some may take longer 4

Return to School Protocol

Gradual Return Strategy

• Begin with 30-60 minutes of light cognitive activity (quiet reading, simple homework) once asymptomatic at rest 1
• If symptoms return with activity, stop immediately and rest until symptoms resolve 1
• Progress to half-days at school with accommodations (extra time for assignments, reduced homework, frequent breaks) before attempting full days 1
• Never allow return to physical education, recess, or sports while any symptoms persist 4, 1

Academic Accommodations

• Provide written documentation to school requesting temporary accommodations including reduced workload, extended time on tests, frequent breaks, and excused absences from physical activities 1

Symptom Management at Home

Headache Management

• Use acetaminophen (15 mg/kg every 6 hours as needed) as first-line for the first 48 hours 4, 5
• After 48 hours, ibuprofen (10 mg/kg every 6-8 hours) may be more effective for persistent headaches 5
• Alternating acetaminophen and ibuprofen showed the best outcomes in pilot studies, with 79% of patients back at school within one week 5

Environmental Modifications

• Reduce light exposure given his photophobia—dim lights, limit screens, use sunglasses if needed 1
• Minimize noise in the home environment 1
• Ensure adequate sleep with consistent sleep-wake schedule 1

Important Caveats

What NOT to Do

• Do not obtain repeat CT imaging unless there is clinical deterioration, as routine follow-up imaging in mild TBI with negative initial CT is not indicated 1
• Do not enforce strict bed rest beyond 48 hours, as this delays recovery 4
• Do not allow return to any contact sports or high-risk activities until completely asymptomatic and cleared by a physician experienced in concussion management 1

Common Pitfalls to Avoid

• The child's initial grogginess and difficulty waking are concerning features that warranted the ED visit and CT, but with negative imaging and normal exam, these symptoms can be managed conservatively with close observation 1
• Vomiting in the first few hours post-injury is common and does not necessarily indicate worsening injury if it resolves and the child remains neurologically stable 1
• The use of ondansetron does not mask clinically significant injuries—studies show no difference in rates of missed intracranial injuries between children treated with and without ondansetron 7

Recovery Expectations

• Most children recover within 7-10 days, though 10-20% may have symptoms persisting beyond one month 4, 1
• Pediatric patients generally have longer recovery times than older adolescents or adults 4
• Symptoms typically improve gradually rather than resolving suddenly 1