A female patient who fell last night with head trauma now has eye pain, tingling in her fingers, and recurrent falls/bumping into objects—what immediate actions should be taken?

Immediate Management of Patient with Head Trauma, Eye Pain, and Neurological Symptoms

This patient requires immediate emergency department evaluation with urgent head CT imaging and ophthalmologic assessment—she has sustained head trauma with concerning neurological symptoms (recurrent falls, tingling fingers, visual disturbance) that mandate emergent workup for intracranial hemorrhage and ocular injury. 1

Immediate Actions Required

1. Emergency Department Transport and Initial Assessment

• Transport to ED immediately if not already there—this patient has sustained head trauma with ongoing neurological symptoms including altered coordination (running into things, falling), sensory changes (tingling fingers), and eye pain following direct head impact 1, 2
• Assess Glasgow Coma Scale (GCS) score to stratify injury severity—mild TBI is defined as GCS 14-15, moderate as GCS 9-13 1, 3
• Document mechanism of injury (fall with head strike), loss of consciousness, post-traumatic amnesia, and timing of symptom onset 1
• Check vital signs including blood pressure (maintain systolic BP >110 mmHg), oxygen saturation (>95%), and ensure airway protection 4

2. Urgent Neuroimaging

• Obtain non-contrast head CT scan immediately—this is the standard of care for acute head trauma with neurological symptoms 1
• The ACR Appropriateness Criteria designate head CT as "usually appropriate" for acute head trauma with any concerning clinical features 1
• Do NOT delay imaging for clinical observation in a patient with progressive neurological symptoms (recurrent falls, coordination problems) 1

3. Ophthalmologic Evaluation

• Perform immediate eye examination including visual acuity testing, pupillary examination, extraocular movements, and direct ophthalmoscopy of both eyes 2, 5
• Eye pain following head trauma raises concern for globe injury, orbital fracture, retinal detachment, or traumatic optic neuropathy 2, 5
• Apply eye shield if globe rupture suspected—do NOT apply pressure to the eye 5
• Obtain ophthalmology consultation emergently if any of the following are present: decreased visual acuity, abnormal pupillary responses, visible globe injury, or hyphema 2, 5

Critical Medication History

• Immediately determine anticoagulant or antiplatelet use—patients on warfarin, NOACs (novel oral anticoagulants), clopidogrel, or ticagrelor have significantly higher risk of intracranial hemorrhage (3.9% vs 1.5% in non-anticoagulated patients) 1
• If on anticoagulation, the threshold for imaging is very low and repeat imaging after 4-6 hours of observation is often indicated even with normal initial CT, as delayed hemorrhage occurs in up to 6% of cases 1

Risk Stratification Using Brain Injury Guidelines (BIG)

Based on initial head CT findings and clinical examination, classify the patient using BIG criteria 6, 7:

BIG 1 (Low Risk)

• Normal head CT, no anticoagulation, GCS 15, no neurological deficits
• May consider ED discharge with close follow-up 6, 7

BIG 2 (Moderate Risk)

• Skull fracture only OR on anticoagulation with normal CT
• Requires admission and observation with possible repeat CT 6, 7

BIG 3 (High Risk)

• Any intracranial hemorrhage on CT OR neurological deterioration
• This patient likely falls into BIG 3 given her progressive neurological symptoms (recurrent falls, coordination problems, sensory changes) 6, 7
• Requires neurosurgical consultation, admission to monitored setting, and repeat head CT if clinical deterioration occurs 6, 7
• 16.3% of BIG 3 patients require neurosurgical intervention 7

Ongoing Monitoring and Repeat Imaging

• Perform serial neurological examinations every 1-2 hours initially, assessing GCS, pupillary responses, motor/sensory function, and coordination 1, 4
• Obtain repeat head CT if any clinical deterioration occurs, including worsening headache, altered mental status, new focal deficits, or seizure 1, 6
• In patients on anticoagulation with initially normal CT, repeat imaging after 4-6 hours of observation is recommended before discharge 1
• Nearly half of moderate head injury patients require repeat CT scanning, with 32% showing radiographic progression 3

Common Pitfalls to Avoid

• Do not discharge a patient with ongoing neurological symptoms (this patient's recurrent falls and coordination problems) without imaging and period of observation 1, 6
• Do not assume eye pain is minor—ocular emergencies including globe rupture, retinal detachment, and acute angle-closure glaucoma require immediate ophthalmologic intervention to preserve vision 2, 5
• Do not rely on skull fracture presence/absence to predict intracranial injury—skull fractures are poor indicators of intracranial abnormalities 3
• Do not use hyperventilation or mannitol prophylactically—reserve these interventions for clinical deterioration with signs of herniation 4

Disposition Planning

• Admit for observation if head CT shows any abnormality, patient is on anticoagulation, or neurological symptoms persist 1, 6, 7
• Neurosurgical consultation required for any intracranial hemorrhage, depressed skull fracture, or clinical deterioration 6, 7
• If BIG 1 classification with completely normal examination and imaging, may consider discharge with strict return precautions 7
• Ensure ophthalmology follow-up within 24 hours if any ocular abnormalities detected 2, 5