Management of Closed Head Injuries in Urgent Care

Table of Contents

 

About This Course

More than 2 million people in the United States seek medical attention for head injury each year, and UC clinicians are challenged almost daily to screen for the small subset of these patients who harbor a potentially dangerous intracranial injury. Across a range of clinical settings, with wide variations in access to advanced imaging and specialty follow-up care, as well as significant differences in proximity to hospitals and trauma centers, UC clinicians play a critical role in the diagnosis and management of mild closed head injury (CHI). Due to variability in the mechanisms of injury, as well as patient-specific factors, there is no “one-size-fits-all” approach to mild CHI. This course will review current recommendations and clinical guidelines for the management of patients with mild CHI.

How should patients with CHI be managed when they present to UC?

What are the risk factors for a clinically significant intracranial injury?

What are the special considerations for mild CHI in children, elderly patients, patients who have bleeding disorders, and patients who take anticoagulants or antiplatelet agents?

1. About This Course
2. Case Presentations
3. Introduction
   1. Definitions
4. Epidemiology
   1. Morbidity and Mortality
5. Pathophysiology
6. Urgent Care Evaluation and Management
   1. Initial Evaluation
   2. History
   3. Physical Examination
      1. Neurological Examination
         • Glasgow Coma Scale Score
         • Pupillary Reflexes
         • Motor and Balance Testing
7. Diagnostic Testing
   1. Laboratory and Bedside Studies
   2. Imaging Studies
      1. Plain Skull Radiography
      2. Computed Tomography
         • Clinical Decision Rules for Computed Tomography
         • Normalized Glasgow Coma Scale Score
8. Special Populations
   1. Elderly Patients
   2. Patients Taking Anticoagulants or Antiplatelet Agents
      1. Anticoagulants
      2. Antiplatelet Agents
   3. Patients With Bleeding Diatheses
   4. Intoxicated Patients
9. KidBits: Closed Head Injury in Pediatric Patients
10. Sports-Related Concussion
11. Post–Concussion Syndrome
12. Discharge and Follow-Up Instruction
13. Summary
14. Risk Management Pitfalls For Closed Head Injuries in Urgent Care
15. Case Conclusions
16. Clinical Pathways
    1. Clinical Pathway for Evaluating the Adult Patient With Closed Head Injury/Traumatic Brain Injury
    2. Clinical Pathway for Evaluating the Pediatric Patient With Closed Head Injury/Traumatic Brain Injury
17. Critical Appraisal of the Literature
18. References

Case Presentations

CASE 1: An 18-year-old boy is brought to the UC clinic by his parents after a head-to-head collision with another player during a soccer game…

• The patient was confused for several minutes and now has a resolving headache.
• His coach told his parents he “has a concussion” and should go to UC to be checked out...

CASE 2: A 38-year-old woman presents after hitting her head on a cabinet door at home…

• The patient was confused for several minutes and now has a resolving headache.
• She thinks she may have “blacked out” for a few seconds.
• She has some scalp tenderness with mild discoloration and a bit of swelling, but no other current complaints…

CASE 3: A 2-month-old girl is brought in by her parents with a visible bump on her head…

• The parents state that their babysitter told them the injury occurred when the baby rolled off the bed during a diaper change.
• They also note some inconsistencies in the babysitter’s story and are concerned that they don’t know all of the details of the event…

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Introduction

Urgent care (UC) clinicians can expect to see several patients each week who have sustained some type of blunt trauma to the head; many of these patients will present with chief complaints of facial or scalp lacerations and other wounds. The clinical approach to these patients varies widely, and despite the availability of clinical guidelines and decision tools, a substantial number of these patients will undergo ED transfer and/or computed tomography (CT) of the head. The large majority of head CTs performed on patients with mild closed head injury (CHI) will be interpreted as normal,¹ so the challenge for the UC clinician is to quickly identify the small subset of patients who harbor serious intracranial injuries, in order to avoid unwarranted ED transfers as well as to limit costly diagnostic procedures and unnecessary radiation exposure. UC clinicians must accurately document a neurologic baseline for serial examinations and provide discharge instructions that educate patients and families about the potential sequelae of head injury, regardless of how minor the injury appears to be. Further challenges include the rapidly evolving research and recommendations on head injury treatment in the sports arena, with nearly all states having active or pending laws on return to play for youth sports, and full elimination of any same-day return to play after concussive events.²

Clinical Pathway for Evaluating the Adult Patient With Closed Head Injury/Traumatic Brain Injury

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. National Conference of State Legislatures. Traumatic Brain Injury Legislation. Accessed December 15, 2021. (Database of state legistlation )

3. * McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-847. (Consensus statement)

6. * Cantu RC, Register-Mihalik JK. Considerations for return-to-play and retirement decisions after concussion. PM R. 2011;3(10 Suppl 2):S440-S444. (Consensus paper)

7. Centers for Disease Control and Prevention. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006 (Blue Book). Accessed December 15, 2021. (Statistical data)

10. * Pandor A, Goodacre S, Harnan S, et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation. Health Technol Assess. 2011;15(27):1-202. (Meta-analysis; 93 studies)

25 * Greenes DS, Schutzman SA. Clinical indicators of intracranial injury in head-injured infants. Pediatrics. 1999;104(4 Pt 1):861-867. (Prospective; 608 patients)

30. * Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59(6):460-468.e461-467. (Prospective; 1064 patients)

48. RadiologyInfo.org. Radiation Dose in X-Ray and CT Exams. Accessed December 15, 2021. (Radiation dosage recommendations)

55. Centers for Disease Control and Prevention amd the American College of Emergency Physicians. Updated Mild Traumatic Brain Injury Guideline for Adults. Accessed December 15, 2021. (Guideline)

80. * Fabbri A, Servadei F, Marchesini G, et al. Predicting intracranial lesions by antiplatelet agents in subjects with mild head injury. J Neurol Neurosurg Psychiatry. 2010;81(11):1275-1279. (Secondary analysis; 14,288 patients)

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Keywords: closed head injury, mild CHI, mTBI, traumatic brain injury, Glasgow Coma Score, GCS, intracranial injury, ICI, computed tomography, CT, loss of consciousness, LOC, PECARN, New Orleans Criteria, Canadian Head CT Rule, CATCH, CHALICE