Test Your Knowledge of Closed Head Injuries (Postscript 2 of 4)

EBUC Postscripts
Management of Closed Head Injuries in Urgent Care | May 2022

Which of the following patients can safely avoid a head CT and/or ED transfer?

A. A fussy but alert 18-month-old girl who is brought to the urgent care clinic by her parents after being struck by a thrown baseball. She has a parietal scalp hematoma, but a normal GCS score and no history of loss of consciousness (LOC).

B. A 72-year-old man who presents to the urgent care clinic with his wife after a slip and fall in his bathroom. He struck his forehead on the sink but had no LOC, according to his wife. He reports that he felt “dazed and foggy for a couple of minutes,” but is now asymptomatic. He takes no antiplatelet or anticoagulant agents, and has a normal neurologic exam.

C. A 38-year-old woman who presents to the urgent care clinic following a bicycle accident. She was helmeted and went over the handlebars after dodging a car and striking a curb. She landed on a concrete sidewalk and struck her head. She doesn’t think she was knocked out, but complains of a headache that is 7 of 10 on the pain scale, as well as right shoulder pain, right chest wall pain, and upper abdominal pain. 

D. A 17-year-old young man who is brought to the urgent care clinic by his father after being struck helmet-to-helmet by an opposing player in a football game. He had a very brief LOC and transient disorientation according to the team trainer’s report. The patient is healthy and not taking any medications. The injury occurred 2 hours before presentation and he has a GCS score of 15, no current symptoms, and a normal neurologic examination.

Answer: D. In patients aged <2 years, nonfrontal scalp hematoma is a high-risk feature that warrants CT/ED transfer. Patients aged >60 years are at higher risk for intracranial injury following head trauma, and CT/ED transfer is recommended for these patients. Patients with closed head injury and signs/symptoms concerning for significant thoracoabdominal trauma should be evaluated in settings that have CT, ultrasound, and STAT laboratory capabilities. Healthy young adult patients who present to urgent care following isolated mild head trauma with a normalized GCS score, mild or no symptoms, and a normal physical examination can be safely discharged with thorough written and verbal instructions and a plan for follow-up.

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