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

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

A 15-year-old girl presents to the urgent care clinic with her parents and coach on a Saturday morning after sustaining a presumed concussion while playing basketball. She is in town for a tournament, and was struck in the left parietotemporal region by an errant elbow during a game; the injury occurred about 4 hours prior to presentation. She was knocked to the ground by the hit but did not sustain any apparent loss of consciousness. Witnesses report that she was confused and “wobbly” for 2 to 3 minutes. She developed a headache and nausea afterwards but both were fleeting and have now resolved. Three years prior, this patient sustained a presumed concussion during a soccer match and recovered fully, quickly, and uneventfully as an outpatient. She takes no medications and has no known medical conditions. Her vital signs and neurologic examination, including gait and finger-nose-finger testing, are normal.

Which of the following options represents the best course of action in the management of this patient?

A. Transfer her to the ED immediately for trauma evaluation and emergent head CT scan.

B. Do not allow return to play today, but clear her for play tomorrow as long as she remains asymptomatic. The family has spent a considerable amount of money on travel and lodging to have her play in the tournament, and the concussion was mild.

C. Pull her from play and institute physical and cognitive rest for the next week, at which point she should be re-evaluated by her primary care provider or a concussion specialist.

D. Order an outpatient head CT; if the CT is negative and the patient remains asymptomatic, she can be cleared to play tomorrow since a negative CT result rules out brain injury.

Answer: C. This patient has sustained a mild concussion, and meets no indication for emergent head CT. Following concussion, patients should be counseled on the importance of physical and cognitive rest. Most sources recommend a minimum brain rest period of 7 to 10 days following a concussion prior to consideration of clearance to resume physical activity.

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