Trivial, Minimal, and Minor Head Trauma (Concussion)

CHAPTER 10

Trivial, Minimal, and Minor Head Trauma

(Concussion)

Presentation

Trivial or minimal head injuries are those that occur when an individual has been struck by a lightweight stick, has banged his head on the underside of a cabinet, or has fallen forward and struck his forehead on an object. There may or may not be an associated laceration, small hematoma, mild headache, or transient nausea or drowsiness. There is no loss of consciousness, amnesia, disorientation, vomiting, or seizure. The patient or family may be alarmed by the deformity caused by a rapidly developing scalp hematoma or “goose egg.”

Minor head injuries or concussion may present after a sports injury, such as a forceful collision with an opponent or stationary object or any unprotected fall onto a hard floor.

Grade 1 concussions cause no loss of consciousness but may cause brief confusion or alteration in mental status that resolves within 15 minutes. Posttraumatic amnesia lasts less than 30 minutes.

Grade 2 concussions cause no loss of consciousness or brief loss of consciousness (less than 5 minutes), but confusion or mental status changes last longer than 15 minutes. Posttraumatic amnesia lasts longer than 30 minutes.

Grade 3 concussions cause loss of consciousness lasting longer than 5 minutes or post-traumatic amnesia lasting longer than 24 hours.

Patients with concussion may appear dazed or demonstrate a change in typical behavior or personality. They may report headache, nausea, dizziness, or feeling “foggy” or “not sharp.” There may also be irritability or inappropriate emotional reaction (laughing, crying).

What To Do:

Corroborate and record the history as given by witnesses. Ascertain why the patient was injured (was there a seizure or sudden weakness?), and rule out particularly dangerous types of head trauma. (A blow inflicted with a brick or a hammer is likely to produce a depressed skull fracture; a pedestrian who has been struck by a vehicle or who is victim of a violent assault is more likely to have a serious intracranial lesion.)

Perform and record a physical examination of the head, looking for signs of a skull fracture, such as hemotympanum, posterior auricular or periorbital ecchymosis (Battle and Raccoon signs), or bony depression, and examine the neck for spasm, bony tenderness, limited range of motion, and other signs of associated injury.

Consider the possibility of child abuse when there are other injuries, especially fractures and facial injuries, particularly if the child is younger than 1 year of age, if the family has a poor support system or resources, or if an unstable family situation exists.

Perform and record a neurologic examination, paying special attention to mental status, cranial nerves, strength, and deep tendon reflexes to all four limbs. A funduscopic examination should be performed, looking for retinal hemorrhages, whenever child abuse is suspected.

If the history or physical examination suggests a clinically significant intracranial injury, obtain a noncontrast CT scan of the head. Criteria for obtaining a CT scan for an adult include documented loss of consciousness, amnesia, severe headache, persistent nausea and vomiting, cerebrospinal fluid leaking from the nose or ear, blood behind the tympanic membrane or over the mastoid (Battle sign), confusion, stupor, coma (a Glasgow Coma Scale score of 14 or less), physical evidence of significant trauma above the clavicles, or any focal neurologic sign. A CT scan should also be ordered if the patient is elderly (older than 60 years of age), is taking anticoagulant medications, has a known or suspected bleeding diathesis, or appears to be abusing alcohol or other drugs, or when there is a dangerous mechanism or previous neurosurgery or epilepsy. A CT scan is also indicated in patients with concerning findings, those who have no one to observe them or are unreliable.

If the history or physical examination suggests a clinically significant depressed skull fracture, such as a blow inflicted with a heavy object, suspected skull penetration, or palpable depression, obtain a CT scan to confirm or rule out the diagnosis. If a depressed skull fracture is discovered, arrange for neurosurgical consultation.

Criteria for obtaining a CT scan for a child include abnormal mental status (i.e., a Glasgow Coma Scale score or pediatric Glasgow Coma Scale score of less than 15 or confusion, somnolence, or repetitive or slow verbal communication), clinical signs of skull fractures (i.e., a palpable depressed fracture, retroauricular bruising, periorbital bruising, hemotympanum, or cerebrospinal fluid otorrhea or rhinorrhea), a history of vomiting or complaint of headache, and, in children aged 2 years or younger, a scalp hematoma.

If the injury is considered trivial or minimal or fits the criteria for a category 1 or category 2 concussion, and no criteria for obtaining a CT scan (as mentioned earlier) have been met, then there is no longer a clinical indication for obtaining a CT scan. Explain to the patient and concerned family and friends why radiographic images are not being ordered. Many patients expect radiograph or CT examinations but will gladly forego them once they understand that they probably would be of little value and not worth the significant risk from ionizing radiation exposure. Also, provide reassurance as to the benign nature of a scalp hematoma, despite the sometimes frightening appearance.

Explain to the patient and a responsible family member or friend that the more important possible sequelae of head trauma are not always diagnosed by reading radiographs but rather by noting certain signs and symptoms that occur later. Ensure that they understand and are given written instructions to seek immediate emergency care if any abnormal behavior, increasing drowsiness or difficulty in rousing the patient, headache, neck stiffness, vomiting, visual problems, weakness, or seizures are noted.

Recommend the appropriate length of time to abstain from sports participation after concussion. With a Grade 1 concussion, an athlete may return to play on the same day if there is a normal clinical examination at rest and after exertion. If the athlete becomes symptomatic, he may return to play in 7 days if he remains asymptomatic at rest and with exertional provocative testing (e.g., sit-ups).

With a Grade 2 concussion, an athlete may return to play in 2 weeks if he remains asymptomatic at rest and with exertion for 7 days.

Parents should be informed about the possibility of postconcussive syndrome, characterized by persistent headache, lightheadedness, easy fatigability, irritability, or sleep disturbance. No player should return to playing sports unless he is completely asymptomatic both at rest and with exertion. If an athlete has persistent symptoms after 1 week, a CT scan or magnetic resonance imaging (MRI) scan is recommended.

Second and third concussions require more extended time before allowing the patient to return to play, and the athlete may have to be removed for the entire season.

What Not To Do:

Do not skimp on the neurologic examination or its documentation.

Do not obtain a head CT scan for isolated loss of consciousness without other signs or symptoms that meet the criteria for CT imaging.

Discussion

There is no universal agreement on the definition of a concussion. One of the most popular working definitions is a trauma-induced alteration in mental status that may or may not be accompanied by a loss of consciousness. Its pathophysiologic basis remains a mystery. It is unclear whether concussion is associated with lesser degrees of diffuse structural change seen in severe traumatic brain injury or if the entire mechanism is caused by reversible functional changes.

Published grading scales for concussion are not validated and represent a view from various experts, not a consensus of scientific evidence. The only exception is the Glasgow Coma Scale.

Good clinical judgment and the ability to identify postconcussion signs and symptoms will ensure that athletes do not return to play while symptomatic. It should be noted that second-impact syndrome, although rare, is a fatal, uncontrollable diffuse brain swelling that occurs after a blow to the head that is sustained before full recovery from a previous injury to the head. Previous concussions may also be associated with slower recovery of neurologic function.

A head CT scan is recommended in all elderly patients with minor head trauma. Known physiologic changes with aging may make the geriatric brain more susceptible to injury. Reduction in overall brain weight increases the space between the brain and the skull, which increases the risk for shearing and tearing of the bridging vessels. This also allows expansion of intracranial pressure and the classic symptoms expected with this pathophysiology.

Loss of consciousness alone is not predictive of significant head injury and is not an absolute indication for head CT. Most children sustaining blunt head trauma do not have traumatic brain injury. The benefits of information gained by CT imaging must be balanced by its disadvantages, which include exposure to ionizing radiation (which may have a significant impact on future cognition and cancer risk), transport of the child away from the ED, the frequent requirement for pharmacologic sedation, additional healthcare costs, and increased time spent in the hospital. When there is no abnormality in mental status, no clinical signs of skull fracture, no history of vomiting, no headache, or no scalp hematoma (in children 2 years of age or younger), careful observation at home is an acceptable approach, with reevaluation and CT scanning for persistent or worsening symptoms. Children who are awake, alert, and asymptomatic (except when child abuse is suspected in children 2 years of age or younger) do not require special imaging.

Because of the risks for late neurologic sequelae (e.g., subdural hematoma, seizure disorder, meningitis, postconcussion syndrome), good follow-up is essential after any head trauma, but most patients without findings on initial examination do well. It is probably unwise to describe to the patient all of the subtle possible long-term effects of head trauma, because many may be induced by suggestion. Concentrate on explaining the danger signs that patients should watch for over the next few days. If postconcussion symptoms occur, a more formal neuropsychologic evaluation can delineate any subtle cognitive changes associated with the injury.

There is no universally accepted rule for determining whether CT head scanning is necessary. The criteria for ordering a CT scan suggested earlier represent a conservative but not scientifically proven approach. Adults and pediatric patients with minor head injuries who meet the criteria for a CT scan but have a normal scan and neurologic examination may be safely discharged and sent home. One exception is with elderly anticoagulated patients, who require at least 6 hours of observation. The risk for delayed deterioration is low, but not zero, in any head-injured patient who is discharged to home. It is therefore mandatory that written discharge instructions be provided to competent caretakers regarding signs and symptoms of complications of head trauma and that these caretakers are able to bring the patient back to medical care if necessary. The patient may be given acetaminophen for headache, but more potent analgesics are best avoided so that any progression of symptoms can be detected. Postdischarge indications for return to the ED include confusion or impaired consciousness, abnormal gait, alteration in behavior, difficulty with eyesight, vomiting, worsening headache, unequal pupil size, or any other worrisome abnormality. Cold packs may be recommended to reduce the swelling, and the patient may be reassured that the hematoma will resolve in a few days to weeks. Patients should be considered for hospital admission for all but minimal or trivial injuries if there is no competent observer at home. Other indications for admission are intractable headache, nausea or other progressive symptoms, alcohol or drug intoxication, and any abnormalities in the neurologic examination.