Management of Head Injury without Loss of Consciousness

Immediate Assessment and Decision for Imaging

Patients who fall and hit their head without loss of consciousness should undergo CT imaging if they have any of the following high-risk features: focal neurologic deficit, vomiting, severe headache, age ≥65 years, physical signs of basilar skull fracture, GCS <15, coagulopathy, or dangerous mechanism of injury (fall >3 feet or 5 stairs) 1
The American College of Emergency Physicians recommends CT imaging for patients with high-risk features, including focal neurologic deficits, vomiting, severe headache, age ≥65 years, physical signs of basilar skull fracture, GCS <15, coagulopathy, or dangerous mechanism of injury 1

Patients should return immediately to the emergency department if they develop worsening or severe headache that doesn't improve with over-the-counter pain medication, repeated vomiting, confusion, disorientation, or difficulty recognizing people/places, slurred speech or difficulty speaking, weakness or numbness in arms, legs, or face, vision changes, seizures or convulsions, unequal pupil size, clear or bloody fluid draining from nose or ears, increasing drowsiness or difficulty staying awake, loss of consciousness at any point after the initial injury, or behavioral changes 1, 2, 3

The Centers for Disease Control and Prevention recommends that someone should check on the patient every 2-3 hours during the first 24 hours, including waking them from sleep, and patients should avoid alcohol completely for at least 48 hours, avoid driving for at least 24 hours or until cleared by physician, and avoid contact sports or activities with fall risk for at least one week 1, 3
Patients should limit screen time as this can worsen headache and cognitive symptoms, and avoid aspirin, ibuprofen, and other NSAIDs for 48 hours, while acetaminophen is preferred for headache management 1, 2

The Centers for Disease Control and Prevention recommends a lower threshold for CT imaging in older adults (age ≥65 is itself an indication for CT), extended observation period due to higher risk of delayed bleeding, careful blood pressure monitoring, review of all medications especially anticoagulants and antiplatelet agents, and home safety assessment before discharge to prevent repeat falls 1, 2, 3, 4

Patients can be safely discharged home without imaging if they have no loss of consciousness, GCS score of 15, no vomiting, no severe headache, age <65 years, no anticoagulation or bleeding disorder, no focal neurologic deficits, no signs of skull fracture, low-energy mechanism, and a reliable caregiver available for observation 1, 2, 3, 4

The American Academy of Emergency Medicine recommends return for routine follow-up in 3-5 days if symptoms persist, gradual return to normal activities over 1-2 weeks as symptoms resolve, cognitive rest initially then gradual resumption, and no return to contact sports until completely symptom-free and cleared by physician 2, 3

Clinicians should assess both retrograde and anterograde amnesia by asking targeted questions about events before and after the injury to determine memory‑loss extent. 5
Although loss of consciousness occurs in fewer than 10 % of concussions, its presence together with amnesia indicates a higher likelihood of significant intracranial pathology. 5

Head CT should be obtained emergently for any patient with post‑traumatic amnesia who also exhibits any high‑risk feature (e.g., age ≥ 65 years, suspected skull fracture, vomiting > 1, coagulopathy, dangerous mechanism, etc.). 6
A focal neurologic deficit is a specific high‑risk sign that mandates immediate CT imaging. 7
The lack of loss of consciousness or amnesia alone does not rule out the need for CT when other high‑risk features are present; two well‑designed studies showed these factors are insufficiently sensitive to identify all at‑risk patients. 8

Patients may be discharged safely when a head CT is negative (or imaging is deemed unnecessary) and the patient has cleared PTA testing, demonstrating full orientation and continuous memory. 9
Discharge instructions should be provided both in writing and verbally at a sixth‑ to seventh‑grade reading level. 9
Patients should be advised to limit screen time and avoid strenuous mental or physical activity until they are completely symptom‑free. 9
Return to the emergency department immediately if any of the following occur: repeated vomiting, worsening headache, new memory problems, confusion, focal neurologic deficit, abnormal behavior, increasing drowsiness or loss of consciousness, or seizures. [7][9]

At the initial assessment, clinicians should document post‑concussive symptoms using a standardized symptom scale. [5][9]
The most frequently reported symptom is headache. [5][9]
Commonly observed symptoms also include memory problems and difficulty concentrating, as well as dizziness and balance disturbances. 7
Persistent symptoms beyond three weeks, or earlier if the patient plans to return to sport, warrant referral to a traumatic brain injury specialist. 7

Retrograde amnesia may appear to improve over time as patients are exposed to others’ recounting of the event, potentially leading to false recollection of details. 5