Eduovisual
Emergency & Toxicology
Head trauma: CT decision rules and disposition
— Traumatic brain injury (TBI) accounts for ~2.5 million ED visits annually in the US; ~75% are classified as mild TBI (mTBI, GCS 13–15)
— Falls dominate in elderly and pediatric groups; motor vehicle collisions and assaults dominate in young adults
— Even "minor" mechanisms in anticoagulated or elderly patients can produce delayed intracranial hemorrhage (ICH)
— Mild TBI: GCS 13–15 after blunt trauma with LOC, amnesia, or disorientation
— Moderate TBI: GCS 9–12 → almost always imaging + admission
— Severe TBI: GCS ≤8 → intubate, ICU, neurosurgery consult, ICP-directed care
— Concussion: clinical syndrome of altered mentation after head impact, with or without LOC; CT is typically normal
— Any focal neurologic deficit, persistent vomiting, seizure, or GCS deterioration
— Signs of basilar skull fracture: raccoon eyes, Battle sign, hemotympanum, CSF oto-/rhinorrhea
— Suspected open or depressed skull fracture
— Dangerous mechanism: ejection, fall >3 ft (peds) or >5 stairs (adults), pedestrian struck
— Anticoagulation or antiplatelet use (including DOACs) — dramatically lowers threshold to image
— Age ≥65, alcohol/drug intoxication obscuring exam, dementia, coagulopathy, prior neurosurgery, shunt, multisystem trauma
— Suspected non-accidental trauma in children or elder abuse
Board pearl: On Step 3, the trigger to image is almost always one of: age ≥65, anticoagulation, vomiting, GCS <15 at 2 h, suspected skull fracture, focal deficit, seizure, or dangerous mechanism. If none of those is present in an alert adult after blunt trauma, validated rules let you safely skip CT — a frequently tested ambulatory decision point.
— Mechanism: object, height of fall, vehicle speed, helmet/seatbelt, surface struck
— LOC: occurred? duration? witnessed vs inferred
— Amnesia: retrograde (events before) and anterograde (events after) — duration is prognostic
— Post-traumatic symptoms: headache, vomiting (number of episodes), seizure, vision change, vertigo, gait instability, confusion
— Anticoagulant/antiplatelet use: warfarin, apixaban, rivaroxaban, dabigatran, clopidogrel, ticagrelor, aspirin — get last dose and indication
— Substance use: alcohol, opioids, stimulants — may both cause and mask injury
— Prior TBI, neurosurgery, shunt, seizure disorder, dementia baseline
— Lucid interval then deterioration → classic epidural hematoma (middle meningeal artery, often pediatric/young adult with temporal blow)
— Gradual cognitive decline over days–weeks in elderly → chronic subdural hematoma
— "Worst headache of life" after trivial trauma → consider underlying aneurysmal SAH that caused the fall
— Repetitive questioning, anterograde amnesia, normal CT → concussion
— ≥2 episodes of vomiting (adults) or persistent vomiting (peds)
— Seizure at or after impact
— Worsening or severe headache
— Any focal neurologic complaint
— Coagulopathy, even with minor mechanism
— Suspected intoxication preventing reliable exam — treat as high risk
— Syncope, arrhythmia, hypoglycemia, stroke, seizure, orthostasis, polypharmacy in elderly
— A head CT may be normal while the cause of the fall (e.g., complete heart block) is the real diagnosis
Step 3 management: In an elderly patient who fell, your workup is parallel: image the head and evaluate the syncope/fall etiology (ECG, glucose, orthostatics, med review) before discharge. Missing the cardiac cause is a high-yield testable error.
— Airway: GCS ≤8 → intubate; protect C-spine with inline stabilization
— Breathing: hypoxia doubles mortality in TBI — target SpO₂ ≥94%
— Circulation: a single episode of SBP <90 mmHg significantly worsens TBI outcomes; resuscitate to SBP ≥110
— Disability: GCS (eye/verbal/motor), pupils, gross motor in all four limbs, glucose
— Exposure: full log-roll, look for other injuries
— GCS components individually documented (motor score is the most prognostic)
— Pupils: size, symmetry, reactivity — unilateral fixed dilated pupil = uncal herniation / CN III compression until proven otherwise
— Cranial nerves, especially extraocular movements and facial symmetry
— Motor: pronator drift, focal weakness, posturing (decorticate vs decerebrate)
— Sensory and reflexes; Babinski
— Gait if safe — tandem gait sensitive for subtle concussion
— Palpate for step-offs, depressed fractures, hematomas
— Basilar skull fracture signs: hemotympanum, CSF otorrhea/rhinorrhea (halo sign on gauze), Battle sign (mastoid ecchymosis, often delayed), raccoon eyes (periorbital ecchymosis without direct orbital trauma)
— Cushing triad (hypertension, bradycardia, irregular respirations) = impending herniation — late and ominous
— Isolated head injury does not cause hypotension in adults — look for another source (chest, abdomen, pelvis, long bones, spinal cord)
— Infants are the exception: large scalp/subgaleal or intracranial bleeds can cause shock
Key distinction: Hypotension in an adult with apparent isolated head trauma should never be attributed to the head injury — find the bleeding source. In contrast, hypotension worsens cerebral perfusion pressure and must be corrected aggressively (CPP = MAP − ICP; target CPP 60–70).
— High risk (need CT to rule out neurosurgical injury):
— GCS <15 at 2 h post-injury
— Suspected open/depressed skull fracture
— Any sign of basilar skull fracture
— ≥2 episodes of vomiting
— Age ≥65
— Medium risk (rule out clinically important injury):
— Retrograde amnesia ≥30 min
— Dangerous mechanism (pedestrian struck, ejection, fall >3 ft/5 stairs)
— More sensitive but less specific than CCHR — more scans ordered
— <2 years — CT if: GCS ≤14, altered mental status, palpable skull fracture
— Observation vs CT if: occipital/parietal/temporal scalp hematoma, LOC ≥5 s, severe mechanism, not acting normally per parent
— ≥2 years — CT if: GCS ≤14, altered mental status, signs of basilar skull fracture
— Observation vs CT if: LOC, vomiting, severe headache, severe mechanism
Board pearl: Step 3 commonly tests which rule applies to which patient. CCHR excludes anticoagulated and seizure patients — those patients essentially always get a CT. PECARN's superpower is justifying not scanning a low-risk child. Memorize the high-risk CCHR criteria; they're directly asked.
— Indicated for clinical deterioration, persistent symptoms, or to follow a known small bleed
— Routine 6-h repeat CT in stable patients with minor isolated traumatic findings has limited yield but is commonly practiced for anticoagulated patients and small contusions
— More sensitive for diffuse axonal injury (DAI), small contusions, brainstem injury, and subacute/chronic blood
— Indicated when CT is normal but neurologic deficit persists, or to characterize injury in moderate–severe TBI once stabilized
— Not the initial study in acute trauma — slower, less practical, contraindicated with unstable patients or unknown metallic foreign bodies
— Obtain for suspected blunt cerebrovascular injury (BCVI): cervical hyperextension/rotation, seatbelt sign on neck, LeFort II/III fractures, basilar skull fracture involving carotid canal, cervical spine fracture (especially C1–C3, transverse foramen involvement), Horner syndrome, neurologic deficit unexplained by imaging
— Modified Denver/Memphis criteria guide screening
— CBC, PT/INR, PTT, platelets, fibrinogen
— Type and screen if any ICH or surgical candidate
— Anti-Xa level if on rivaroxaban/apixaban (availability-dependent); thrombin time/ecarin time for dabigatran
— Toxicology screen and alcohol level when intoxication confounds exam
— Serum GFAP and UCH-L1 (FDA-cleared as the "Brain Trauma Indicator") can rule out the need for CT in select adults with mTBI within 12 h — negative predictive value ~99% for intracranial injury
— Not yet universally adopted; useful where available to reduce imaging
— Severe TBI (GCS ≤8) with abnormal CT, or normal CT plus 2 of: age >40, motor posturing, SBP <90
— Target ICP <22 mmHg, CPP 60–70
CCS pearl: In a CCS case with severe TBI, sequence is: intubate → noncontrast head CT → neurosurgery consult → ICU admit → ICP monitor placement → serial neuro checks q1h. Advancing the clock without imaging or consult will cost points.
— GCS 15, normal CT, no risk factors: low risk → discharge with head injury precautions and reliable observer
— GCS 13–15, normal CT, persistent symptoms or risk factors (anticoagulation, age ≥65, intoxication): observation 4–6 h (some centers 24 h for anticoagulated); consider repeat CT
— GCS 13–15, abnormal CT: neurosurgery consult, admission, repeat CT in 6 h
— GCS 9–12 (moderate): ICU or step-down, neurosurgery, serial CT
— GCS ≤8 (severe): intubate, ICU, ICP monitoring, neurosurgery
— Avoid hypoxia: SpO₂ ≥94%, PaO₂ ≥60
— Avoid hypotension: SBP ≥110 mmHg in adults with TBI (recent BTF guidance)
— Avoid hypercarbia and hypocarbia: PaCO₂ 35–40; transient hyperventilation to 30–35 only for impending herniation
— Head of bed 30°, neck midline, avoid tight C-collars when possible
— Normothermia (avoid fever); euglycemia (140–180)
— Seizure prophylaxis for severe TBI or high-risk findings (depressed fracture, penetrating injury, hematoma, GCS <10) — levetiracetam ×7 days
— Warfarin: 4-factor PCC + IV vitamin K 10 mg
— Dabigatran: idarucizumab
— Apixaban/rivaroxaban: andexanet alfa (or 4F-PCC if unavailable)
— Antiplatelets: platelet transfusion is not routinely recommended (PATCH trial showed harm in spontaneous ICH); discuss with neurosurgery if operative
— Reverse TXA within 3 h of injury in moderate–severe TBI (CRASH-3 benefit)
Step 3 management: For any anticoagulated patient with head trauma — even minor — get the CT, and if positive, reverse immediately while consulting neurosurgery. Don't anchor on "GCS 15 looks fine"; delayed deterioration in this group is the classic vignette.
— Short-acting agents preferred: fentanyl boluses, propofol infusion if intubated (allows neuro checks when paused)
— Avoid long-acting benzodiazepines and morphine in non-intubated patients
— Acetaminophen for mild headache; avoid NSAIDs and aspirin until bleed excluded
— Ondansetron 4 mg IV — first-line; helps stratify vomiting from intracranial cause vs medication-responsive
— Levetiracetam 1000 mg IV load, then 500–1000 mg BID ×7 days — preferred over phenytoin (fewer interactions, no levels)
— Phenytoin 20 mg/kg load acceptable alternative
— Prophylaxis prevents early (≤7 day) post-traumatic seizures; does not prevent late epilepsy
— 3% hypertonic saline 250 mL bolus, or 23.4% NaCl 30 mL via central line
— Mannitol 1 g/kg IV — caution if hypotensive (osmotic diuresis)
— Target serum Na 145–155, osmolality <320
— CRASH-3: 1 g IV over 10 min, then 1 g over 8 h, given within 3 hours of injury in mild–moderate TBI (GCS 9–15) with intracranial bleeding — mortality benefit
— Not for severe TBI with bilateral fixed pupils
— Hypotension: isotonic crystalloid; norepinephrine if needed; target MAP ≥80, SBP ≥110
— Hypertension in ICH: avoid abrupt drops; treat SBP >180 with nicardipine or labetalol infusion; avoid nitroprusside (raises ICP)
— Steroids — CRASH trial showed increased mortality in TBI
— Prophylactic hyperventilation
— Routine prophylactic antibiotics for basilar skull fracture (no benefit)
Board pearl: Steroids in TBI = wrong answer, always. Levetiracetam = preferred AED. TXA within 3 h = correct. Andexanet for factor Xa inhibitor ICH = correct. These four pharmacology points show up repeatedly.
— Intubate for GCS ≤8, inability to protect airway, hypoxia despite supplemental O₂, combative patient requiring CT
— RSI with etomidate (hemodynamically neutral) or ketamine (no longer contraindicated in TBI — evidence supports safety)
— Avoid succinylcholine in chronic neuro injury; rocuronium acceptable
— Pretreatment lidocaine is not routinely required (older teaching)
— External ventricular drain (EVD): measures and treats (CSF drainage); preferred for hydrocephalus or large IVH
— Intraparenchymal monitor (bolt): measures only; less infection risk
— Stepwise ICP management: HOB 30°, sedation/analgesia, hyperosmolar therapy, CSF drainage, paralysis, hypothermia, decompressive craniectomy
— Epidural hematoma: >30 mL volume, >15 mm thickness, or midline shift >5 mm — emergent craniotomy
— Acute subdural hematoma: >10 mm thickness or midline shift >5 mm regardless of GCS; smaller with GCS drop
— Depressed skull fracture: open, contaminated, or depressed greater than skull thickness
— Penetrating injury: surgical exploration, debridement
— Refractory elevated ICP: decompressive craniectomy (RESCUEicp showed survival benefit, more disability)
— NEXUS or Canadian C-Spine Rule for low-risk; CT C-spine for any high-risk feature or GCS <15
— Maintain collar until cleared clinically and radiographically
— Halo sign test on gauze for suspected CSF leak
— Avoid NG tube placement in suspected basilar skull fracture — use orogastric instead (risk of intracranial NG passage)
CCS pearl: In a CCS case with epidural hematoma, the winning sequence is: ABCs → intubate if GCS ≤8 → noncontrast head CT → emergent neurosurgery consult for craniotomy → ICU → reverse any anticoagulation → seizure prophylaxis. Delaying the neurosurgery call costs the case.
— Cerebral atrophy stretches bridging veins → higher subdural risk even with trivial mechanism
— Polypharmacy: anticoagulants, antiplatelets, antihypertensives, sedatives
— Baseline cognitive impairment masks subtle changes
— Frailty and comorbidity increase mortality at every GCS level
— Age ≥65 is itself a CCHR high-risk criterion → CT almost universally
— Even GCS 15 with no LOC may warrant CT if anticoagulated or on antiplatelet
— Delayed ICH in anticoagulated elderly: 0.6–6% within 24 h with initially normal CT → many centers admit for 24-h observation or repeat CT at 6–24 h
— Don't withhold based on age alone — untreated ICH mortality far exceeds reversal risk
— Restart anticoagulation typically 1–4 weeks after stable ICH, in conjunction with neurology/neurosurgery (especially for mechanical valves, recent VTE, high-risk AF)
— Adjust levetiracetam by CrCl (e.g., 500 mg BID for CrCl 30–50; 250–500 mg BID for <30)
— Mannitol worsens renal injury — prefer hypertonic saline if AKI or CKD
— Contrast for CTA: weigh BCVI risk vs contrast nephropathy — usually proceed if indicated
— Dabigatran clearance prolonged in CKD; idarucizumab still effective
— Coagulopathy from cirrhosis worsens bleeding — give FFP/PCC, vitamin K, platelets as indicated
— Avoid acetaminophen >2 g/day; avoid NSAIDs
— Sedation: titrate carefully; propofol cleared hepatically but short-acting
— Orthostatic vitals, ECG, glucose, electrolytes, medication review (especially benzos, opioids, anticholinergics, antihypertensives), gait assessment, vision check
— Refer to falls clinic or PT; consider vitamin D, calcium, bone density
Step 3 management: Every elderly head-injured patient gets a dual disposition decision: (1) Is the head safe? and (2) Why did they fall, and what prevents the next one? The second question is what differentiates Step 3 from Step 2.
— Apply PECARN to avoid unnecessary CT (lifetime cancer risk from pediatric head CT is real: ~1 in 1,000–10,000)
— Infants <3 months: very low threshold to image — exam is unreliable
— Scalp hematoma location matters in <2 y: frontal hematomas are low-risk; non-frontal (parietal, temporal, occipital) raises concern
— Vomiting alone after head injury is less specific in children — isolated vomiting in otherwise well child with normal exam can often be observed
— Injury inconsistent with developmental stage (e.g., "rolled off couch" at 1 month)
— Delayed presentation, changing history, multiple caregivers
— Retinal hemorrhages, posterior rib fractures, metaphyseal corner fractures, multiple healing fractures of different ages
— Abusive head trauma / shaken baby: subdural hemorrhages (often bilateral), retinal hemorrhages, diffuse axonal injury without external signs
— Mandatory reporting to Child Protective Services — physician judgment, not certainty, triggers report
— Skeletal survey in <2 y with suspected abuse; consider ophtho exam, social work, admission for safety
— Shield abdomen during head CT (negligible fetal dose anyway from head CT — ~0.001 mGy)
— Do not withhold indicated head imaging
— Consider placental abruption if abdominal/pelvic trauma — fetal monitoring ≥4–6 h for ≥20 weeks gestation
— Rh status: anti-D immunoglobulin if Rh-negative with any abdominal trauma
— Consider intimate partner violence (IPV) as cause — screen privately
— Remove from play same day; no return until asymptomatic and through graduated return-to-play protocol
— Second-impact syndrome: rare but catastrophic in adolescents
— Cognitive and physical rest initially, then gradual reintroduction
Board pearl: Bilateral subdural + retinal hemorrhages in an infant = abusive head trauma until proven otherwise → admit, report, ophtho, skeletal survey, social work. Do not discharge to the suspected caregiver.
— Cerebral herniation (uncal, central, tonsillar, subfalcine): Cushing triad, blown pupil, posturing → emergency hyperosmolar therapy, hyperventilation bridge, OR
— Expansion of hematoma: especially in anticoagulated; repeat CT for any deterioration
— Cerebral edema: peaks 24–72 h; manage ICP
— Hydrocephalus: from IVH or CSF outflow obstruction → EVD
— Seizures: early (≤7 days) and late (>7 days, true post-traumatic epilepsy)
— Vasospasm: especially with traumatic SAH — monitor with TCD
— Neurogenic pulmonary edema: sudden hypoxia after severe TBI
— SIADH, cerebral salt wasting, diabetes insipidus — distinguish by volume status and urine sodium
— SIADH: euvolemic hyponatremia, concentrated urine — fluid restrict
— CSW: hypovolemic hyponatremia, high urine Na — replace salt and volume
— DI: hypernatremia, dilute urine, polyuria — desmopressin
— Coagulopathy: TBI-induced (release of tissue factor) — common, worsens bleeding
— VTE: high risk; mechanical prophylaxis immediately, chemoprophylaxis (enoxaparin 40 mg) typically started 24–72 h after stable bleed, in consultation with neurosurgery
— Stress ulcers: PPI prophylaxis in ICU
— Fever: workup but also consider central fever
— Post-concussive syndrome: headache, dizziness, cognitive complaints, mood changes — usually resolves within weeks to months
— Chronic traumatic encephalopathy (CTE): associated with repeated TBI
— Post-traumatic epilepsy: risk ~10–15% after severe TBI
— Cognitive and behavioral sequelae: depression, PTSD, executive dysfunction — refer for neuropsychiatric care
— Endocrine: hypopituitarism in 15–20% after moderate–severe TBI — screen at 3–6 months
Key distinction: Hyponatremia after TBI — fluid status is the discriminator. Hypovolemic + high urine Na = cerebral salt wasting (give salt and saline). Euvolemic = SIADH (restrict). Getting this backward worsens cerebral perfusion in CSW.
— GCS ≤8 (always)
— GCS 9–12 with any abnormal CT
— Any ICH requiring monitoring (epidural, subdural, contusion with mass effect, traumatic SAH with vasospasm risk)
— Need for ICP monitoring, ventriculostomy, or hyperosmolar therapy
— Post-craniotomy or craniectomy
— Hemodynamic instability, intubated patients, status epilepticus
— Small stable ICH on anticoagulation post-reversal
— Moderate TBI improving
— Need for serial neuro checks q1–2h but stable airway and hemodynamics
— GCS 15 with small stable traumatic finding and reliable exam
— Anticoagulated patient with normal CT but needing 24-h observation
— Skull fracture without intracranial injury but concerning location
— Neurosurgery: any ICH, depressed/open skull fracture, penetrating injury, deteriorating exam
— Trauma surgery: polytrauma, any concerning mechanism
— Neurology: seizures, persistent altered mental status with normal CT, post-concussive management
— Ophthalmology: suspected NAT, traumatic optic neuropathy, orbital fracture
— ENT/Maxillofacial: facial fractures, CSF leak
— Psychiatry/SW: suspected NAT, IPV, self-harm, substance use disorder
— PM&R: rehab planning for moderate–severe TBI
— If no neurosurgery on-site and ICH present → stabilize, reverse anticoagulation, transfer
— Document everything; use EMTALA-compliant transfer
CCS pearl: Don't forget to "Call Neurosurgery" as an explicit order in CCS for any ICH or skull fracture, even small — the case rewards involving the right consultant early. Also order "Serial neuro checks q1h" and "Head of bed 30°" as standing orders.
— Arterial — usually middle meningeal artery laceration from temporal bone fracture
— Lens-shaped (biconvex), does NOT cross suture lines
— Classic: lucid interval then rapid deterioration
— Young adults and children; emergent craniotomy if large
— Venous — bridging veins torn by acceleration/deceleration
— Crescent-shaped, CROSSES suture lines but not falx/tentorium
— Elderly, anticoagulated, alcoholics — atrophic brains
— Higher mortality than EDH despite "less dramatic" appearance because of underlying brain injury
— Days to weeks after often-forgotten trauma
— Hypodense or mixed density on CT
— Elderly with gradual cognitive decline, gait change, headache, focal deficit
— Burr-hole drainage; consider middle meningeal artery embolization (emerging)
— Blood in sulci and basal cisterns — typically convexity in trauma (vs basal cisterns in aneurysmal)
— Usually managed conservatively; monitor for vasospasm if extensive
— Distinguish from aneurysmal SAH that caused the fall — consider CTA if pattern atypical
— Coup/contrecoup pattern — frontal and temporal poles most common
— May "blossom" (expand) over 24–48 h — repeat CT
— Surgical evacuation if large, expanding, or causing herniation
— Associated with severe injury, DAI
— Risk of obstructive hydrocephalus → EVD
— High-velocity rotational injury
— CT often normal or minimal punctate hemorrhages at gray-white junction, corpus callosum, brainstem
— MRI is more sensitive
— Prolonged coma, poor prognosis
Key distinction: Biconvex + doesn't cross sutures + lucid interval = epidural. Crescent + crosses sutures + elderly/anticoagulated = subdural. Sulcal blood = SAH. These three CT patterns are the most commonly tested visual associations in head trauma.
— Step 3 vignettes often blur trauma with the underlying cause
— Syncope from arrhythmia (AV block, VT, sick sinus), aortic stenosis, pulmonary embolism, vasovagal
— Orthostatic hypotension from dehydration, medications, autonomic dysfunction
— Workup: ECG, telemetry, echo if structural disease suspected, orthostatics
— Spontaneous ICH from hypertension, amyloid angiopathy, AVM, tumor — patient may then fall
— Ischemic stroke causing the fall — look for focal deficits not explained by mechanism
— Aneurysmal SAH — thunderclap headache preceded fall
— Seizure with post-ictal fall — tongue laceration, incontinence, witnessed activity
— Subdural presenting as "dementia" or gait disturbance (chronic SDH)
— Hypoglycemia, hyponatremia, hypercalcemia, uremia, hepatic encephalopathy
— Alcohol intoxication or withdrawal
— Opioid, benzodiazepine, stimulant intoxication
— Carbon monoxide poisoning (think when multiple household members affected)
— UTI in elderly causing delirium and fall
— Meningitis/encephalitis with altered mental status
— Hypothermia, heat stroke
— Inner ear pathology, BPPV (recurrent falls)
— Vision impairment, peripheral neuropathy, sarcopenia
— Elder abuse — pattern injuries, multiple ED visits, inconsistent history
— Glucose, electrolytes, CBC, BUN/Cr, LFTs, troponin, lactate, TSH, ECG, urinalysis, blood alcohol, drug screen as indicated
— Imaging beyond head: C-spine, chest x-ray, hip x-ray for elderly fallers (occult hip fracture)
Board pearl: An elderly patient who "fell and hit her head" with a normal head CT but new focal weakness on exam — the diagnosis is ischemic stroke, and the fall was the consequence, not the cause. Order an MRI and start the stroke pathway.
— GCS 15, normal neuro exam, normal CT (or no CT indicated by validated rule)
— Tolerating PO, no persistent vomiting, ambulating safely
— Reliable observer at home for 24 h
— Understands return precautions
— No active intoxication
— Adequate transportation; not driving home alone after head injury
— Return immediately for: worsening or severe headache, repeated vomiting, seizure, confusion, weakness/numbness, slurred speech, vision changes, unequal pupils, clear fluid from nose/ear, difficulty waking
— Rest physically and cognitively for 24–48 h; gradual return to activities
— No alcohol or sedatives for 24 h
— No contact sports/strenuous activity until cleared
— Acetaminophen for headache; avoid NSAIDs/aspirin for 24–48 h if any concern for bleeding
— After ICH: hold anticoagulation; reassess restart at 1–4 weeks based on indication and bleed stability with neurology/neurosurgery
— After normal CT in anticoagulated patient: typically continue as before, but reassess indication, dose, and bleeding risk
— Consider switching warfarin to DOAC if appropriate; reassess INR control
— Medication review — deprescribe benzos, anticholinergics, sedatives, unnecessary antihypertensives
— Vitamin D 800–1000 IU/day if deficient
— Home safety evaluation, grab bars, lighting, remove rugs
— PT for strength and balance (Otago, tai chi)
— Vision and hearing optimization
— Bone health: DEXA, calcium, consider bisphosphonate if osteoporotic
— Consider deprescribing as part of comprehensive geriatric assessment
— Graduated return to learn and return to play
— Avoid second impact while symptomatic
— Cognitive rehab referral if persistent symptoms >4 weeks
Step 3 management: For elderly patients discharged after a fall with negative head CT, document a falls-prevention plan — medication reconciliation, PT referral, vitamin D, home safety. This is the longitudinal, value-based care thinking Step 3 rewards.
— mTBI, discharged from ED: PCP follow-up within 1–2 weeks; sooner if symptomatic
— Concussion in athletes/students: sports medicine or concussion clinic in 3–7 days
— Post-ICH discharged from hospital: neurosurgery follow-up in 2–4 weeks with repeat imaging; neurology for seizure management
— Moderate–severe TBI: PM&R, neuropsychology, neurology, social work coordination
— Post-concussive symptom scales (e.g., SCAT5 for athletes, RPQ)
— Cognitive testing (e.g., ImPACT in athletes)
— Mood screening: PHQ-9, GAD-7 — depression and anxiety common
— Sleep: insomnia and sleep-disordered breathing worsen recovery
— Headache pattern: post-traumatic headache may need preventive therapy if frequent
— No driving until cleared — especially after seizure (state laws vary; typically 3–12 months seizure-free)
— Return to work plan: graduated, with cognitive accommodations
— School: 504 plan or IEP for students with prolonged symptoms
— Acute inpatient rehab for moderate–severe TBI with functional deficits
— Multidisciplinary: PT (balance, strength), OT (ADLs, cognition), speech-language (cognition, communication, swallowing), neuropsychology
— Vestibular therapy for persistent dizziness
— Vision therapy for convergence insufficiency post-concussion
— Hypopituitarism in 15–20% after moderate–severe TBI — check cortisol, TSH/free T4, IGF-1, testosterone/estradiol, prolactin at 3 and 12 months
— DI symptoms (polyuria, polydipsia) → check sodium and urine osmolality
— Increased risk of dementia, depression, suicide
— Post-traumatic epilepsy risk after severe TBI — continue AEDs only if clinically indicated (prophylaxis stops at 7 days)
— Substance use surveillance
Board pearl: A common Step 3 follow-up question: when do you stop levetiracetam started for severe TBI? Answer: after 7 days unless a seizure occurred — extended prophylaxis does not prevent late post-traumatic epilepsy.
— TBI itself impairs capacity — assess at the time of each decision
— A patient with altered mental status from head injury cannot refuse indicated imaging or treatment in true emergency — proceed under implied consent
— Document capacity assessment: understanding, appreciation, reasoning, expression of choice
— Surrogate decision-maker hierarchy if patient lacks capacity (spouse, adult child, parent, sibling — varies by state)
— Cannot validly refuse if intoxicated and have a potentially life-threatening injury — restrain (chemical or physical) only as necessary, document, and proceed with workup
— Reassess capacity as intoxication resolves
— Suspected child abuse (NAT, abusive head trauma) → CPS; reasonable suspicion, not proof, is the threshold
— Elder abuse / vulnerable adult → adult protective services
— Intimate partner violence: most states do not mandate reporting for competent adults; offer resources and safety planning
— Gunshot/stab wounds: most states require law enforcement notification
— Impaired driving causing crash: state-specific reporting laws (e.g., new seizure diagnosis, dementia)
— Anticoagulated patient discharged after negative CT: explicitly communicate return precautions; ensure 24-h reliable observer; document discussion
— Ensure follow-up appointment is scheduled, not just recommended — closing the loop reduces readmissions
— Medication reconciliation at discharge — common source of post-discharge harm
— Warm handoff for transfers; use SBAR; transmit imaging
— Following state "Zackery Lystedt"–type laws: same-day removal, medical clearance before return
— Document conversation with athlete, parents, coaches
— Avoid premature clearance — second-impact syndrome risk
— Falls precautions for confused or sedated patients
— Restraints only with order, documentation, and frequent reassessment
— Avoid anchoring bias: "intoxicated patient" is the classic missed subdural
Step 3 management: An intoxicated patient with a head laceration refuses CT. Capacity is impaired → workup proceeds under implied consent; use minimal necessary restraint; document capacity assessment and the clinical reasoning. Discharging "AMA" without capacity is the wrong answer.
— Biconvex, doesn't cross sutures → epidural (middle meningeal artery, temporal fracture)
— Crescent, crosses sutures → subdural (bridging veins, elderly/anticoagulated)
— Sulcal/cisternal blood → subarachnoid
— Hypodense crescent in elderly with gradual decline → chronic SDH
— Punctate hemorrhages at gray-white junction → DAI (better on MRI)
— Lucid interval = epidural until proven otherwise
— Cushing triad (HTN, bradycardia, irregular respirations) = herniation, late finding
— Raccoon eyes, Battle sign, hemotympanum, CSF rhinorrhea = basilar skull fracture
— Halo sign on gauze = CSF leak
— Unilateral blown pupil = ipsilateral uncal herniation, CN III compression
— CCHR: adults ≥16, GCS 13–15, excludes anticoagulated/seizure
— NOC: GCS 15 with LOC — image if any criterion
— PECARN: validated to avoid CT in low-risk children
— NEXUS-II: broader applicability
— Steroids in TBI = harmful (CRASH) — never the answer
— Levetiracetam ×7 days for severe TBI seizure prophylaxis
— TXA within 3 h for mild–moderate TBI with ICH (CRASH-3)
— Hypertonic saline or mannitol for elevated ICP
— Andexanet for apixaban/rivaroxaban ICH; idarucizumab for dabigatran; 4F-PCC for warfarin
— No platelets routinely for antiplatelet-associated ICH (PATCH)
— SBP ≥110, SpO₂ ≥94, PaCO₂ 35–40, ICP <22, CPP 60–70
— Avoid hypoxia, hypotension, hypercarbia, hyperthermia, hypoglycemia
— Boxer/football player with cognitive/mood changes → CTE
— Infant with bilateral SDH + retinal hemorrhages → abusive head trauma
— Elderly with gradual dementia-like decline → chronic SDH (potentially reversible!)
— Trauma + Horner syndrome → carotid dissection → CTA
Board pearl: "Reversible dementia" in elderly that responds to surgical drainage = chronic subdural hematoma. Always image elderly with new cognitive decline plus any history of falls.
— "82-year-old on apixaban falls from standing, GCS 15, no LOC, mild headache, normal exam"
— Right answer: noncontrast head CT now; consider 24-h observation or repeat CT even if initial negative; if positive → andexanet alfa, neurosurgery consult
— Wrong answers: discharge home, skip CT because GCS 15, give platelets
— "Young adult struck in temple, briefly LOC, awoke alert, now drowsy with dilated pupil"
— Right answer: emergent head CT (will show biconvex hematoma), intubate, neurosurgery for craniotomy, mannitol/hypertonic saline bridge
— "Hemotympanum, periorbital ecchymosis, clear nasal drainage"
— Right answer: CT head; avoid NG tube (use OG); no prophylactic antibiotics; admit; ENT/neurosurgery consult
— Wrong answer: prophylactic antibiotics
— "Drunk patient with scalp lac and GCS 14 wants to leave AMA"
— Right answer: lacks capacity; obtain CT under implied consent; reassess later
— Wrong answer: discharge AMA
— "2-year-old fell from couch, brief crying, now playful, normal exam, small frontal scalp bump"
— Right answer: observation, no CT; reassurance, return precautions
— Wrong answer: routine CT
— "3-month-old with vomiting, lethargy, bulging fontanelle, retinal hemorrhages; story doesn't fit"
— Right answer: CT (will show subdurals), admit, report to CPS, skeletal survey, ophtho, social work
— Wrong answer: discharge with reassurance
— "GCS 6 after MVC, intubated, pupils reactive, CT shows contusion"
— Right answer: ICU, ICP monitor, head of bed 30°, sedation, normocapnia, MAP/CPP targets, levetiracetam, no steroids, neurosurgery
— Wrong answer: dexamethasone
— "78-year-old with 3 weeks progressive gait imbalance and confusion, distant fall"
— Right answer: head CT → chronic SDH → neurosurgery for burr-hole drainage
Key distinction: When the stem features anticoagulation, age ≥65, lucid interval, basilar fracture signs, or NAT clues — the test is asking about a specific guideline-driven action. Match the trigger to the action and you'll get it right.
Bottom line: In head trauma, use validated decision rules (CCHR, NOC, PECARN) to choose who needs a noncontrast head CT, image and reverse aggressively in anticoagulated and elderly patients, escalate immediately for any intracranial bleed or GCS deterioration, and pair every disposition with a longitudinal plan addressing fall etiology, secondary prevention, and follow-up.
— Anticoagulated, age ≥65, GCS <15 at 2 h, ≥2 vomits, basilar/depressed fracture signs, focal deficit, seizure, or dangerous mechanism → CT now
— SBP ≥110, SpO₂ ≥94, PaCO₂ 35–40, HOB 30°, normothermia, euglycemia, levetiracetam ×7 days for severe TBI, no steroids ever
— Warfarin → 4F-PCC + vitamin K; dabigatran → idarucizumab; apixaban/rivaroxaban → andexanet alfa; TXA within 3 h for mild–moderate TBI with ICH
— GCS ≤8 → ICU and ICP monitor; any ICH → neurosurgery + admission; anticoagulated with normal CT → observe 24 h; low-risk mTBI with reliable observer → discharge with precautions and 1–2 week follow-up; elderly faller → falls-prevention plan before discharge
— Bilateral subdurals + retinal hemorrhages in infant → abusive head trauma, report
— Elderly with gradual cognitive/gait decline → chronic SDH (reversible)
— Adult hypotensive after "isolated" head injury → find the other bleeding source
— Patient who "fell" → ask why they fell (syncope, stroke, arrhythmia, hypoglycemia, medications)
Board pearl: The single highest-yield Step 3 reflex in head trauma is matching the patient's risk modifier (age, anticoagulation, mechanism, exam) to the evidence-based action — image, reverse, consult, admit, or safely discharge with a closed-loop follow-up plan.