60 y/o F with PMHx of HTN and DM presents after striking head on piping in garage ~1 hr prior.  Pt was standing up after getting out of a car and walked into pole.  Remembers incident fully.  Currently complaining of dizziness, mild temporal HA where she struck pipe, and nausea.  Denies LOC, drug or EtOH use, vomiting, numbness tingling, weakness, blurry vision, gait problems.

PDx: NAD, Well-appearing, anxious, normocephalic, no visualized lacerations, swelling and mild TTP over area struck on R temporal area, PEERLA, EOMI, Strength 5/5 ext x 4, Sensation intact to lt touch ext x 4, CN II-XII grossly intact.

Pt’s family are asking whether you are going to do anything.  Shouldn’t she get an XR or a CT?

ACEP Clinical Guidelines

Which patients with mild TBI should have a noncontrast head CT scan in the ED?

Level A recommendations:

A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy.

Level B recommendations:

A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury.*

* Dangerous mechanism of injury includes ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs.

Level C recommendations:

None specified.

From: Jagoda, A. S., & Bazarian, J. J., et. al. (2008). Clinical policy: Neuroimaging and decision making in adult mild traumatic brain injury in the acute setting. Annals of Emergency Medicine52(6), 714-48.

Based on these criteria, the patient does not meet Level B criteria for a head CT; the provider would meet standard of care by not obtaining a CT.