Approach to Trauma & Head Injuries

Trauma? in urgent care? You’d be surprised that what walks in our doors. Falls off the roof. Motor vehicle accidents (MVA). Concussions. TikTok accidents. No matter the source of trauma, patients often don’t know whether their injury requires an urgent care or ER visit. That’s where we come in. Cue the super hero music & don that cape (just kidding)
 
Quick side note: thanks to the educators over at HippoEd for continuing to collaborate with me on this 8-week mini-series on their Urgent Care Boot Camp CME. The glimpses of what I give you here are just a fraction of the whole course—which has seriously made me a better Urgent Care clinician in so many ways. As always, my series of lectures and content is free. However, be sure to check out the entire HippoEd UC Boot camp CME course: here. You get a $25 discount if you use my link--hey, anything helps :)
 
Where do I start? 
 
Primary survey

• Airway—assess for patency, protection, and phonation. In setting of UC, if pt is unstable in any way, this is a 911 call and needs to be quickly diverted to higher acuity care
• Breathing—determine rate/depth/effort of breathing.  In setting of UC, if pt is unstable in any way, this is a 911 call and needs to be quickly diverted to higher acuity care. 
• Circulation—remember importance of obtaining vitals. If hypotension consider IV access/begin resuscitation, hemorrhage control (apply pressure) 
• Disability—Glasglow Coma scale (GCS)? is patient alert? Awake? Obtain POC glucose. Basic neurological exam
• Exposure—you want to be able to exam the entire patient. Do not forget about other injuries that could be missed if patient is completely clothed. Again, use your best judgement based on mechanism of trauma!

 
Which patient do I transfer versus discharge?
 
Consider transfer if:

• High-risk mechanism
• Any alteration in mental status
• Suspicion for abuse—child/elderly abuse
• Sick/frail/elderly
• Multisystem trauma
• Pregnant patients

 Head injury/Trauma
 
What is considered high risk mechanism?

• Struck pedestrian—struck by any type of vehicle
• Unrestrained/ejected MVC
• Fall greater than 3 feet or > 5 stairs
• Crush to head

 
Other important info to obtain:

• Prescence/absence of safety gear—helmet, eye gear
• Any LOC or alteration in mental status (even if resolved)
• Associated intoxicants (also common)

 
Is there penetrating injury?—Protip: do not remove penetrating object
 
To CT or not? That is the question
Let’s be honest, there are a TON of different head CT rules and guidelines out there. Instead of list each guideline, I’ll direct you to: mdcalc. By far one of my most used apps on a daily basis. Did I mention it's free? You’re able to search any of these rules & calculate the score (yay!). As with any rule or guidelines, it is just a guideline-- your clinical gestalt always trumps any guideline/rule!
 
Common CT guidelines: 

• American College of Emergency Physicians-MTBI guidelines
• New Orleans CT rule
• Canadian Head CT rule
• Nexus II 
• PECARN pediatric head injury rule (use this one a ton!)

 
Are there signs of basilar skull fracture? 

• hemotympanum
• Racoon eyes
• CSF otorrhea or rhinorrhea--
• Battle sign

*Presence or absence of these are always included in my notes

If your final diagnosis is concussion:

• Ensure you document a detailed neurological exam
• Ensure you examine for spine or other trauma
• It is okay to treat nausea, but avoid sedatives
• Wake up instructions are no longer indicated!
• Remove from play until symptoms resolve and are off medications—in my practice pt must be cleared by PCP in order to return to play
• Patient education:
  • Patient should not be alone for twenty four hours
  • Education about post-concussive symptoms
  • Need brain rest to best heal from a concussion—no electronics
  • Give strict ER/return precautions, have a VERY LOW threshold to return

ATTENTION: Red flags
It is NOT a concussion if any of the following are present & these patients need to be transferred immediately:

• Focal neurological deficits
• Seizure
• Limb weakness
• Visual field deficit
• Pupil abnormality
• Neurologic deterioration—e.g. patient came in at a GCS 15 and is now GCS 10

We are nearing the end of this urgent care boot camp series. If you have any last requests, be sure to comment below or let me know on my Instagram. Also, if this series has helped you, let me know--always love hearing from you.

​For now, I have a second part for the approach to trauma set for next week focusing on neck and abdomen