Trivial, Minimal, and Minor Head Trauma: (Concussion)

Presentation

A patient presents after a fall from standing with a head strike. There was no loss of consciousness, but a small laceration is noted on the occiput with surrounding swelling, described by bystanders as a “goose egg.”The patient complains of a dull headache and transient nausea and drowsiness. There was no seizure, vomiting, amnesia, or alteration in mental status and the patient exhibits no focal neurologic deficits on examination.

Head trauma is a common chief complaint of adult and pediatric patients presenting to the emergency department (ED), accounting for over 1.5 million visits annually, the majority of which are for minor injuries.

Trivial or minimal head injuries occur after a slight impact of a lightweight blunt object (such as a small stick) or when the calvarium is bumped against a hard surface (such as the underside of a cabinet). The forehead and occiput are common sites of impact.

Minor head injuries are common after motor vehicle accidents, sports-related injuries, and assaults. There is usually a more forceful impact, and patients may exhibit signs or characteristic symptoms of concussion (retrograde amnesia with or without loss of consciousness, dizziness, nausea, feeling “dazed” or “foggy,” and decreased awareness of surroundings). Over the ensuing days, patients may exhibit irritability, sensitivity to light/noise, and sleep disturbances.

The term concussion is synonymous with mild traumatic brain injury (TBI) and is commonly used to describe the constellation of clinical symptoms after a head injury. TBI occurs as a result of sudden motion of a viscoelastic brain in a rigid cranial vault. This causes tissue strains, such as cortical contusions and compressive hematomas, as well as cellular excitotoxic injury and neuroinflammation. Accurately differentiating minor from major TBI is an important skill of the emergency clinician.