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Original author: Joe Toscano
Originally published in 2014. Substantially updated and clinically reviewed in 2026 to reflect current evidence, guidelines, and urgent care practice.
Introduction
The spectrum of traumatic brain injury (TBI) spans from inconsequential to disabling to life-threatening. Patients with obvious distress or deficits after head injury require prompt transfer from the urgent care facility to an emergency department. Fortunately the overwhelming majority of head injuries are minor, and patients can be evaluated by medical history and physical exam alone. In cases of TBI, the main diagnostic decision for the practitioner is determining which patients require imaging for evaluation of a potentially significant intracranial injury when some appear otherwise well. Treatment decisions at the urgent care level involve recommendation of appropriate activity modification and, if needed, medication for symptom management.
Current practice emphasizes selective imaging with validated decision rules, early recognition of patients who need emergency evaluation, and active recovery rather than prolonged strict rest after uncomplicated concussion.
Presentation
Concussion or TBI can manifest as any of several central nervous system symptoms after head impact or acceleration-deceleration force on the brain, even in the absence of any direct head impact. Loss of consciousness is not required to establish the diagnosis. The worst TBI situations involve intracranial hemorrhage, cerebral edema, herniation, or brain compression and require rapid identification and transfer.
Most patients with TBI symptoms do not have demonstrable structural injury on routine imaging. Symptoms may be reversible but recovery occurs at varying rates.
TBI symptoms after force to the head can include the following:
- Headache
- Nausea
- Vomiting
- Dizziness
- Vertigo
- Visual disturbances
- Drowsiness or fatigue
- Disturbed sleep
- Coordination difficulties
- Mood or behavioral changes
- Concentration, memory, or other cognitive difficulties
- Decreased level of consciousness
- Focal neurologic deficit
Triage Pearls
The Glasgow Coma Scale (GCS) score is a traditional assessment tool for patients with TBI; although scores represent symptom severity, values at a single point in time are not predictive of future outcome. Patients should be reassessed periodically and serial scores can be helpful in indicating and succinctly communicating improvement or worsening over time. Scores range from 3 (deep coma) to 15 (“normal”), although even patients with a GCS score of 15 can have potentially significant intracranial injuries.
- Clinic protocols should provide for immediate clinician assessment of patients with altered mental status, focal neurologic deficit, seizure, repeated vomiting, worsening or severe headache, unequal pupils, signs of skull fracture, or a declining GCS score.
- In-clinic stabilization followed by EMS transfer to an emergency department is appropriate for a GCS score below 15 that is not rapidly improving, penetrating or suspected open skull injury, persistent or worsening neurologic symptoms, significant intoxication that prevents reliable assessment, or any concern for intracranial hemorrhage or cervical spine injury.
- A normal initial examination does not exclude clinically important intracranial injury. Reassess patients whose symptoms evolve while they are in the clinic.
Table 1. Glasgow Coma Scale
| Response | Adults / verbal children | Score | Nonverbal children | Score |
|---|---|---|---|---|
| Eye opening | Spontaneous | 4 | Spontaneous | 4 |
| To speech | 3 | To speech | 3 | |
| To pain | 2 | To pain | 2 | |
| No response | 1 | No response | 1 | |
| Verbal response | Alert and oriented | 5 | Coos, babbles | 5 |
| Disoriented | 4 | Irritable cry | 4 | |
| Speaking but nonsensical | 3 | Cries to pain | 3 | |
| Moaning | 2 | Moans to pain | 2 | |
| No response | 1 | No response | 1 | |
| Motor response | Follows commands | 6 | Spontaneous movement | 6 |
| Localizes pain | 5 | Withdraws to touch | 5 | |
| Withdraws to pain | 4 | Withdraws to pain | 4 | |
| Decorticate flexion | 3 | Decorticate flexion | 3 | |
| Decerebrate extension | 2 | Decerebrate extension | 2 | |
| No response | 1 | No response | 1 |
History Pearls
Obtaining a medical history for patients with possible TBI traditionally includes establishment of the mechanism of injury and determining whether there was loss of consciousness or associated seizure, headache, nausea, vomiting, or other injuries relating to the traumatic incident.
- In adults, ask about age, loss of consciousness or amnesia, repeated vomiting, severe or worsening headache, seizure, coagulopathy, anticoagulant or antiplatelet use, intoxication, and a dangerous mechanism of injury.
- Document the exact time and mechanism of injury and whether symptoms are improving, stable, or worsening.
- Identify prior concussion, migraine, seizure disorder, bleeding disorder, and medications that may affect neurologic assessment or bleeding risk.
- All children with possible TBI should receive a basic screening for nonaccidental trauma when clinically appropriate. Important pediatric factors include abnormal mental status or behavior, loss of consciousness and duration, severe mechanism, vomiting, severe headache, and age-specific signs of skull injury.
Physical Exam Pearls
Assess level of consciousness and cranial nerve, motor, sensory, cerebellar, and cognitive function. Sometimes only subtle cognitive deficits are present; these may represent concussion even when there is no structural lesion requiring neurosurgical treatment.
- Record serial GCS when symptoms are significant or changing.
- Look for hemotympanum, raccoon eyes, Battle sign, cerebrospinal fluid otorrhea or rhinorrhea, open or depressed skull injury, and scalp hematoma.
- Check pupils, extraocular movements, speech, facial symmetry, strength, sensation, coordination, and gait when safe.
- Assess the cervical spine for midline tenderness, neurologic symptoms, and a mechanism that warrants immobilization or emergency imaging. Avoid forcing range of motion when cervical spine injury is suspected.
- In children, pay particular attention to altered mental status, palpable skull fracture, and nonfrontal scalp hematoma in children younger than 2 years.
Testing And Diagnosis Pearls
Several evidence-based, clinically validated instruments are available to guide imaging decisions after minor head injury. They should be applied only to the populations in which they were validated.
| Population / tool | Use | Important limitations |
|---|---|---|
| Adults – Canadian CT Head Rule (CCHR) | Preferred adult decision support tool when inclusion criteria are met. High-risk findings include failure to reach GCS 15 within 2 hours, suspected open skull fracture, signs of basal skull fracture, vomiting more than once, or age >64 years. | Do not apply outside its validated population. The original rule excludes patients on blood thinners and certain other groups. |
| Adults – NEXUS Head CT | Can also support CT decision making. Criteria include skull-fracture evidence, scalp hematoma, neurologic deficit, abnormal alertness or behavior, persistent vomiting, coagulopathy, or age >=65 years. | Lower specificity than CCHR may lead to more imaging. |
| Children – PECARN | Use age-specific PECARN predictors to identify children at very low risk of clinically important TBI and reduce unnecessary CT. | Observation versus CT depends on the combination of predictors, age, mechanism, symptom course, and clinician judgment. |
- For adults with minor head injury, current ACEP guidance favors the CCHR when its inclusion and exclusion criteria are met. NEXUS Head CT or the New Orleans Criteria may also be used, but are less specific.
- Do not use adult clinical decision rules to reliably exclude the need for CT in patients taking anticoagulants or antiplatelet therapy other than aspirin alone.
- For children, do not routinely image to diagnose mild TBI. Use validated age-appropriate decision rules such as PECARN together with the history, examination, and observation when appropriate.
- Noncontrast head CT remains the primary acute imaging test when intracranial injury is suspected. MRI is not routinely required for uncomplicated acute concussion and should not delay emergency transfer when serious injury is suspected.
- There is no useful role for routine skull radiographs in the evaluation of mild head injury.
- Blood-based GFAP/UCH-L1 brain-trauma tests are FDA-cleared for selected adults with suspected mild TBI within defined time windows to aid CT decisions. Availability varies, and these tests do not replace clinical assessment or imaging when CT is otherwise indicated.
Patients Taking Anticoagulants or Antiplatelet Agents
- Have a low threshold for ED evaluation and CT when clinically indicated; validated decision tools should not be used to rule out CT in patients on anticoagulation or antiplatelet therapy other than aspirin alone.
- For an adult who has a normal baseline neurologic examination and a negative initial head CT, ACEP does not recommend routine repeat imaging solely because the patient is taking an anticoagulant or antiplatelet medication.
- Routine hospital admission or observation is also not required solely for anticoagulant or antiplatelet use after a negative CT if the patient is otherwise appropriate for discharge and has no other reason for extended monitoring.
- Patients with hemorrhage on CT, neurologic deterioration, or other high-risk findings require emergency management and consideration of anticoagulant reversal according to the specific agent and local protocol.
Treatment And Disposition Pearls
- Patients with moderate to severe symptoms, worsening symptoms, abnormal neurologic findings, suspected skull fracture, or concern for intracranial hemorrhage should be transferred to an emergency department rather than observed indefinitely in urgent care.
- Patients who do not require imaging, or who have had appropriate evaluation with no intracranial injury identified, may often be managed as outpatients when symptoms are stable and reliable follow-up is available.
- Treat headache and nausea symptomatically with nonopioid medication when possible. Avoid medications that cause unnecessary sedation or interfere with serial neurologic assessment.
- Prolonged strict “brain rest” is no longer recommended for uncomplicated concussion. Relative physical and cognitive rest for the first 24 to 48 hours is reasonable, followed by a gradual return to routine activity that does not more than mildly worsen symptoms.
- Children and adolescents should return gradually to school and other nonsport activities after no more than 1 to 2 days of rest, with symptom-based accommodations as needed.
- Athletes with suspected concussion should not return to contact or collision activity on the day of injury. Return to sport should follow a graduated progression under appropriate medical supervision, with each later stage generally taking at least 24 hours and medical clearance before activities that carry a meaningful risk of head impact.
- Reevaluate or refer patients whose symptoms are worsening, are not progressively improving, or persist beyond the expected recovery period. Persistent vestibular, cognitive, headache, sleep, or mood symptoms may benefit from targeted rehabilitation or specialty care.
Medicolegal Pearls
- Document the mechanism and time of injury, serial mental status when indicated, neurologic examination, cervical spine findings, and the rationale for imaging, transfer, observation, or outpatient management.
- If a clinical decision rule is used, document that the patient meets the population for which the rule was validated and record the relevant positive and negative criteria.
- Be cautious in patients taking anticoagulants or antiplatelet medication. Their risk of intracranial hemorrhage is increased, but a normal baseline neurologic examination and negative initial CT do not by themselves mandate routine repeat CT or hospital observation.
- Document counseling regarding activity, driving or work restrictions when symptoms impair attention or reaction time, and the need for reassessment if symptoms worsen or fail to improve.
- If CT imaging is obtained, document the clinical indication and discuss radiation exposure when appropriate.
References
- Valente JH, Anderson JD, Paolo WF, et al. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury. Ann Emerg Med. 2023;81(5):e63-e105. doi:10.1016/j.annemergmed.2023.01.014.
- Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-1170.
- Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357:1391-1396.
- Mower WR, Gupta M, Rodriguez R, et al. Validation of the sensitivity of the NEXUS Head CT decision instrument for selective imaging of blunt head injury patients. PLoS Med. 2017;14:e1002313.
- Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Br J Sports Med. 2023;57:695-711.
- Centers for Disease Control and Prevention. Clinical Guidance for Pediatric Mild TBI. Updated July 29, 2025.
- U.S. Food and Drug Administration. i-STAT TBI Plasma cartridge (GFAP/UCH-L1), 510(k) K201778; indications for use in adults with suspected mild TBI.