Concussion Care Pathway

4. Serious Head or Neck Injuries

 

ACTION: Refer to emergency care immediately if any one of these red flags is present.

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Canadian CT Minor Head Injury/Trauma Rule:

• Application Criteria:

  • Applies to patients aged ≥16 years with a Glasgow Coma Scale (GCS) score of 13-15.

  • Excludes patients on warfarin or with bleeding disorders.

  • Excludes patients with an obvious open skull fracture.

• High-Risk Indicators (for Neurosurgical Intervention):

  • GCS score <15 at 2 hours after injury.

  • Suspected open or depressed skull fracture.

  • Any sign of basal fracture: Look for fluid leakage from ears or nose, “raccoon eyes” (periorbital ecchymosis), or Battle’s sign (bruising behind the ear).

  • Vomiting ≥2 episodes

  • Age ≥65 years

• Medium-Risk Indicators (for Brain Injury on CT):

  • Amnesia before impact ≥30 minutes

  • Dangerous Mechanism of Injury:

    • Pedestrian struck by motor vehicle

    • High-speed motor vehicle collision

    • Rollover or ejection from motor vehicle

    • Fall from elevation ≥3 feet or 5 stairs

    • Axial load to the head (e.g., diving injury)

 

Canadian C-Spine Rule:

• Application Criteria: Primarily used to evaluate the necessity for cervical spine imaging in trauma patients.

• Key Indicators:

  • Age ≥65 years

  • Dangerous Mechanism:

    • Pedestrian struck by motor vehicle

    • High-speed motor vehicle collision

    • Rollover or ejection from motor vehicle

    • Fall from elevation ≥3 feet or 5 stairs

    • Axial load to the head

• Neurological Symptoms: Weakness, tingling, or burning in extremities suggest potential spinal cord involvement.

• Inability to Rotate Neck 45° Left and Right: A reduced range of motion in the neck may indicate cervical spine injury.

• Midline Cervical Spine Tenderness: Palpable tenderness along the cervical spine increases suspicion for fracture or ligamentous injury.

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PECARN Minor Head Injury/Trauma Rule (Children <2 years):

• Key Indicators:

  • GCS score ≤14

  • Altered mental status: Symptoms such as irritability, lethargy, or unresponsiveness.

  • Palpable skull fracture

  • Scalp hematoma (except frontal)

  • Loss of consciousness ≥5 seconds

  • Severe mechanism of injury: Falls >3 feet, high-impact trauma, or motor vehicle accidents.

  • Parental concern: If a parent reports that the child is “not acting normally.”

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Additional Red Flags:

• Seizure or convulsion

• Double vision

• Severe or increasing headache

• Visible skull deformity

• Loss of consciousness

• Deteriorating conscious state

• Restlessness, agitation, combative behavior

• GCS <15