This question came to me via my blog comments section.

Melody asks:

I’m working on a hockey injury scenario where it’s the second hit to the head in a matter of a week, with a dull headache that hadn’t really went away to begin with (but he kept it to himself).

The second hit knocks him out for a few minutes, and he has confusion (and afterwards his demeanor is now very mean vs his nice personality before the hit). Would a second hit to the head with confusion, headache (and I’ll add nausea) require the CT scan? Would they be worried about brain swelling? Would they keep him or send him home with a headache that is extremely sensitive to every little sound (like a baby crying would send him through the roof)?

Jordyn Says:

Hi Melody. Thanks for submitting your question.

Yes, shame on this character for not being honest about his symptoms because if he had persistent headache then he shouldn’t be playing hockey until that resolves— like at all.

To be honest, if this is an adult patient, he’s going to get a CT scan of his head. In reality, CT scanning is much more prevalent in an adult ED (or community ED) than in a pediatric ER run by specially trained pediatric ER physicians. There are many reasons for this that I won’t go into here.

The CT scan will show if there is brain swelling. Depending on the extent of the brain swelling then medical decisions would be made. If mild, then admission to the hospital and observation. If significant, this could require specialized medications, going on a breathing machine, and ICU admission. Though if the swelling were severe the patient would likely be unconscious.

Sometimes headaches associated with concussion are treated like migraine headaches to see if that will improve the pain. But no, a patient wouldn’t be sent home until his headache pain is significantly improved, but it doesn’t have to be entirely gone. We just want to make sure it improves with medications. In some more serious medical conditions like brain tumors and brain bleeds, medications have little effect on the pain.

Then again, in this patient, CT scan would have shown whether or not these other things are present.