Head Injury Assessment in Primary Care for New Nurse Practitioners
A patient comes in after a head injury with a headache, dizziness, brain fog, or nausea. Is this a concussion—or could something more serious be going on? And how do you know who needs imaging?
Sometimes patients come in as a follow-up to a concussion that was diagnosed in urgent care, other times you see them for the first time after their initial head injury. We need to know whether its safe to care for them outpatient, escalate care to the ER, and what kind of management and follow up they need.
In this episode, I walk through how to evaluate a head injury in primary care, including concussion symptoms, red flags, the neurologic exam, imaging decision tools, and follow-up care.
2026 Update: The overall approach to evaluating concussion in this episode is still relevant, but a few recommendations for concussion recovery have changed since it was recorded. Visual symptoms can occur with concussion; focal neurologic findings such as a visual-field deficit or pupillary abnormality warrant evaluation for more serious injury. In addition, prolonged strict physical and cognitive rest is no longer recommended. Current guidance favors light activity during the first 24–48 hours as tolerated, followed by a gradual return to regular activities.
For current point-of-care guidance—including updated assessment tools, imaging decision rules, and return-to-activity recommendations—get your copy of the updated Concussion Evaluation & Management Cheat Sheet inside the Digital NP Binder here.
Watch
What I Covered in This Episode:
How to recognize common concussion symptoms after a head injury
Red flags that should raise concern for a more serious intracranial or cervical spine injury
What to include in the neurologic and head/neck exam
How symptom checklists can help assess and follow concussion symptoms
When to consider head CT and the clinical decision tools used for adults
How the approach to imaging differs in children, including PECARN
Follow-up and return-to-activity considerations after concussion
How to approach a graduated return to sports after a concussion
Key Takeaways
Concussion is a clinical diagnosis. A patient does not need to lose consciousness to have a concussion, and imaging is used to look for intracranial injury—not to diagnose the concussion itself.
Rule out serious injury first. Worsening mental status, focal neurologic findings, seizure, signs of skull fracture, repeated vomiting, or other concerning findings should prompt evaluation for more serious traumatic brain injury.
Visual symptoms can occur with concussion. Blurred vision and other visual disturbances may be part of the presentation; focal findings such as a visual-field deficit or pupillary abnormality are more concerning for another injury.
Not every head injury needs a CT. Use the patient's presentation and an appropriate validated decision tool to determine when acute imaging is indicated.
Strict physical and cognitive rest is no longer recommended. Encourage light activity during the first 24–48 hours as tolerated, followed by a gradual return to normal cognitive and physical activity.
Return to sports should be gradual. Athletes should progress through a stepwise return-to-sport process and should not return to activities that put them at risk for another head injury prematurely.
Give clear follow-up and return precautions. Patients need to know which symptoms warrant urgent reevaluation and what to expect as they gradually resume school, work, exercise, and other activities.
Want a Quick Reference for Concussion Visits?
The Concussion Evaluation & Management Cheat Sheet gives you a step-by-step approach to evaluating a head injury—including red flags, the focused neurologic exam, concussion assessment tools, when to consider head CT, and return-to-activity guidance. Get your copy inside the Digital NP Binder.
Resources Mentioned in This Episode
CDC HEADS UP — concussion resources and graduated return-to-play guidance
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Liz Rohr (they/she) | Real World NP (00:00.216)
Hey there, it's Liz Rohr from Real World MP, and you're watching MP Practice Made Simple. The weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. So if you ever get uneasy when you have patients come in with a head injury of some kind, they're worried they have a concussion, you're wondering how to diagnose them, what you should look for, what imaging you need to do, and the follow-up care, I got you. This is what it's all about. Before we jump in, I'm I've gotten some feedback from nurse practitioners that it's hard to keep up with the videos because there's so much to
Them that I've made so far, and maybe this is just the nature of NP life, and it is what it is. But if you find that this is you, I really want to make sure that I make these videos for you. So I really want to make sure that you can actually fully enjoy them. And so if you feel like it's just too much, you want them to be short and sweet, more to the point, just give me the information, and there it goes. leave a comment below with short and sweet, and I can kind of work on abbreviating these to be as you know as quick and easy as possible. Versus, do you want to comment below, keep it the same if you like this kind of like built-out.
Case study type of model. Definitely leave me a comment. I'd love to hear from you again, because these are made for you. Jumping into concussions though, so the thing that you're thinking about with concussions, it's really defined as a trauma-induced altered change in mental altered mental status with or without loss of consciousness. I believe is how the American Academy of Neurology defines it. So it's a little bit vague, is the moral of the story, what I'm trying to say here. And what you're looking for when you have somebody who comes in, you're worried about a concussion, you just want to make sure that you're doing step one is triage. So our
Are they at risk for an alarm sign? An alarm sign would be something like
structural damage in your brain, skull fractures, brain bleeding, brain swelling, or spinal cord injury. So those are the things you're kind of assessing for, making sure it's not that. And then when you are left when it's left over with that, you're kind of left with concussion and it has a constellation of symptoms that go along with it, right? So the symptoms that you're gonna get with a concussion are things like headache, possible loss of consciousness at the time, cognitive fog, nausea, photophobia, phonophobia.
Liz Rohr (they/she) | Real World NP (02:05.462)
Amnesia, like before the accident or after it. Those are kind of the constellation of symptoms. Things you're not going to see in a concussion are any neurologic, focal neurologic deficits. So limb weakness, numbness, hemiplegia, vision loss, visual changes, and then yeah, other stroke-like symptoms or any other focal neurologic deficits. Those are really concerning for brain-specific injury. So you want to have them be seen in the ER for some imaging. There's some physical exam findings.
you also want to watch out for. So you want to look specifically as doing again, like you're looking for focal neurologic deficits, you're doing a full neurologic exam. So not like grossly intact, like they're walking and talking fine. No, I'm talking two to twelve, the full thing, finger to nose testing, the rapid alternating movements one, Rhomber testing, shin heel to heel to shin, that kind of thing. So that doing that full that full one, seeing if they have any focal neurologic signs. And then the specific ones to head injury that are uncommon in primary care.
Typically they would be going self-triaging to the ER, hopefully, are things like signs of bleeding, signs of skull fracture. So you can have those like raccoon eyes where it's basically like blood all in this whole area. you can have bleeding behind your ear, the battle sign. You can have hemato tympanum. I'm probably not saying that right, but the blood behind the TMs. And you can also have signs of like a CSF leak. So, like if they have any kind of like that clear fluid coming out of their nose, that kind of thing. So those are all the.
Alarm signs that you want to watch out for. So those are kind of like the easier, kind of like more obvious ones. They're not obvious, but they're easier ones to send out. So you're kind of left with the people who don't have that. And so further from there, you kind of need to decide do they have risk factors of developing into that if they don't have those more like clear clinical signs. And so that brings me to some tools. So I super love tools, as you probably know. They make life a lot easier. So there's two different tools that I it's categories of tools that I'm talking about. So below this video is going to be a cheat sheet for
A lot of this summary of this information, including the links to these checklist tools. And so the first one has to do with assessing their symptoms. And so, like I said, there's a constellation of symptoms that patients will have that go along with this diagnosis. These can happen at the time of the injury or can progress over the course of hours to days. And so you're going to assess their symptoms with this checklist, and going from there, you're going to kind of decide how severe this concussion is, and that's also the thing you're going to.
Liz Rohr (they/she) | Real World NP (04:35.082)
To monitor their symptoms. So that's the kind of like the first category of tool. The second category of tool are are three different ones that can help you make the decision about whether or not somebody needs imaging. So one of them is the Canadian head CT rules, which is the one I most commonly see and that I ascribe to the most. There's also the Norlin new New Orleans criteria, New Orleans criteria, and the Nexus 2.
And it basically just it's a checklist for and you can kind of combine all of them, which is going to be in the cheat sheet, to kind of use your judgment with that. the caveat I want to make here is that any tool or assessment that you're doing, especially if you're on the fence and it's not clear, cut, and dry either way, of like, this person definitely doesn't need imaging, or they really need to go to the ER, me I wouldn't recommend discussing that with your supervisor and just letting them know that, like, hey, here's my assessment. I'm using the Canadian head CT rules, here's my kind of gut feeling of like I really want to go send them to the ERC.
still for some imaging, things like that, discussing that with your supervisor again, because there's different roles depending on what criteria you're using. And so it talks and and what it talks about but before you download the checklist or if you've downloaded it all already.
Is it's talking about mechanism of injury, age, past medical history, like are they on blood thinners, like was it how severe of like an injury it was? Are they intoxicated right now? Were they intoxicated at the time? Things like that. That all kind of changes your judgment about whether or not they need imaging. And to save some time, I'm not going through all of them, but I do recommend taking a look at that cheat sheet to kind of just literally going through the points and applying each of those and helping you decide if they need imaging. And I really do recommend that you send them to the ER for imaging if they're having a head injury.
at the time. There are nuances, of course, which again you should discuss with your supervisor, but typically if you need imaging right now and you're doing STAT and you're expediting things, like typically that needs to be done in the ER, right? Because if you get an abnormal result, what are you gonna do with it, right? So they probably need observation and higher level of care and things like that. So so yeah, so just to recap, you're kind of looking for the alarm signs, sending them out, assessing them based on their history of the
Liz Rohr (they/she) | Real World NP (06:37.218)
You want to ask things like, and this comes with all the tools, right? But you're assessing things like: did they lose consciousness at the time of the injury? Was it witnessed or was it unwitnessed?
And what are the symptoms that they're having now? Again, are they the having the classic concussion symptoms? Are they having any of those neurologic symptoms, the vision changes, stuff like that? And then following up with them, if you've just safely determined, and based on your physical exam too, right? And so if you've safely determined that they have a concussion, the interventions are basically just rest. So what you're looking for is physical and mental rest. So even things like looking at a screen, watching TV on your phone, on the computer.
reading a book, all those things, anything that's mentally taxing that's making your symptoms worse, you need to not do, which is real a real drag if you have a more serious concussion, because you just have to lay around and listen to music basically. That's all you're allowed to do really. And what it is is and then any physical symptoms too because usually if you have mental anything mentally taxing is giving you symptoms, physical is just gonna make it worse. So if you can do you can do those things without any pain, any brain fog or headache or nausea, again looking at that symptom checklist, if you can do all of those things, then you can kind of progress
next level and basically the treatment is for adults if we're talking about adults that are trying to go back to work you're kind of just there's no real strict criteria it's kind of just until you're feeling better and so it's at least 24 hours kind of taking it day by day usually what I do for patients is have them come in once a week if they've had a really bad concussion and every single time assessing their symptoms and how much they're getting better how often because it's you there's like a rating scale that goes in there too. And then the and if we're talking about kids the assessment is typically the same the same physical assessment
Only they have a PCARN role instead of the Canadian head CT roles because we're a little bit more conservative with the kiddos in terms of whether or not we're going to order imaging for them. So typically when I have kids come in, I look at that PCARN and I do my full neuroassessment and I'm a little bit more conservative sending them to the ER for observation, even if you don't need the CT scan, right? Because you always want to make sure that you're given really safe care. So that's kind of like a side note about the pediatrics. And then when with their like return to play, if we're talking about like an adolescent, the CDC has a really great website.
Liz Rohr (they/she) | Real World NP (08:41.924)
That kind of describes this return to play process. And basically it's at least five days because you need to be at each step of like mental, mentally taxing things, light physical activity, heavier physical activity, things like that without symptoms for at least 24 hours in each of those steps until they can go back to play. And again, I just have them come back in if you're seeing them in urgent care and they're like, I need this note to clear me, like you just don't, right? You can't clear them, that's not safe. So you have them come back with their PCP. If you're the PCP, you have them come back in a couple of you have them come back in like five days, right?
Because that's the bare minimum, and then you know every week after that to make sure that they're doing better and better. so that's it, that's all about for cut conc concussions. there's more to be said about every topic, right? But that's just one keeping it short and sweet. Be sure to download that cheat sheet down below this video and leave me a comment again. Keep it short and sweet or keep it the same. This is a little bit of a more short and sweet one, it's not that much shorter. I try, I ramble a little bit, but
But anyway, I'd love to hear from you because I really do want these to be helpful. So, important note, it's the holidays are coming up and I celebrate Christmas. So I'm going to be not making a video next week or the week after, but I'll be back with a fresh new video for the first week of the year. So definitely stay tuned for that and hop on the email list because I got some goodies coming up in the next two weeks for my email list only. I will definitely see you in the new year. I've got a great couple great videos coming up.
Lab Interpretation Crash Course for New Nurse Practitioners is coming up again, which I'm super super psyched about. So definitely sign up at realworldnp.com slash labs if you want to hear more about that. I'll be talking about it more when I come back from my little Christmas break. So thank you so much for watching. Hang in there and I'll see you soon.
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