ER or Not: Line Drive to the Head

Interviewer: All right. Play along and see if you know the answer for today's "ER or Not" with emergency room physician Dr. Jeffrey Druck. Dr. Druck, are you ready?

Dr. Druck: I am. Let's go, Scot.

The Scenario: Line Drive to the Head

Interviewer: All right. So playing softball and you take a line drive to the forehead, or maybe you're playing soccer and the ball really nails you in the head. Any sporting event, a ball to the noggin, ER or not?

Dr. Druck: So we see a lot of this, Scot, in terms of people coming in after getting hit in the head and there are two big concerns. The most emergent and the one that's life-threatening is actually bleeding in the brain, and that's the one that we as emergency physicians are most concerned about.

The one that most people are most concerned about is actually a concussion. And a concussion, the way that we diagnose that in the emergency department is symptoms, and the most common symptoms that you see with that are obviously a headache and trouble focusing.

Potential Brain Bleed

But the things that we get more concerned about are the life threats, and the life threats are bleeding in the brain. And those usually have symptoms such as a loss of consciousness, meaning that you got knocked out, nausea, vomiting, inability to remember key elements, and then ongoing headache and any motor or neurologic symptoms that are going on in terms of having trouble feeling, having trouble seeing, having trouble with any elements of your normal neurologic assessment.

And so what I mean by that is if you're having trouble walking after getting hit in the head, you've got to come in. If you're having trouble speaking after getting hit in the head, you have to come in, because those are all signs that you might have a bleed in your brain, and that would be life-threatening.

Interviewer: All right. Not necessarily, but concerning enough that you should talk to an emergency room physician.

Dr. Druck: No question.

Interviewer: And if those other symptoms aren't there, then is the person scot-free or not?

Recognizing Concussion Signs

Dr. Druck: Well, there's definitely always a chance that you have a concussion. The chances that you do have a concussion are much higher, but those aren't something that you need to come to the emergency department for.

So if you didn't get knocked out, you don't have any nausea, no vomiting, no persistent headache, no trouble focusing, no other issues, you don't need to come to the emergency department, but you still probably need to get checked out by your primary care doctor to be assessed for a concussion.

There's actually some really interesting research that's being done on how it is that you treat concussions going forward. And also it's one of those things, especially if your kid is the one that gets hit, that you want to make sure that they don't have any repetitive trauma to make sure that they don't have worsening symptoms later on.

Interviewer: If a person doesn't have those concerning symptoms, does that mean that they likely don't have a brain bleed, or could they still have a life-threatening brain bleed?

Dr. Druck: There's always a chance. And I think that we've all heard about cases that have happened in the media and some famous celebrities that have fallen down, hit their head, seem to be fine immediately afterward, and then subsequently have something that's life-threatening and end up dying from it. But that's the kind of thing that you need to watch the person closely and make sure that there aren't any worsening symptoms as time goes on.

Interviewer: All right. And how often do you see that type of thing from a ball to the head, from a sporting event? Does that happen quite a lot, or not very frequently?

Dr. Druck: I mean, it does happen. Usually not from a soccer ball, but more commonly from a baseball or something like that.

I think that the other concern is that there are some other factors that'll make you more or less likely to have a bleed in your brain. So, for example, for people who are on anticoagulants, such as Coumadin or Eliquis, which are blood thinners that are designed to prevent any clots from happening, you're more likely to have a bleed in your brain. And so if you get hit in the head and you have one of those things going on at the same time, you definitely should come in.

And the way that we would diagnose this is with a CT scan of the head to make sure that there isn't any bleeding going on.

Primary Care or Emergency Department for Ball-to-Head Injuries?

Interviewer: All right. So final diagnosis, ER or not? Line drive to the head, soccer ball to the head, some other type of ball to the noggin, what do we do?

Dr. Druck: So without any concerning symptoms, you probably need to schedule a follow-up visit with your primary care doctor for a concussion. But if you are having any loss of consciousness, trouble thinking, speaking, walking, persistent nausea or vomiting, or you're just really worried, it might warrant a trip to the emergency department.