STEP 2: Concussion Live Course - November 5-6, 2024, in San Diego, CA-Case Discussion: Assessing Concussion in the Emergency Department

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A 42-year-old man suffered a fall from a horse, resulting in a clavicle fracture and head trauma. Initially admitted to the emergency department with a noticeable shoulder deformity and confusion, the man received pain management but showed additional symptoms often associated with a mild traumatic brain injury (TBI), such as a concussion. The patient lost consciousness briefly, displayed unusual hostility, experienced nausea and concentration difficulties, and reported symptoms like severe headaches, sleepiness, and irritability. <br /><br />Orthopedics successfully treated his clavicle fracture with operative reduction and internal fixation. However, during outpatient follow-up, concerns arose about his alcohol and opioid use due to unusual pain complaints and behavioral changes. Accompanied by his wife, the patient described feeling "hungover," attributed to his persistent use of alcohol and Norco as current treatments.<br /><br />Diagnosis of a concussion was confirmed, with education provided that symptoms are typically self-limiting but can be delayed, often resolving naturally within 1-2 weeks. Recommendations included abstaining from alcohol, limiting opioid use, and avoiding horseback riding until full recovery. He was also advised to follow up in two weeks and undergo vestibular testing as part of physical therapy before returning to riding. The follow-up also emphasized addressing potential alcohol abuse and considering cognitive-behavioral therapy (CBT) or medication for frontal symptoms.<br /><br />The case underscores the challenge faced in emergency settings, where immediate life-threatening injuries, such as the clavicle fracture, may take precedence over diagnosing concussions despite obvious symptoms, highlighting the need for comprehensive follow-up care. Despite medical advice, the man credited his recovery to drinking and other unconventional methods.

Asset Subtitle

Scott R. Laker, MD

Keywords

clavicle fracture

head trauma

mild traumatic brain injury

concussion symptoms

alcohol and opioid use

pain management

operative reduction

vestibular testing

cognitive-behavioral therapy

emergency follow-up care