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Traumatic Brain Injury (Mild - Adult)

Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting (December 2008)

Complete Clinical Policy on Mild Traumatic Brain Injury (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments (EDs).

Inclusion Criteria. This guideline is intended for patients with blunt trauma to the head who present to the ED within 24 hours of injury, who have a GCS score of 14 or 15 on initial evaluation in the ED, and are 16 years of age or older.

Exclusion Criteria. This guideline is not intended for patients with penetrating trauma or multisystem trauma, who are younger than 16 years, or who have a GCS score of less than 14 on initial evaluation in the ED.

Critical Questions

1. Which patients with mild TBI should have a noncontrast head CT scan in the ED?

  • Level A recommendations. A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy.


  • Level B recommendations. A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury.*
    *Dangerous mechanism of injury includes ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs.


  • Level C recommendations. None specified.

2. Is there a role for head MRI over noncontrast CT in the ED evaluation of a patient with acute mild TBI?

  • Level A recommendations. None specified.


  • Level B recommendations. None specified.


  • Level C recommendations. None specified.

3. In patients with mild TBI, are brain specific serum biomarkers predictive of an acute traumatic intracranial injury?

  • Level A recommendations. None specified.


  • Level B recommendations. None specified.


  • Level C recommendations. In mild TBI patients without significant extracranial injuries and a serum S-100B level less than 0.1 μg/L measured within 4 hours of injury, consideration can be given to not performing a CT.*
    *This test has not yet received Food and Drug Administration approval for clinical use in the United States.

4. Can a patient with an isolated mild TBI and a normal neurologic evaluation result be safely discharged from the ED if a noncontrast head CT scan shows no evidence of intracranial injury?

  • Level A recommendations. None specified.


  • Level B recommendations. Patients with an isolated mild TBI who have a negative head CT scan result are at minimal risk for developing an intracranial lesion and therefore may be safely discharged from the ED.*
    *There are inadequate data to include patients with a bleeding disorder; who are receiving anticoagulation therapy or antiplatelet therapy; or who have had a previous neurosurgical procedure in this population.


  • Level C recommendations. Mild TBI patients discharged from the ED should be informed about postconcussive symptoms.

Purpose of ACEP's Clinical Policies

Clinical Findings and Strength of Recommendations