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Mild Traumatic Brain Injury

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

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

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

    Recommendations
    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.

    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.

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

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    None specified.

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    None specified.

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

    Recommendations
    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.

    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.

  • 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?

    Recommendations
    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.

    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.

Download the Policy

PDF Icon mtbi2008.pdf April 2018

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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