ACEP ID:

Mild Traumatic Brain Injury

Decision-making in Adult Mild Traumatic Brain Injury in the Acute Setting (December 2008)

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

Inclusion Criteria.
The guideline is intended for adults with blunt head injury (Q1/Q2), or adults diagnosed with mild traumatic brain injury or concussion (Q3).

Exclusion Criteria.
This guideline is not intended for patients with a history of a bleeding disorder, pregnant patients, patients with a primary presentation of a seizure disorder, pediatric patients, patients with an obvious open or penetrating head injury, or patients with unstable vital signs with multisystem trauma.


Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician’s judgment and patient preferences.

Critical Questions

  • In the adult ED patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head CT?

    Recommendations
    Level A Recommendations

    Use the Canadian CT Head Rule (CCHR) to provide decision support and improve head CT utilization in adults with a minor head injury.

    Level B Recommendations

    Use the National Emergency X-Radiography Utilization Study (NEXUS) Head CT decision tool (NEXUS Head CT) or the New Orleans Criteria (NOC) to provide decision support in adults with minor head injury; however, the lower specificity of the NEXUS Head CT and NOC compared with CCHR may lead to more unnecessary testing.

    Level C Recommendations

    Do not use clinical decision tools to reliably exclude the need for head CT in adult patients with a minor head injury on anticoagulation therapy or antiplatelet therapy exclusive of aspirin.

    Resources:

    Level A Recommendations

    Use the Canadian CT Head Rule (CCHR) to provide decision support and improve head CT utilization in adults with a minor head injury.

    Level B Recommendations

    Use the National Emergency X-Radiography Utilization Study (NEXUS) Head CT decision tool (NEXUS Head CT) or the New Orleans Criteria (NOC) to provide decision support in adults with minor head injury; however, the lower specificity of the NEXUS Head CT and NOC compared with CCHR may lead to more unnecessary testing.

    Level C Recommendations

    Do not use clinical decision tools to reliably exclude the need for head CT in adult patients with a minor head injury on anticoagulation therapy or antiplatelet therapy exclusive of aspirin.

    Resources:

  • In the adult ED patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head CT?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    Do not routinely perform repeat imaging in patients after a minor head injury who are taking anticoagulants or antiplatelet medication and are at their baseline neurologic examination, provided the initial head CT showed no hemorrhage.

    Do not routinely admit or observe patients after a minor head injury who are taking anticoagulants or antiplatelet medications, who have an initial head CT without hemorrhage, and who do not meet any other criteria for extended monitoring.

    Level C Recommendations

    Provide instructions at discharge that include the symptoms of rare, delayed hemorrhage after a head injury (Consensus recommendation).

    Consider outpatient referral for assessment of both fall risk and risk/benefit of anticoagulation therapy (Consensus recommendation).

    Resources:

    Discharge instructions and other materials for patients

    Fall risk screening and assessment for providers and fall prevention materials for patients

    Level A Recommendations

    None specified.

    Level B Recommendations

    Do not routinely perform repeat imaging in patients after a minor head injury who are taking anticoagulants or antiplatelet medication and are at their baseline neurologic examination, provided the initial head CT showed no hemorrhage.

    Do not routinely admit or observe patients after a minor head injury who are taking anticoagulants or antiplatelet medications, who have an initial head CT without hemorrhage, and who do not meet any other criteria for extended monitoring.

    Level C Recommendations

    Provide instructions at discharge that include the symptoms of rare, delayed hemorrhage after a head injury (Consensus recommendation).

    Consider outpatient referral for assessment of both fall risk and risk/benefit of anticoagulation therapy (Consensus recommendation).

    Resources:

    Discharge instructions and other materials for patients

    Fall risk screening and assessment for providers and fall prevention materials for patients

  • In the adult ED patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome (PCS) or to identify patients with delayed sequelae after ED discharge?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Consider referral for patients with PCS and the following potential risk factors: female sex; previous preconcussive psychiatric history; GCS score <15; etiology of assault, acute intoxication; loss of consciousness; and preinjury psychological history such as anxiety/depression.

    Do not use current diagnostic tools (including biomarkers) to reliably predict which patients are at risk for PCS.

    Provide concussion-specific discharge instructions and selected outpatient referrals of patients at high risk for prolonged PCS (Consensus recommendation).

    Resources:

    Discharge instructions and other materials for patients

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Consider referral for patients with PCS and the following potential risk factors: female sex; previous preconcussive psychiatric history; GCS score <15; etiology of assault, acute intoxication; loss of consciousness; and preinjury psychological history such as anxiety/depression.

    Do not use current diagnostic tools (including biomarkers) to reliably predict which patients are at risk for PCS.

    Provide concussion-specific discharge instructions and selected outpatient referrals of patients at high risk for prolonged PCS (Consensus recommendation).

    Resources:

    Discharge instructions and other materials for patients

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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