Mild Traumatic Brain Injury
Variable definitions. Some consider GCS 13-15 after trauma.
Important questions
LOC, Post-traumatic amnesia, ETOH use, on anticoagulation or has coagulopathy. Retrograde amnesia more worrisome than anterograde.
GCS scale was developed for comas present at least 6 hours.
Abulia-flatness of affect and voice can be indicative of damage to the frontal lobes
No role for skull films
Scan if HA, vomiting, Age>60, drugs, ETOH, deficits in short-term memory, physical evidence of trauma above clavicle, or seizures, Initial GCS of 13 or 14 or <15 at 4 hours. Amnesia before impact of greater than 30 minutes. Witnessed LOC. 15 minutes. Repeated Vomiting. Object recall < 3 of 3. Evidence of basilar skull fracture.
When all of the policies are evaluated the CT screening for all mild head injuries is most cost effective (Acta Neurol Scand 1996;93:207-210)
If GCS of 13, 38% will have IC lesion on CT, 10% will need neurosurgical intervention. Patients who have received a direct blow to the temporal-parietal region deserve a higher level of suspicion secondary to the possibility of epidural hematoma.
28% of patients older than 60 with a GCS of 15 and LOC or amnesia had an intracranial lesion.
D/C c negative head ct after 6 hours of evaluation, or earlier if with a third party
(Annals 2002 40:2)
elderly:
High Risk Factors in patients with loc, disorientation, change in mental status Age > 65 failure to reach GCS of 15 within 2 hrs of injury suspected open skull fracture any sign of basal skull fracture vomiting >2 episodes 100% sensitive (95% CI 92-100%) for predicting need for neurological intervention Head CT indicated if 1 or more high risk factors (Stiell IG – Lancet – 5-MAY-2001; 357(9266): 1391-6)
GCS score of 13-15
loss of consciousness
no neurologicaldeficit
no seizure
no anticoagulation
aged 16 y/o or greater
Get CT Scan in folks: GCS score not 15 at 2 h postinjury suspected skull fracture,
any sign of basal skullfracture
vomiting ( 2 times)
aged >65 y/o retrograde amnesia >30 min, dangerous mechanism (pedestrian vs motor vehicle; ejected from motor vehicle; fall from height 1 m or 5 stairs)
(Ext Validation (JAMA 2005;294(12):1519) Comparision with new orleans (JAMA 2005;294(12):1511)
PROSPECTIVE VALIDATION OF A PROPOSAL FOR DIAGNOSIS AND MANAGEMENT OF PATIENTS ATTENDING THE EMERGENCY DEPARTMENT FOR MILD HEAD INJURY Fabbri, A., et al, J Neurol Neurosurg Psych 75:410, 2004 METHODS: This prospective Italian study examined the accuracy of a diagnostic protocol of the Neurotraumatology Committee of the World Federation of Neurosurgical Societies for patients with mild head injury. Findings were evaluated in 6,444 patients aged ten years or older seen from 1999 through 2001. The protocol called for no imaging in “low risk” patients (GCS 15, with no clinical findings [see below], neurologic deficits, skull fractures or risk factors [see below]); CT scanning or skull x-rays with in-hospital observation for 3-6 hours after CT or 24 hours after plain x-rays in “medium-risk” patients (GCS 15 with clinical findings [amnesia, diffuse headache, vomiting and/or loss of consciousness with no neurologic deficits, skull fractures] or risk factors); and CT scanning with 24-48 hours of inpatient observation in “high-risk” patients (GCS 14 or 15 with neurologic deficits or skull fracture, or risk factors [coagulopathy, age over 60, previous neurosurgery, pre-trauma epilepsy, alcohol and/or drug misuse] with or without the aforementioned clinical findings). RESULTS: Of 1,676 low-risk patients, 52 (3%) reattended for post-concussive syndrome (PCS) and a delayed
diagnosis of intracranial injury was made in one. Of 1,200 medium-risk patients, 49 (4%) reattended for PCS and no patient was diagnosed with an intracranial injury. Of 2,702 high-risk patients, 76 (2.8%) reattended for PCS and intracranial injuries were diagnosed in 15. CONCLUSIONS: The variables outlined in this study are suggested to be accurate outcome predictors in adolescents and adults presenting to the ED with mild head injury. 23 references (andfabbri@libero.it)
NEXUS II
(ACAD EMERG MED 2006;13:302)
some patients with sig. lesions had entirely benign presentation
Canadian Head CT
examination of the cohort to see GCS 15 who decomp (Ann Emerg Med 2006;48:245)
vomiting (any)
restlessness
any GCS decrease
severe HA
confusion
focal temporal blow
added to rule caught all cases, but not prospectively validated:
CT head scan is required only for minor-head injury patients with any one of the following findings. Minor head injury patients present with a GCS score of 13 to 15 after witnessed loss of consciousness, amnesia, or confusion.
J Trauma. 2006 Sep;61(3):558-66. Related Articles, Links
Indications for CT scanning in mild traumatic brain injury: A cost-effectiveness study. Stein SC, Burnett MG, Glick HA. Department of Neurosurgery, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19106, USA. BACKGROUND: There is considerable uncertainty about the indications for cranial computed tomography (CT) scanning in patient with minor traumatic brain injury (TBI). This analysis involves an evidence-based comparison of several strategies for selecting patients for CT with regard to effectiveness and cost. METHODS: We performed a structured literature review of mild traumatic brain injury and constructed a cost-effectiveness model. The model estimated the impact of missed intracranial lesions on longevity, quality of life and costs. Using a 20-year-old patient for primary analysis, we compared the following strategies to screen for the need to perform a CT scan: observation in the emergency department or hospital floor, skull radiography, Selective CT based on the presence of additional risk factors and scanning all. RESULTS: Outcome measures for each strategy included average years of life, quality of life and costs. Selective CT and the CT All policy performed significantly better than the alternatives with respect to outcome. They were also less expensive in terms of total direct health care costs, although the differences did not reach statistical significance. The model yielded similar, but smaller, differences between the selective imaging and other strategies when run for older patients. CONCLUSIONS: Although the incidence of intracranial lesions, especially those that require surgery, is low in mild TBI, the consequences of delayed diagnosis are forbidding. Adverse outcome of an intracranial hematoma is so costly that it more than balances the expense of CT scans. In our cost-effectiveness model, the liberal use of CT scanning in mild TBI appears justified.
ACEP Clinical Policy
Ann Emerg Med. 2008;52:714-748
CRITICAL QUESTIONS
1. 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.
Concussion and Athletes
tABLE 1. Concussion grading
Guideline Grade 1 Grade 2 Grade 3 Cantu7
No LOC* Amnesia lasting <30 minutes
LOC Amnesia lasting >30 minutes
LOC Amnesia lasting >24 hours
Colorado8
No LOC No Amnesia Confusion
No LOC Amnesia Confusion
LOC AAN9
No LOC Concussive Symptoms lasting <15 minutes
No LOC Concussive Symptoms lasting >15 minutes
LOC
*LOC: Loss of consciousness
TABLE 2. Length of time Recommended out of play after first concussion According to Respective Concussion Criteria
Guideline Grade 1 Grade 2 Grade 3 Cantu7 1 week * 1 week* 1 month Asymptomatic* 1 week prior to return Colorado8 If asymptomatic* or no amnesia, may return after 20 minutes If amnesia occurs treat as a grade 2 injury Return to play in 1 week if asymptomatic* Transport to ED Return to play in 2 weeks if asymptomatic* and negative imaging study AAN9 If asymptomatic* after 15 min may return to play that day Any symptoms, treat as grade 2 Return to play in 1 week if asymptomatic* Transport to ED Return to play in 1 week if asymptomatic*, negative imaging, LOC <5 minutes Return to play in 2 weeks if asymptomatic*, negative imaging, LOC >5minutes
*Asymptomatic at rest and with exertion
7) Cantu RC Guidelines for return to contact sports following cerebral concussion. Physician sports med. 1986; 14(10); 75. 8) Guidelines for the management of concussion in sports. Rev. May 1991. Denver: Colorado Medical Society, 1991 9) Practice parameter: the management of concussion in sports. Neurology 1997; 48: 581. (emedhome)
Considerable confusion persists among physicians and the public regarding concussion and the postconcussion syndrome. The extent of concussive amnesia roughly correlates with the duration of loss of consciousness and the severity of the head injury. There is both anterograde amnesia (the inability to retain new information) and retrograde amnesia, with the latter encompassing the moments before injury or, in rare cases, extending backward for several days or longer.3 In exceptional cases, a very minor blow to the head causes a memory disturbance that lasts for several subsequent hours.4 The period of anterograde memory loss tends to be briefer than the period of retrograde memory loss, and both improve over a period of hours or in less time.5 Concussion does not cause a loss of autobiographical information, such as one’s name and birth date; this type of memory loss is a symptom of hysteria or malingering. Patients with concussion-related amnesia do not confabulate, and in many ways the clinical state resembles transient global amnesia.
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