A Survey of Mild Traumatic Brain Injury Treatment in the Emergency Room and Primary Care Medical Clinics

Military Medicine,  Jun 2006  by Kennedy, Jan Elizabeth,  Lumpkin, Robin James,  Grissom, Joyce Rothleder

• E-mail
• Print
• Link

This study surveyed health care providers about their evaluation and treatment of mild traumatic brain injury (TBI) in adults. We presented two vignettes describing mild TBI cases to staff in the emergency department (N = 22) and primary care clinics (N = 16) at Wilford Hall Air Force Medical Center and asked how they would evaluate and treat these patients. Most providers said they would assess visual changes, nausea/vomiting, headache, and neck pain. More emergency department personnel than primary care clinic providers would make referrals to different specialties, whereas more primary care clinic providers would schedule a follow-up appointment Neither group of providers mentioned assessing common postconcussive symptoms of fatigue, emotional changes, and problems sleeping. Comparing findings to current literature suggest that added focus on emotional, cognitive and psychosocial factors, and education of the patient and family could improve early identification of mild TBI patients at risk for poor recovery.

Introduction

The annual Incidence of traumatic brain injury (TBI) is estimated at 1.4 million, >10 times the incidence of breast cancer.1 The number of hospitalizations for TBI (230,000 annually) is >20 times the number for spinal cord injuries.2 It is one of the most common neurological conditions, surpassed in incidence only by migraine headache and herpes zoster.3 Approximately 75% of all TBIs are mild.4 Recent incidence figures have estimated 1 million emergency department (ED) visits for TBI not subsequently hospitalized, most of which would be in the mild TBI category.5 Approximately 1 of every 200 people in the United States will be seen in a medical care setting after a mild TBI in any given year. A survey of two national databases from EDs and clinics from 1995 to 1997 estimated 1.4 million visits per year, with more than twice as many visits for mild TBI in the ED compared to outpatient clinic settings.6 Given these statistics, proper care and treatment of mild TBI in EDs and outpatient clinics is an important priority for medical education and administration.

Methods

To determine how providers evaluate and treat mild TBI, we developed a survey consisting of two mild TBI case scenarios that was presented to military ED (N = 22) and primary care clinic (PCC; JV = 16) providers at military treatment facilities (see "Appendix"). Surveys were individually administered to providers attending a continuing education lecture on TBI. After reading case 1, they answered questions about what additional complaints, historical data, and physical examination data they would solicit from the described case. Providers then reviewed case 2 and were asked what additional consultations or referrals they would consider, if they would request neuroimaging and if they would appoint the patient for follow-up or prescribe medication. Answers from the survey were compiled and entered into an Excel database (Microsoft, Redmond, Washington). Each answer to a question was placed in a corresponding category and the frequencies of each category across ED and PCC providers were computed.

Results

In evaluating case 1, the providers identified 17 potential symptoms as important for examination. Of these 17 symptoms, 4 were mentioned by more than one-half of the providers, including headache, neck pain, nausea, and visual changes. AU of these symptoms correspond to factors identified in the literature as associated with risk for clinical deterioration and/or poor subsequent outcome.

Relating risk factors for clinical deterioration as identified in the TBI literature fTable I) to the results of our survey, we found that providers varied somewhat in their solicitation of these factors fTables II and III). The first symptomatic risk factor of drowsiness, confusion, lethargy, or altered consciousness was labeled "mental status changes" in our survey results and was included in only 29% of providers' responses. Neurological deficit, including unspecified and specific focal findings, was mentioned by 37% of the sample. One specific focal disturbance that was mentioned by two-thirds of the providers surveyed was visual changes. In addition, 53% of the providers stated that they would conduct a neurological examination, without specifying the components included. This examination would normally include an assessment of the level of consciousness and focal neurological deficits, raising the rate of evaluation of these risk factors for deterioration.

Important risk symptoms of nausea and headache were each mentioned by slightly more than one-half of the providers. Thirty-two percent of the providers mentioned assessing memory/ posttraumatic amnesia. The scenario indicated that the patient did not remember many details of the accident, which may have reduced the number of providers including this symptom. The risk factor of skull fracture was evaluated via assessment for blood/fluid discharge, mentioned by about one-fourth of the providers and via head palpation and computed tomography (CT) scan. Approximately one-third of the ED providers and one-fifth of the PCC providers said they would include head palpation in their physical examination of the patient. More than 20% of the ED providers said they would order a CT scan, whereas