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

The Food and Drug Administration conducted a large-scale investigation of clinical deterioration following TBI, Involving >7,000 patients with head Injury from 31 hospitals, Outcome data from >3,600 of these patients were used to divide the sample into low-, moderate-, and high-risk groups and each was given appropriate management recommendations.9 The lowrisk group included individuals with no symptoms or only mild headache, dizziness, or superficial bumps, bruises, or cuts. The panel recommended that these individuals be discharged without admission, given written information about signs of possible intracranial lesion, and observed for these signs by another responsible individual.

The moderate-risk group included patients with severe/worsening headache, vomiting, altered consciousness, intoxication, amnesia, skull fracture, and/or seizures. The recommendation for these patients was repeated and extended observation, consideration for CT scan, or neurosurgical consultation. Characteristics of the high-risk group were similar to the moderate group but were clearly present and more specifically defined. An additional characteristic of this group was the presence of focal neurological signs. Recommendations for this high-risk group included obtaining an immediate CT scan and neurosurgical consult. Mental status changes and focal neurological findings are once again included as important clinical risk factors, consistent with findings of the previously cited studies.

More recently, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies (WFNS) proposed a classification system for mild TBI in adults including categories of low-risk, medium-risk, and high-risk mild injuries.10 With minor variations, these guidelines are similar to those developed earlier. Low-risk patients are those with a Glasgow Coma Scale (GCS) score of 15 without loss of consciousness, amnesia, vomiting, or difluse headache. Recommended treatment for these patients Is release to home with written Instructions. Mediumrisk patients are those with a GCS of 15 and one or more of the symptoms of loss of consciousness, posttraumatic amnesia, vomiting, and diffuse headache. The high-risk category is reserved for patients with admission GCS of 14 or 15 with a skull fracture or neurological deficits. In addition, patients with coagulopathy, drug or alcohol consumption, previous neurosurgical procedures, pretrauma epilepsy or over the age of 60 are also considered to be in the high-risk group, regardless of other aspects of their clinical presentation.

A recently published outcome study" with 5,578 mild TBI patients presenting to EDs has validated these guidelines. The predictor variables recommended by the WFNS of GCS, posttraumatic amnesia, diffuse headache, vomiting, loss of consciousness, neurological deficits, and skull fracture combined with risk factors including age >60 years, alcohol or substance abuse, dangerous mechanism, previous neurosurgery or epilepsy, and coagulopathy were highly accurate in predicting outcome. Three separate ways of defining outcome were examined: (1) presence of posttraumatic lesions on CT scan, (2) need for neurosurgical intervention, and (3) unfavorable clinical outcome at 6 months, defined as death, permanent vegetative state, or severe disability. The predictor variables showed good sensitivity and specificity for identifying risk of all three outcomes: positive CT, need for neurosurgery, and poor clinical outcome.

Rosenthal12 has provided comprehensive, holistic recommendations for evaluation and treatment of TBI in the ED that are consistent with the major goals of acute evaluation and the guidelines based on risks for poor outcome. He recommends a thorough neurological examination, which should (1) address the major risk factors for clinical deterioration (altered consciousness, skull fracture, older patient age, increasing severe headache, vomiting, focal signs), (2) assess cognitive and behavioral functioning, and (3) include family and witness interviews to obtain accurate and complete information about the details and mechanism of injury and any change or loss of consciousness. Rosenthal12 also recommends that written information be provided about possible cognitive and behavioral changes that can be expected following TBI. in addition to the information provided about the signs of clinical deterioration. He also recommends that the provider give reassurance that symptoms will likely dissipate in days or weeks. This information can prevent the development of an exaggerated psychological reaction to common symptoms experienced during the short-term recovery of TBI. Finally, instruction to seek further evaluation if symptoms persist for 4 to 6 weeks addresses cases that do not follow the normal course of recovery and need further evaluation and intervention to prevent the development of persistent postconcussive syndrome.