> Mild TBI

Mild Traumatic Brain Injury

Official guideline from the American College of Emergency Physicians.

summary by Eric Steinberg, DO

Risk Stratification

A noncontrast head computerized tomography (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, Glasgow Coma Scale (GCS) score less than 15, focal neurologic deficit, or coagulopathy.

Level A

A noncontrast head computerized tomography (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, Glasgow Coma Scale (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 B

Diagnosis

Imaging

ACEP does not specify any recommendations regarding the role of head magnetic resonance imaging (MRI) over noncontrast computerized tomography (CT) for the evaluation of a patient with mild traumatic brain injury (TBI).

Biomarkers

In mild traumatic brain injury (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 computerized tomography (CT). This test has not yet received Food and Drug Administration approval for clinical use in the United States.

Level C

Disposition

Patients with an isolated mild traumatic brain injury (TBI) who have a negative head computerized tomography (CT) scan result are at minimal risk for developing an intracranial lesion and therefore may be safely discharged from the emergency department (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 B

Mild traumatic brain injury (TBI) patients discharged from the emergency department (ED) should be informed about postconcussive symptoms.

Level C

What do the icons mean?

Level A

Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

Level B

Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies).

Level C

Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature, based on panel consensus.

Literature

Original/Primary Reference

Jagoda AS, Bazarian JJ, Bruns JJ, et al. American College of Emergency Physicians. Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting. Ann Emerg Med. 2008;52(6):714-48.

Calc Function

Risk Stratification

Diagnosis

Disposition