Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury (Executive Summary)

For the complete list of authors including members American College Emergency Physicians Clinical Policies Committee (Oversight Committee) and to read this ACEP clinical policy please go to: https://www.acep.org/patient-care/clinical-policies/ This from addresses key issues in management adult patients presenting emergency department with mild traumatic brain injury. A writing subcommittee conducted a systematic review literature derive evidence-based recommendations answer below critical questions. each question, search was performed, evidence graded synthesized, were made based on strength available data. 1.In (ED) patient minor head injury, are there decision tools identify who do not require CT? Use Canadian CT Head Rule (CCHR) provide support improve utilization adults injury (Table 1).Table 1Clinical tools. (Used permission).Canadian RuleNew Orleans CriteriaNEXUS CTHigh-risk features for predicting CIBIAny one of:•Failure reach GCS score 15 within 2 hours injury•Suspected open skull fracture•Signs basal fracture•Vomiting more than once•Age greater 64 yAny of:•Headache•Vomiting•Age over 60 y•Drug or alcohol intoxication•Deficits short-term memory•Physical trauma above clavicles•Posttraumatic seizureAny of:•Evidence fracture•Scalp hematoma•Neurologic deficit•Abnormal level alertness•Abnormal behavior•Persistent vomiting•Coagulopathy•Age 65 y greaterExclusion Criteria•Age <16 y•Blood thinners•Seizure after injury•GCS <15•Age ≤3 y•GCS <15CIBI, clinically important injury; CT, computed tomography; GCS, Glasgow Coma Scale. Open table new tab CIBI, National X-Radiography Utilization Study (NEXUS) tool (NEXUS CT) New Criteria (NOC) however, lower specificity NEXUS NOC compared CCHR may lead unnecessary testing 1). Do use reliably exclude need anticoagulation therapy antiplatelet exclusive aspirin. •Canadian Rule:https://www.mdcalc.com/canadian-ct-head-injury-trauma-rule•New Orleans/Charity Trauma/Injury Rule:https://www.mdcalc.com/new-orleans-charity-head-trauma-injury-rule•NEXUS CT:https://bit.ly/NEXUSHeadCT2.In ED normal baseline neurologic examination, taking an anticoagulant medication, is discharge safe single None specified. routinely perform repeat imaging anticoagulants medication at their provided initial showed no hemorrhage. admit observe medications, have without hemorrhage, meet any other criteria extended monitoring. Provide instructions that include symptoms rare, delayed hemorrhage (consensus recommendation). Consider outpatient referral assessment both fall risk risk/benefit Discharge materials patients•CDC Mild Traumatic Brain Injury Concussion: Information Adults:https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Patient_Instructions-a.pdf•CDC educational mTBI:https://www.cdc.gov/traumaticbraininjury/mtbi_guideline.html Fall screening providers prevention Algorithm Risk Screening, Assessment & Intervention:https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508.pdf•CDC patients:https://www.cdc.gov/steadi/patient.html•CDC Stay Independent Brochure:https://www.cdc.gov/steadi/pdf/STEADI-Brochure-StayIndependent-508.pdf3.In diagnosed concussion, factors requiring follow-up care postconcussive syndrome (PCS) sequelae discharge? PCS following potential factors: female sex; previous preconcussive psychiatric history; <15; etiology assault, acute intoxication; loss consciousness; preinjury psychological history such as anxiety/depression. current diagnostic (including biomarkers) predict which PCS. concussion-specific selected referrals high prolonged Adultshttps://www.cdc.gov/traumaticbraininjury/pdf/TBI_Patient_Instructions-a.pdf•CDC Translation Classes Evidence Recommendation Levels In accordance drafted supporting text, synthesizing using guidelines: Generally accepted principles reflect degree scientific certainty (eg, 1 Class I multiple II studies demonstrate consistent effects estimates). Recommendations particular strategy range strategies moderate III or, absence adequate published literature, expert consensus. instances where consensus made, “consensus” placed parentheses end recommendation. The findings conclusions manuscript those Committee, necessarily represent official position Centers Disease Control Prevention.