On February 1, 2023, the ACEP Board of Directors approved a clinical policy developed by the ACEP Clinical Policies Committee on critical issues in the management of adult patients presenting to the emergency department (ED) with mild traumatic brain injury (mTBI). This clinical policy will be published in the May 2023 issue of the Annals of Emergency Medicine, and can be found on ACEP’s website and will also be included in the ECRI Guidelines Trust upon its acceptance.

Traumatic brain injuries affect the lives of millions of Americans and represent a serious healthcare challenge for emergency department clinicians. Approximately 70 percent to 90 percent of patients presenting to the ED with a head injury and traumatic brain injury will be diagnosed with mTBI. While most patients with mTBI are treated and discharged from the ED, an estimated five percent to 15 percent of patients with head injury will have intracranial injuries on imaging and be classified as having moderate or severe traumatic brain injury. Roughly one percent of patients classified as having more severe traumatic brain injury will require surgical intervention and 0.1 percent will die. This clinical policy is intended to help improve the evaluation and management of patients with mild traumatic brain injury who present to an emergency department by answering three critical questions representing current interest or controversy.

Based on feedback from ACEP membership, the Clinical Policies Committee conducted an updated systematic review of the literature to assess any needed changes to the 2008 clinical policy and to determine whether there was a need for additional evidence-based recommendations. After a thorough review of the literature, the topics of the 2008 clinical policy were updated or readdressed for this 2023 clinical policy. This 2023 clinical policy focuses on emergent mTBI research related to clinical decision tools, patients using anticoagulant or antiplatelet medication, and post-concusive syndrome (PCS).

Critical Questions and Recommendations

1. In the adult ED patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head CT?

Patient Management Recommendations

Level A recommendations. Use the Canadian CT Head Rule (CCHR) to provide decision support and improve head CT utilization in adults with a minor head injury.

Level B recommendations. Use the National Emergency X-Radiography Utilization Study (NEXUS) Head CT decision tool (NEXUS Head CT) or the New Orleans Criteria (NOC) to provide decision support in adults with minor head injury; however, the lower specificity of the NEXUS Head CT and NOC compared with CCHR may lead to more unnecessary testing.