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.

Level C recommendations. Do not use clinical decision tools to reliably exclude the need for head CT in adult patients with a minor head injury on anticoagulation therapy or antiplatelet therapy exclusive of aspirin.

Resources

• Canadian CT Head Rule: https://www.mdcalc.com/canadian-ct-head-injury-trauma-rule
• New Orleans/Charity Head Trauma/Injury Rule: https://www.mdcalc.com/new-orleans-charity-head-trauma-injury-rule
• NEXUS Head CT: https://bit.ly/NEXUSHeadCT

2. In the adult ED patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head CT?

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. Do not routinely perform repeat imaging in patients after a minor head injury who are taking anticoagulants or antiplatelet medication and are at their baseline neurologic examination, provided the initial head CT showed no hemorrhage. Do not routinely admit or observe patients after a minor head injury who are taking anticoagulants or antiplatelet medications, who have an initial head CT without hemorrhage, and who do not meet any other criteria for extended monitoring.

Level C recommendations. Provide instructions at discharge that include the symptoms of rare, delayed hemorrhage after a head injury (consensus recommendation).

Consider outpatient referral for assessment of both fall risk and risk/benefit of anticoagulation therapy (consensus recommendation).

Resources

Discharge instructions and other materials for patients

• CDC Mild Traumatic Brain Injury and Concussion: Information for Adults: https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Patient_Instructions-a.pdf
• CDC educational materials for adults with mTBI: https://www.cdc.gov/traumaticbraininjury/mtbi_guideline.html

Fall risk screening and assessment for clinicians and fall prevention materials for patients

• CDC Algorithm for Fall Risk Screening, Assessment & Intervention: https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508.pdf
• CDC fall prevention materials for patients: https://www.cdc.gov/steadi/patient.html
• CDC Stay Independent Brochure: https://www.cdc.gov/steadi/pdf/STEADI-Brochure-StayIndependent-508.pdf

3. In the adult ED patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for PCS or to identify patients with delayed sequelae after ED discharge?

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. Consider referral for patients with PCS and the following potential risk factors: female sex; previous preconcussive psychiatric history; GCS score <15; etiology of assault, acute intoxication; loss of consciousness; and preinjury psychological history such as anxiety/depression.

Do not use current diagnostic tools (including biomarkers) to reliably predict which patients are at risk for PCS. Provide concussion-specific discharge instructions and selected outpatient referrals of patients at high risk for prolonged PCS (consensus recommendation).

Resources

Discharge instructions and other materials for patients

• CDC Mild Traumatic Brain Injury and Concussion: Information for Adults: https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Patient_Instructions-a.pdf
• CDC educational materials for adults with mTBI: https://www.cdc.gov/traumaticbraininjury/mtbi_guideline.html

Translation of Classes of Evidence to Recommendation Levels

In accordance with the strength of evidence for each critical question, the subcommittee drafted the recommendations and supporting text synthesizing the evidence using the following guidelines:

Level A recommendations. Generally accepted principles for patient care that reflect a high degree of scientific certainty (eg, based on evidence from one or more Class of Evidence I or multiple Class of Evidence II studies that demonstrate consistent effects or estimates).

Level B recommendations. Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate scientific certainty (eg, based on evidence from one or more Class of Evidence II studies or multiple Class of Evidence III studies that demonstrate consistent effects or estimates).

Level C recommendations. Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances where consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.

Dr. Valente is an emergency physician and a national committee member of both the ACEP Pediatric Emergency Medicine Committee and ACEP Clinical Policies Committee.