Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury

Official 2023 guideline from the American College of Emergency Physicians.

Strength

Risk Stratification

Clinical Decision Tools

Level A

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

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

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.

Diagnosis

Imaging

Level B

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.

Disposition

Level B

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

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

Level C

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

Postconcussive Syndrome

Follow-Up

Level C

Consider referral for patients with postconcussive syndrome (PCS) and the following potential risk factors: female sex, previous preconcussive psychiatric history, GCS score <15, etiology of assault, acute intoxication, LOC, and preinjury psychological history such as anxiety/ depression.

Level C

Do not use current diagnostic tools (including biomarkers) to reliably predict which patients are at risk for PCS.

Level C

Provide concussion-specific discharge instructions and selected outpatient referrals of patients at high risk for prolonged PCS (consensus recommendation).

Literature

Original/Primary Reference

Valente JH, Anderson JD, et al. Clinical policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department with Mild Traumatic Brain Injury. Ann Emerg Med. 2023;81(5):e63-e105.

Summary By

Eric Steinberg, DO, MEHP

What do the ratings 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.