Management of Adult Patients Presenting to the Emergency Department with Mild Traumatic Brain Injury
Publication Date: February 27, 2023
Last Updated: March 1, 2023
Summary of Recommendations
Use the Canadian CT Head Rule (CCHR) to provide decision support and improve head CT utilization in adults with a minor head injury (Table 1). (A)
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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 (Table 1) (B)
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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. (C)
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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. (B)
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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. (B)
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Provide instructions at discharge that include the symptoms of rare, delayed hemorrhage after a head injury (Consensus recommendation). (C)
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Consider outpatient referral for assessment of both fall risk and risk/benefit of anticoagulation therapy (Consensus recommendation). (C)
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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; LOC; and preinjury psychological history such as anxiety/depression. (C)
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Do not use current diagnostic tools (including biomarkers) to reliably predict which patients are at risk for PCS. (C)
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Provide concussion-specific discharge instructions and selected outpatient referrals of patients at high risk for prolonged PCS (Consensus recommendation). (C)
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Table 1. Overview of Clinical Decision Support Tools
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| Clinical Decision Tool | Criteria | Exclusion Criteria |
| Canadian CT Head Rule | Any one of: Failure to reach GCS score of 15 within 2 hours of injury Suspected open skull fracture Signs of basal skull fracture Vomiting more than once Age greater than 64 y |
Without: Age <16 y Blood thinners Seizure after injury |
| New Orleans Criteria | Any one of: Headache Vomiting Age over 60 y Drug or alcohol intoxication Deficits in short-term memory Physical evidence of trauma above the clavicles Posttraumatic seizure |
Without: GCS score of <15 Age ≤3 y |
| Nexus Head CT | Any one of: Evidence of skull fracture Scalp hematoma Neurologic deficit Abnormal level of alertness Abnormal behavior Persistent vomiting Coagulopathy Age 65 y or greater |
Without: GCS score of <15 |
Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Management of Adult Patients Presenting to the Emergency Department with Mild Traumatic Brain Injury
Authoring Organization
American College of Emergency Physicians
Publication Month/Year
February 27, 2023
Last Updated Month/Year
April 1, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Target Patient Population
Adult patients with suspected brain injury
Target Provider Population
Emergency physicians, internal medicine and other allied care providers
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Emergency care, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Diseases/Conditions (MeSH)
D001930 - Brain Injuries, D000070642 - Brain Injuries, Traumatic
Keywords
traumatic brain injury, TBI, mild traumatic brain injury