New ACEP Clinical Policy on Mild TBI

August 25, 2023

Written by Laura Murphy

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ACEP has issued an updated Clinical Policy to provide evidence-based guidelines for management of adult patients presenting to the ED with mild traumatic brain injury based on systematic review of available literature.

(Head) bang for the buck
Traumatic brain injury leads to significant number of hospitalizations and causes significant economic burden. Most patients with ED visits for head injury are diagnosed with mild traumatic brain injury (mTBI). As such, appropriate management of mTBI is important to reduce economic and societal burden of mTBI. This clinical policy addressed three main questions in patients with mTBI, which was defined as age 16 years or older with GCS of 14 or 15, with improvement to score of 15 within 2 hours after injury, with or without loss of consciousness, amnesia, or disorientation presenting for evaluation within 24 hours of injury (more here).

• Clinical Decision Tools for Utilization of Head CT
  Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), and National Emergency X-Radiography Utilization Study (NEXUS) decision tools, have demonstrated excellent sensitivities close to 100% for significant intracranial injury. The CCHR has higher specificity than the NOC and NEXUS tools, which may lead to less unnecessary imaging, resulting in a Level A recommendation for CCHR compared to level B recommendation for NEXUS and NOC. Notably, the sensitivity and specificity of these tools are limited to the study populations and may not perform as well in high-risk patients, including those patients on anticoagulation or antiplatelet therapy or who are intoxicated, and they should not be routinely applied to these groups.

• Repeat Head CT in Patients on Anticoagulation or Antiplatelet Therapy
  Initial neuroimaging should be sufficient to exclude clinically significant injuries in patients with reassuring neurologic exam (Level B recommendation), as incidence of clinically significant delayed intracranial hemorrhage (ICH) after blunt head trauma is low in patients presenting with baseline neurologic exam. The highest risk group seems to be in elderly patients on antiplatelet agents.  However, patients should be advised of symptoms of delayed ICH at discharge with special consideration of a safe discharge environment with regard to fall risk and continuation of anticoagulation or antiplatelet therapy (Level C Recommendation).

• Tools to Identify Patients at High Risk for Post-Concussive Syndrome (PCS)
  PCS continues to be poorly understood but leads to increased morbidity; while there is not a single bedside tool for ED use, the following risk factors seem to increase risk of PCS: female sex, previous psychiatric history, GCS<15, etiology of assault or intoxication, LOC. These patients are likely to benefit from concussion-specific discharge instructions and/or referral to multidisciplinary teams for early follow-up. 

How will this change my practice?
While this clinical policy is unlikely to drastically change my practice, ACEP’s evidence-based guidelines support safe management of ED patients with mTBI while being conscientious about healthcare resource utilization.

Source
Clinical Policy: Critical Issues in Management of Adult Patients Presenting to the Emergency Department with Mild Traumatic Brain Injury. Ann Emerg Med. 2023 May; 81(5): e63-e105. doi: 10.1016/j.annemergmed.2023.01.014.