Traumatic brain injury remains a common complaint in emergency departments, accounting for more that 1 million visits annually.1 Even though most of these are classified as “mild,” an estimated 10% will have an acute traumatic lesion on head CT, less than 1% will have a lesion requiring a neurosurgical intervention, and up to 15% of these patients may have some degree of functional compromise at 1 year after their injury.
Explore This IssueACEP News: Vol 28 – No 05 – May 2009
Thus, two challenges confront the clinician: 1) determining which patients can be safely discharged home and which ones have an acute intracranial injury requiring further monitoring, imaging, or possibly neurosurgical intervention; and 2) which patients are at risk for developing postconcussive symptoms.
In 2002, the American College of Emergency Physicians published a clinical policy on the management of mild traumatic brain injury (TBI).2 In the 2002 document, an evidence-based approach was used to answer clinically relevant questions on the acute management of mild TBI. New evidence has become available that prompted an update of the 2002 clinical policy.
The most integral challenge in this topic is actually defining ‘mild traumatic brain injury.’
The revised clinical policy was developed by a multidisciplinary panel and funded by the Centers for Disease Control and Prevention. Presented below is an abstraction of the revised clinical policy which was published in the Annals of Emergency Medicine in December 2008.3 This clinical policy can also be found on ACEP’s Web site at www.acep.org under “Practice Resources.”
The most integral challenge in this topic is actually defining “mild traumatic brain injury.” Delineated inclusion criteria for a diagnosis of mild TBI from the American Congress of Rehabilitation Medicine4 and the Centers for Disease Control and Prevention5 were taken into consideration. Both of these classification schemes include one or more of the following criteria: alteration in mentation, amnesia, and a period of loss of consciousness.
Traditionally, mild TBI has included a Glasgow Coma Scale score (GCS) of 13-15; however, a growing body of literature supports moving a GCS of 13 into the “moderate” category. The document acknowledges that the GCS was originally developed before the availability of head computed tomography (CT) as a standardized clinical scale to facilitate reliable interobserver neurologic assessments of comatose patients with head injury. The GCS was neither developed nor suited to classify mild traumatic brain injury based upon one initial measurement.
On the other hand, serial GCS scores are quite valuable in patients with mild TBI. A low GCS score that remains low, or a high GCS that decreases, predicts a poorer outcome than a high GCS score that remains high or a low GCS score that progressively improves.6 From an emergency medical services and ED perspective, the key to using the GCS in patients with mild TBI is in serial determinations.