How to Implement

Other studies utilizing ED observation pathways have been shown to safely discharge patients home without the need for an admission to the hospital.^4,5 Multidisciplinary teams involving neurosurgery, trauma, and emergency medicine can create pathways for isolated tICH that do not require admission or transfer. A phased approach can be used starting with a protocol like BIG and having neurosurgery review images for all patients with tICH. In the authors’ experience of more than 120 patients at several community sites, no unexpected adverse outcomes have been seen over the last two years. While local validation is important, safely reducing unnecessary transfers and admissions can not only reduce costs and inconvenience to the patient, it also helps referral centers that struggle with capacity.

Conclusion

You decided to take the consultant’s recommendation and while waiting for the repeat CT, read this ACEP Now article on the practicality of discharging tICH from the ED. Six hours later, the repeat CT head showed no difference in the size of the hemorrhage. Your patient’s neurologic exam remained unchanged. After discussing with neurosurgery again, they recommended discharge and you felt comfortable and in agreement.

Dr. Lo is the chief of emergency medicine at Sentara Norfolk General Hospital and professor at Eastern Virginia Medical School. He is a partner at Emergency Physicians of Tidewater, a private, democratic group in Norfolk, Virginia.

Dr. Weingart is the assistant medical director at Sentara Norfolk General Hospital emergency department and an assistant professor at Eastern Virginia Medical School. He is a partner at Emergency Physicians of Tidewater.

Dr. Gartman is an education fellow and Instructor at Eastern Virginia Medical School department of emergency medicine in Norfolk, Virginia.

References

1. Borczuk P, Van Ornam J, Yun BJ, et al. Rapid discharge after interfacility transfer for mild traumatic intracranial hemorrhage: frequency and associated factors. West J Emerg Med. 2019;20(2):307-315.
2. Pruitt P, Castillo R, Rogers A, et al. External Validation of a Tool to Identify Low-Risk Patients With Isolated Subdural Hematoma and Preserved Consciousness. Ann Emerg Med. 2023;18:S0196-0644(23)01138-1. Epub ahead of print.
3. Joseph B, Obaid O, Dultz L, et al. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022;93(2):157-165.
4. Singleton JM, Bilello LA, Greige T, et al. Outcomes of a novel ED observation pathway for mild traumatic brain injury and associated intracranial hemorrhage. Am J Emerg Med. 2021;45:340-344.
5. Wheatley MA, Kapil S, Lewis A, O’Sullivan JW, Armentrout J, Moran TP, Osborne A, Moore BL, Morse B, Rhee P, Ahmad F, Atallah H. Management of Minor Traumatic Brain Injury in an ED Observation Unit. West J Emerg Med. 2021;15(4):943-950.