Highlights from #EAST2014 - Concussion evaluation

This adds to the growing evidence that "minor" head injury isn't so minor.

YOU CAN’T GO HOME: ROUTINE CONCUSSION EVALUATION IS NOT ENOUGH
M. Chance Spalding, DO, PhD, Jennifer L. Hartwell, MD, Brian Fletcher, MS, RN, ACNP-BC

Grant Medical Center

Presenter: M. Chance Spalding, DO, PhD

Objectives: Traumatic brain injury affects almost 2 million people in the US each year with 75% classified as mild traumatic brain injury (MTBI), or concussion. Traditional care is to allow these patients to go home from the Emergency Department (ED) if their GCS is 15 and they have a normal head CT. However, this does not address short-term deficits or the benefits of early screening and treatment. Our hypothesis is that a notable percentage of patients with concussive symptoms will need outpatient neurocognitive therapy despite a reassuring initial evaluation.

Methods: This is a single institution retrospective review of patients suffering from MTBI at an urban level 1 trauma center between August 2010 and December 2011. Inclusion criteria were age 14 years or older with a diagnosis of MTBI, GCS of 15, negative head CT, a neurocognitive evaluation within 48 hours, blunt mechanism, and no confounding psychiatric comorbidities.

Results: 6032 trauma patients were seen during the study period. 905 patients had MTBI and a negative CT head. 396 met inclusion criteria. Average age was 38 years (range 14-93), 64% male, with a mean ISS of 8.2. 41% were cleared for discharge without any follow up or supervision. 25% required outpatient therapy. 3% were unsafe for discharge home. Of those cleared for discharge home, 88% had positive or questionable loss of consciousness (LOC) and 81% requiring additional therapy had positive or questionable LOC (p=0.20). Age, gender, ISS, and alcohol use were compared between the groups and were found to not be significantly different.

Conclusions: A surprisingly high percentage (28%) of our patients who would have met traditional criteria for discharge from the ED after MTBI required ongoing therapy. LOC was an unreliable predictor of clearance for discharge home. We provide evidence to suggest that premature discharge places patients with MTBI at risk for not being referred for appropriate neurocognitive therapy.