Mild Traumatic Brain Injury - Observation vs Discharge

The disposition of trauma patients with mild TBI has been investigated by multiple authors; however, no clear consensus been attained. These patients are defined as GCS 15 with a negative Head CT. Practice varies from immediate discharge to periods of observation ranging 6-24 hours in length. The time frames of these observation periods can be presumed linked to studies by Knuckey, et al (6 hour) and Nagy, et al (24 hour). The study by Nagy was a Class III prospective study of 1,170 mild TBI patients with a GCS score of 15 and a negative Head CT who underwent admission for 24 hours. This study found that not a single patient had clinical deterioration in that period. This would suggest that patients should be cleared for discharge after their initial negative Head CT. However, a prospective study of 2,152 patients released 1 year later by Livingston, et al found that of mild TBI patients with negative Head CT, 33 (0.2%) required neurosurgical or critical care. This study’s methodology has come under scrutiny as the clinical characteristics of the miss group were not well described. Further studies aimed to clarify the issue. Specifically, a Class I prospective study involving 39 hospitals in Sweden by Geijerstam, et al randomized Mild TBI patients with GCS 15 to immediate Head CT or hospital admission for observation. 1,292 patients were randomized to immediate CT, 82 of which had positive CT read. Those with a negative Head CT and no other indication for admission were discharged home without any complications requiring admission or surgery in the 3 month follow up period. 

Taking these studies into account, the American College of Emergency Physicians and CDC have made a Level B Recommendation regarding the disposition of Mild TBI patients:

         Patients with an isolated mild TBI who have a negative head CT scan result are at   minimal risk for developing an intracranial lesion and therefore may be safely discharged from the ED.*

            *There are inadequate data to include patients with a bleeding disorder; who are receiving anticoagulation therapy or antiplatelet therapy; or who have had a previous neurosurgical procedure in this population.

This suggests that further studies are needed to formulate concrete recommendations regarding the disposition of these patients.

-Knuckey NW, Gelbard S, Epstein MH. The management of “asymptomatic” epidural hematomas. A prospective study. Journal of Neurosurgery. 1989;70(3):392–6.

-Nagy, KK, Joseph, KT, Krosner, SM, et al. The utility of head computed tomography after minimal head injury. J Trauma Injury Infect Crit Care. 1999; 46:268-273

-Livingston DH, Lavery RF, Passannante MR, et al. Emergency department discharge of patients with a negative cranial

computed tomography scan after minimal head injury. Ann Surg.

2000;232:126-132.

-af Geijerstam JL, Oredsson S, Britton M; OCTOPUS Study

Investigators. Medical outcome after immediate computed tomography or admission for observation in patients with mild head injury: randomised controlled trial. BMJ. 2006;333:465- 571.

-Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting

From the American College of Emergency Physicians (ACEP)/Centers for Disease Control and Prevention (CDC) Panel to Revise the 2002 Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.

Ann Emerg Med. 2008;52:714-748.

from Dr. Kristopher Wnek