Neuro

Management of Mild Head Injury

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Management of Mild Head Injury, Mild Traumatic Brain Injury, MTBI, Minor Head Injury, Mild Head Injury, Mild Head Trauma, Mild Closed Head Injury, Disposition in Mild Head Injury, Brain Injury Guidelines 1, BIG 1 Criteria in Traumatic Brain Injury

  • See Also
  1. Head Injury
  2. Concussion
  3. Mild Head Injury Home Management
  4. Management of Moderate Head Injury
  5. Management of Severe Head Injury
  6. Post-Concussion Syndrome
  • Epidemiology
  1. Mild Traumatic Brain Injury (MTBI) accounts for 75-90% of the 2.8 Million people in U.S. who suffer TBI annually (2013)
    1. Mild Traumatic Brain Injury is under-reported and likley approaches 3.8 Million in U.S.
  • Background
  1. Mild Traumatic Head Injury is the preferred term for Concussion and Minor Head Injury
    1. These terms are interchangeable, referring to the same condition
  • Criteria
  1. Glasgow Coma Scale: 13-15 (at two hours)
  2. Loss of consciousness may have occurred with injury
  3. Awake and oriented with normal Neurologic Examination
  • History
  1. See Concussion
  2. See Closed Head Injury
  • Exam
  1. See Trauma Secondary Survey
  2. Exclude concurrent systemic injury
  3. Limited Neurologic Exam
  • Labs
  1. Consider toxicology testing
    1. Blood Alcohol Level
    2. Urine Drug Screen
  2. I-Stat TBI Plasma
    1. Detects 2 markers of intracranial injury (UCH-L1, GFAP)
    2. May be used to risk stratify to Head CT Imaging
      1. Indicated for adults within 12 hours of Closed Head Injury with GCS 13 to 15
      2. CT Indicated if UCH-L1 > 327 pg/ml, or GFAP >22 22 pg/ml
    3. Efficacy
      1. Test Sensitivity: 97.6% for intracranial Head Injury
      2. Negative Predictive Value: 99.6%
    4. References
      1. Bazarian (2018) Lancet Neurol 17(9): 782-9 [PubMed]
  • Imaging
  1. Head CT
    1. See Head Injury CT Indications in Adults
    2. See Head Injury CT Indications in Children
    3. See Pediatric Head Injury Algorithm (PECARN)
  2. C-Spine XRay as indicated
  3. Skull XRay Indications
    1. Penetrating Head Injury
    2. CT Head not available
  • Diagnosis
  • Brain Injury Guidelines 1 (BIG 1) Criteria
  1. Mild Head Injury
    1. No Skull Fracture
    2. If present, Hemorrhages are small
      1. No intraventricular Hemorrhage
      2. Subdural Hematoma or Epidural Hematoma <=4 mm thick
      3. Single intraparenchymal Hemorrhage <=4 mm
      4. Trace Subarachnoid Hemorrhage
  2. Normal Neurologic Exam
  3. No Intoxication
  4. No major risk factors
  5. No Anticoagulation or antiplatelet use
  6. References
    1. Joseph (2014) J Trauma Acute Care Surg 76(4):965-9 +PMID: 24662858 [PubMed]
    2. Joseph (2022) J Trauma Acute Care Surg 93(2):157-65 +PMID: 35343931 [PubMed]
  • Disposition
  • Criteria for Hospital Observation
  1. No CT scan available (and warranted) or abnormal CT Head
  2. All penetrating head injuries
  3. Glasgow Coma Scale <15 at time of disposition
  4. History of loss of consciousness
  5. Deteriorating Level of Consciousness
  6. Moderate to severe Headache
  7. Significant Alcohol or drug Intoxication
  8. Skull Fracture
    1. Single, non-displaced Skull Fracture without Hemorrhage may be safe for discharge and close follow-up
    2. Discuss disposition with neurosurgery
  9. Focal neurologic deficit
  10. Cerebrospinal Fluid Leakage (Otorrhea or Rhinorrhea)
  11. Significant associated injuries
  12. Persistent Vomiting
  13. No reliable companion at home or displaced home
  14. Amnesia persists at time of disposition
  15. Nonaccidental Trauma
  16. Anticoagulant use (e.g. Warfarin)
    1. Risk of delayed Intracranial Hemorrhage (see Head Injury)
  • Disposition
  • Criteria for home observation
  1. Criteria
    1. At least 4 hours (6 hours per BIG-1 guidelines) after injury
    2. Normal clinical exam
    3. No findings as above indicating hospital observation
    4. Normal Head CT without acute injury
      1. CT Head is not repeated in BIG-1 guidelines unless dictated by symptoms, signs
  2. Studies suggesting safety for discharge in children after blunt Head Trauma and reassuring findings
    1. Hamilton (2010) Pediatrics 126(1): e33-9 [PubMed]
    2. Holmes (2011) Ann Emerg Med 58(4): 315-22 [PubMed]
  3. Studies suggesting safety for discharge in children after blunt Head Trauma with known pre-existing Bleeding Disorders
    1. Lee (2011) J Pediatr 158(6): 1003-8 [PubMed]
  4. Delayed Intracranial Hemorrhage following minor head injuries is rare beyond 6 hours in children
    1. Hamilton (2010) Pediatrics 126(1): e33-9 [PubMed]
  • Complications
  1. Post-Concussion Syndrome
  • Management
  1. See Concussion
  2. See Mild Head Injury Home Management (includes Head Injury Precautions)
  3. Follow-up primary care (or Concussion clinic)
  • Precautions
  • Red Flags
  1. See Concussion Red Flags
  • References
  1. Abuguyan (2024) Crit Dec Emerg Med 38(7): 4-11
  2. Claudius in Majoewsky (2012) EM:RAP 12(2): 7-8
  3. Lawler (1996) J Head Trauma Rehabil 11:18-28 [PubMed]
  4. Jagoda (2002) Ann Emerg Med 40:231-40 [PubMed]