Management of Mild Head Injury

Aka: 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

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II. 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.

III. 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

IV. 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

V. History

  1. See Concussion
  2. See Closed Head Injury

VI. Exam

  1. See Trauma Secondary Survey
  2. Exclude concurrent systemic injury
  3. Limited Neurologic Exam

VII. 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]

VIII. 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

IX. 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)

X. Disposition: Criteria for home observation

  1. Criteria
    1. At least 4 hours after injury
    2. Normal clinical exam
    3. Normal Head CT without acute injury
    4. No findings as above indicating hospital observation
  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]

XI. Complications

  1. Post-Concussion Syndrome

XII. Management

  1. See Concussion
  2. See Mild Head Injury Home Management (includes Head Injury Precautions)
  3. Follow-up primary care (or Concussion clinic)

XIII. Precautions: Red Flags

  1. See Concussion Red Flags

XIV. 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]

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Related Studies

Ontology: Brain Concussion (C0006107)

Definition (MEDLINEPLUS)

A concussion is a type of brain injury. It's the most minor form. Technically, a concussion is a short loss of normal brain function in response to a head injury. But people often use it to describe any minor injury to the head or brain.

Concussions are a common type of sports injury. You can also have one if you suffer a blow to the head or hit your head after a fall.

Symptoms of a concussion may not start right away; they may start days or weeks after the injury. Symptoms may include a headache or neck pain. You may also have nausea, ringing in your ears, dizziness, or tiredness. You may feel dazed or not your normal self for several days or weeks after the injury. Consult your health care professional if any of your symptoms get worse, or if you have more serious symptoms such as

  • Seizures
  • Trouble walking or sleeping
  • Weakness, numbness, or decreased coordination
  • Repeated vomiting or nausea
  • Confusion
  • Slurred speech

Doctors use a neurologic exam and imaging tests to diagnose a concussion. Most people recover fully after a concussion, but it can take some time. Rest is very important after a concussion because it helps the brain to heal.

Centers for Disease Control and Prevention
Definition (MSHCZE) Náhlá porucha mozkových funkcí vyvolaná úrazem a provázená různě dlouhým bezvědomím (od zlomků sekundy po hodiny). Následují obvykle bolesti hlavy, vegetativní poruchy (nevolnost, zvracení). Pacient si nevzpomíná na události těsně předcházející úrazu (retrográdní amnézie). Není přítomen zřetelný neurologický deficit. Prognóza je většinou dobrá a stav se upraví, i když určité obtíže např. bolesti hlavy mohou přetrvávat i měsíce. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) A violent jar or shock, or the condition which results from such an injury.
Definition (NCI_FDA) A violent jar or shock, or the condition which results from such an injury.
Definition (MSH) A nonspecific term used to describe transient alterations or loss of consciousness following closed head injuries. The duration of UNCONSCIOUSNESS generally lasts a few seconds, but may persist for several hours. Concussions may be classified as mild, intermediate, and severe. Prolonged periods of unconsciousness (often defined as greater than 6 hours in duration) may be referred to as post-traumatic coma (COMA, POST-HEAD INJURY). (From Rowland, Merritt's Textbook of Neurology, 9th ed, p418)
Concepts Injury or Poisoning (T037)
MSH D001924
ICD9 850.9, 850
ICD10 S06.0 , S06.00, S06.0X9, S06.0X
SnomedCT 157321003, 209832007, 81371004, 110030002
LNC LA7422-4
English Brain Concussions, Concussion, Brain, Concussion, unspecified, concussion (diagnosis), concussion, Cerebral Concussion, Cerebral Concussions, Concussion, Cerebral, Commotio Cerebri, Brain Concussion [Disease/Finding], Concussive injury, brain concussion, cerebral concussion, commotio, concussion disorder, brain concussions, concussions, Concussion NOS, Brain Concussion, Concussion NOS (disorder), concussion injury of brain (diagnosis), Brain--Concussion, CONCUSSION, Concussion, Commotio cerebri, Cerebral concussion, Brain concussion, Commotio, Concussion (disorder), Concussion injury of brain (disorder), Concussion injury of brain, brain; blast, brain; commotio, brain; concussion, cerebral; concussion, cerebri; commotio, commotio cerebri, commotio; brain, concussion; brain, concussion; cerebral, Concussion (Brain), Injury;concussion;head
Italian Concussione, Concussione non specificata, Commotio cerebri, Commozione cerebrale
Dutch commotio cerebri, hersenschudding, niet-gespecificeerd, cerebraal; concussie, cerebri; commotie, commotie; hersenen, concussie; cerebraal, concussie; hersenen, hersenen; commotie, hersenen; concussie drukgolf, hersenen; concussie, hersenschudding, Hersenschudding, Commotio cerebri
French Commotion , non précisée, Commotion de l'encéphale, Commotion cérébrale, Commotion encéphalique, Commotion
German Gehirnerschuetterung, unspezifisch, Gehirnerschuetterung, Commotio cerebri, Gehirnerschütterung
Portuguese Concussão NE, Comoção cerebral, Concussão Encefálica, Concussão Cerebral, Comoção Cerebral, Comoção Encefálica, Concussão
Spanish Conmoción no especificada, Conmoción cerebral, Conmoción Encefálica, Conmoción Cerebral, conmoción (trastorno), conmoción(trastorno), conmoción, SAI (trastorno), conmoción, SAI, Concusión Cerebral, Concusión Encefálica, concusión cerebral (trastorno), concusión cerebral, concusión, conmoción cerebral (trastorno), conmoción cerebral, conmoción, lesión cerebral por concusión, Conmoción
Japanese 脳振盪、詳細不明, ﾉｳｼﾝﾄｳ, ﾉｳｼﾝﾄｳｼｮｳｻｲﾌﾒｲ, 脳振とう, 脳振とう症, 脳振盪, 脳振盪症, 脳震とう, 脳震盪
Swedish Hjärnskakning
Finnish Aivotärähdys
Russian MOZGA GOLOVNOGO SOTRIASENIE, МОЗГА ГОЛОВНОГО СОТРЯСЕНИЕ
Czech Otřes mozku, blíže neurčený, Komoce mozková, Otřes mozku, otřes mozku, komoce mozku, mozek - komoce, commotio cerebri
Korean 뇌진탕
Croatian POTRES MOZGA
Polish Wstrząśnienie mózgu
Hungarian Commotio, nem meghatározott, Commotio cerebri, Commotio
Norwegian Hjernerystelse, Commotio cerebri
Derived from the NIH UMLS (Unified Medical Language System)

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