Management of Mild Head Injury

1. 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
2. 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.
3. 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
4. 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
5. History
   1. See Concussion
   2. See AMPLE History
   3. Time and mechanism of injury
   4. Loss of Consciousness
      1. How long?
      2. Contiguous with initial injury?
   5. Level of Consciousness (AVPU)
      1. Immediately post injury
      2. Subsequent evaluations
   6. Amnesia (Retrograde and antegrade)
   7. Headache
   8. Seizures
6. Exam
   1. See Trauma Secondary Survey
   2. Exclude concurrent systemic injury
   3. Limited Neurologic Exam
7. 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]
8. 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
9. 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
   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
   15. Anticoagulant use (e.g. Warfarin)
       1. Risk of delayed Intracranial Hemorrhage (see Head Injury)
10. Disposition: Criteria for home observation
    1. Criteria
       1. At least six 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]
11. Complications
    1. Post-Concussion Syndrome
12. Management
    1. See Concussion
    2. See Mild Head Injury Home Management (includes Head Injury Precautions)
    3. Follow-up primary care (or Concussion clinic)
13. Precautions: Red Flags
    1. See Concussion Red Flags
14. References
    1. Claudius in Majoewsky (2012) EM:RAP 12(2): 7-8
    2. Lawler (1996) J Head Trauma Rehabil 11:18-28 [PubMed]
    3. Jagoda (2002) Ann Emerg Med 40:231-40 [PubMed]