The annual number of emergency department (ED) visits for traumatic brain injury (TBI) is rising in the United States, with the majority of these visits resulting in a diagnosis of mild traumatic brain injury (mTBI), or concussion. There are limited data to support objective clinical measures to guide the management of concussion, but several guidelines have been published that provide recommendations for evaluation and management of concussion and mTBI. This supplement provides a summary of 2 recently published, consensus-based guidelines and discusses practical aspects of ED management of patients with concussive injuries, including the initial evaluation, diagnostic criteria, assessment tools, and aftercare recommendations.
The United States Centers for Disease Control and Prevention (CDC) estimates the incidence of sports-related mTBI in the United States to be 1.6 to 3.8 million per year, based on extrapolation of data from a 1991 study.1 A more recent study estimates that 1.1 to 1.9 million sports-related concussions occur each year in youth athletes in the United States.2 Concussive injuries account for an increasing number of presentations to the ED in the United States. A 2014 study demonstrated an 8-fold increase in ED visits for TBI when compared to total ED visits between 2006 and 2010. This increase may be due to a combination of factors, including improved screening and diagnostic tools, increased exposure to TBI due to early dedication to competitive sport, and more public awareness of TBI.3
The concussion literature is evolving rapidly, but rigorous, standardized research protocols remain limited. This is largely due to heterogeneity in the patient population, clinical trial design, concussion management technologies, and the data analysis techniques used to study an inherently complex disease process. Even with limited quality evidence, several consensus-based concussion guidelines have been published. This article reviews updated guidelines by the Concussion in Sport Group (CISG)4 and new guidelines by the CDC.5 The American Medical Society for Sports Medicine and the American Academy of Pediatrics Council on Sports Medicine and Fitness have also recently published clinical reports on sport-related concussion; these reports are generally reflective of the recommendations presented in the CISG and CDC guidelines.6,7
The CISG and CDC guidelines provide a general review of concussion management and do not address the management of concussion in the ED specifically. The emergency clinician is often first line when diagnosing concussion and initiating treatment. Once a concussion is diagnosed, an important role of the emergency clinician is to provide concussion education (including anticipated signs, symptoms, and recovery course), outpatient referral, and information on preventing re-injury. The CISG consensus statement specifically addresses sport-related concussion (SRC), but much of the information it presents is applicable to concussion management regardless of the mechanism of injury.
Sport-related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilised in clinically defining the nature of a concussive head injury include:
The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc) or other comorbidities (eg, psychological factors or coexisting medical conditions).
Reproduced from British Journal of Sports Medicine, McCrory P, Meeuwisse W, Dvorak J, et al, Volume 51, pages 838-847, with permission from BMJ Publishing Group Ltd.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent in-formation about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available.
Dr. Susan Kirelik, a concussion specialist and emergency medicine physician, discusses the key points of concussion diagnosis and management from the perspective of the emergency medicine clinician. The topics covered include:
Susan B. Kirelik is the Medical Director of the Rocky Mountain Pediatric OrthoONE Center for Concussion and is an attending pediatric emergency medicine physician at the Rocky Mountain Hospital for Children in Denver, Colorado.
McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838- 847. (Consensus statement)
Meeuwisse WH, Schneider KJ, Dvorak J, et al. The Berlin 2016 process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport. Br J Sports Med. 2017;51(11):873-876. (Conference summary)
Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort study; 42,412 patients)
Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396. (Prospective cohort study; 3121 patients)
Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014;42(10):2479-2486. (Cross-sectional study; 64 patients)
REAP concussion management (NOTE: this is the new URL for “center4concussion.com,” which is mentioned in the podcast)
Points to keep in mind:
Why to Use
The Glasgow Coma Scale (GCS) is an adopted standard for mental status assessment in the acutely ill trauma and nontrauma patient and assists with predictions of neurological outcomes (complications, impaired recovery) and mortality.
When to Use
Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use. Clinical management decisions should not be based solely on the GCS score in the acute setting.
The modified GCS (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14-point original GCS) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale 1974).
The evidence presented in 53 published reports on the reproducibility of the GCS was synthesized in a systematic review by Reith et al in 2016. Eighty-five percent of the findings in the studies identified as high quality showed substantial reliability of the GCS as judged by the standard criterion of a kappa statistic > 0.6. Reproducibility of the total GCS score was also high, with kappa > 0.6 in 77% of the observations. Education and training on usage of the GCS resulted in a clear beneficial effect on reliability (Reith 2016).
In its most common usage, the 3 sections of the scale are often combined to provide a summary of severity. The authors themselves have explicitly objected to the score being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality. A GCS score of 4 predicts a mortality rate of 48% if calculated 1 + 1 + 2 for eye, verbal, and motor components, respectively, and a mortality rate of 27% if calculated 1 + 2 + 1, but a mortality rate of only 19% if calculated 2 + 1 + 1 (Healey 2014).
In summary, the modified GCS provides a nearly universally accepted method of assessing patients with acute brain damage. Summation of its components into a single overall score loses information and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the motor component of the scale (as in the SMS) can perform as well as the GCS and is less complicated. However, the scores like the SMS may be less informative in patients with lesser injuries.
Sir Graham Teasdale, MBBS, FRCP
The PECARN Pediatric Head Injury Prediction Rule is a well-validated clinical decision aid that allows physicians to safely rule out the presence of clinically important traumatic brain injuries.
Why to Use
Unlike in the adult population, CT imaging of the head in pediatric patients is believed to be associated with an increased risk of lethal malignancy over the life of the patient, with the risk decreasing with age. The estimated lifetime risk of lethal malignancy from a head CT for a 1-year-old patient is 1 in 1000 to 1500, with risk decreasing to 1 in 5000 for a 10-year-old patient.
There are over 600,000 emergency department visits annually in the United States for head trauma among patients aged ≤ 18 years. Applying the PECARN Pediatric Head Injury Prediction Rule allows providers to determine which pediatric patients they can safely discharge without obtaining a head CT.
When to Use
ciTBI was a rare event (0.9%) and neurosurgical intervention was even more rare (0.1%). Over 50% of each age cohort did not meet any predictors, and CT imaging is not indicated for the vast majority of these patients, as risk of ciTBI was exceedingly low. Risk of ciTBI was > 4% with either of the 2 higher-risk predictors in each age cohort, and imaging is recommended.
For the remaining 4 lower-risk predictors in each cohort, the risk of ciTBI is approximately 0.9% per predictor, and CT imaging is indicated rather than observation. Judgment may be based on clinical experience, single versus multiple findings, signs of clinical deterioration during the observation period, patient age, and/or parental preference.
The original PECARN trial included 42,412 children aged < 18 years presenting to one of the 25 North American PECARN-affiliated emergency departments. There were 33,785 patients in the derivation cohort (8502 of whom were aged < 2 years) and 8627 in the validation cohort (2216 of whom were aged < 2 years).
CT scans were performed at the physician’s dis-cretion in 35.3%, while medical records, telephone surveys, and county morgue records were used to assess for cases of missed ciTBI in those discharged without imaging. The potential for CT reduction quoted above is likely underestimated, given that CT utilization in this study (35.3%) was significantly lower than the estimated average in North American emergency departments (50%).
TBI occurred in 5.2% of patients. Nine percent of patients were admitted to the hospital. ciTBI occurred in 0.9% of the cohort, neurosurgery was performed in 0.1% of the overall cohort, and 0 patients died. In patients aged < 2 years who were negative for any PECARN risk factor, the aid was 100% sensitive (95% confidence interval [CI], 86.3-100) with a negative predictive value (NPV) of 100% (95% CI, 99.7-1000) for ruling out ciTBI in the validation cohort. In patients aged > 2 years who were negative for any PECARN risk factor, the aid was 96.8% sensitive (95% CI, 89.0-99.6) with 99.95% NPV (95% CI, 99.8-99.99) for ruling out ciTBI in the validation cohort.
External validation studies have demonstrated sensitivity of 100% for ciTBI and any injury requiring neurosurgery. The algorithm has reasonable specificity (53%-60%), considering its extremely high sensitivity.
Sixty of 376 patients (15.9%) with ciTBI underwent neurosurgery, 8 patients (2.1%) with ciTBI were intubated > 24 hours, and 0 patients died.
As a result of the infrequency of ciTBI, the lower bounds of the CIs of sensitivity started at 86% and 89%, respectively, for the cohorts aged < 2 years and > 2 years. The NPV CIs very closely approximated 100%.
The PECARN Rule has now been externally validated in 2 separate studies. One trial of 2439 children in 2 North American and Italian centers found the PECARN Rule to be 100% sensitive for ruling out ciTBI in both age cohorts. The rates of 0.8% (19/2439) of patients with ciTBI and 0.08% (2/2439) of patients requiring neurosurgery were similar to the rates in the PECARN trial.
A second trial at a single United States emergency department of 1009 patients aged < 18 years prospectively compared the PECARN Rule to 2 other pediatric head CT decision aids, CHALICE and CATCH, as well as to physician estimates and physician practice. In this sample, 2% (21/1009) of patients had ciTBI and 0.4% (4/1009) of patients needed neurosurgery. Again, the PECARN Rule was found to be 100% sensitive for identifying ciTBI.
The PECARN Rule outperformed both the CHALICE and CATCH decision aids, which were 91% and 84% sensitive for ciTBI, respectively). Although the goal was to rule out those with very low risk of ciTBI, the PECARN Rule also performed well to rule out TBI on head CT. In patients aged < 2 years, sensitivity and NPV were 100% for TBI on CT, with narrow CIs. In patients aged > 2 years, sensitivity was 98.4% and NPV was 94% for TBI on CT, with relatively narrow confidence intervals.
Two PECARN Rule subgroup analyses attempted to further risk-stratify patients with single predictors (eg, isolated scalp hematoma in patients aged < 2 years). ciTBI was too uncommon to apply age, hematoma size, or hematoma location predictors. There were several non–statistically significant trends for higher rates of TBI on head CT that may affect imaging tendencies (eg, age < 3 months, nonfrontal hematoma, and large size).
Another subanalysis of those with isolated vom-iting (eg, no other PECARN predictors) reiterated the parent study results. In the cohort of patients aged > 2 years, there was a low rate of TBI on head CT (3.2%, 26 of 806 patients) and an even lower rate of ciTBI (0.7%, 10 of 1501 patients), so observation rather than emergent imaging is indicated in the majority of these patients. Number of vomiting episodes and timing of episodes was not helpful in predicting ciTBI or TBI on head CT, as there was a non–statistically significant counterintuitive trend towards less ciTBI/TBI on CT with more episodes.
Nate Kupperman, MD, MPH
|CATCH||Canadian Assessment of Tomography for Childhood Head injury [Rule]|
|CHALICE||Children's Head injury ALgorithm for the prediction of Important Clinical Events [Rule]|
|ciTBI||Clinically-important traumatic brain injury|
|GCS||Glasglow Coma Scale|
|NPV||Negative predictive value|
|PECARN||Pediatric Emergency Care Applied Research Network|
|TBI||Traumatic brain injury|
The Canadian CT Head Rule (CCHR) was developed to help physicians determine which patients with minor head injury need head CT imaging.
Why to Use
There are more than 8 million patients who present annually to emergency departments in the United States for evaluation of head trauma. The vast majority of these patients have minor head trauma that will not require specialized or neurosurgical treatment. At the same time, rates of CT imaging of the head more than doubled from 1995 to 2007.
When to Use
The CCHR has been validated in multiple settings and has been consistently demonstrated to be 100% sensitive for detecting injuries that will require neurosurgery. Depending on practice environment, it may not be considered acceptable to miss any intracranial injuries, regardless of whether they would have required intervention.
Providers may want to consider applying the New Orleans Criteria for head trauma, as there has been at least 1 trial finding it to be more sensitive than the CCHR for detecting clinically significant intracranial injuries (99.4% vs 87.3%), though this comes at the price of markedly decreased specificity (5.6% vs 39.7%). Furthermore, there are other trials in which the CCHR was found to be more sensitive than the New Orleans Criteria for detecting clinically important brain injuries.
The validation study (Stiell 2005) included a convenience sample of 2702 patients aged ≥ 16 years, who presented to 9 Canadian emergency departments with blunt head trauma resulting in witnessed loss of consciousness, disorientation, or definite amnesia and a Glasglow Coma Scale score of 13 to 15. Within the sample, 8.5% (231/2707) of the patients had a clinically important brain injury, and 1.5% (41/2707) of the patients had an injury that required neurosurgical intervention. In the validation trial, the CCHR was 100% sensitive for both clinically important brain injuries and injuries that required neurosurgical intervention, and was 76.3% and 50.6% specific, respectively, for these injuries.
Subsequent studies have all found the CCHR to be 100% sensitive for identifying injuries that require neurosurgical intervention. Applying the CCHR would allow physicians to safely reduce head CT imaging by around 30% (range of 6%-40%, with most studies showing an estimated 30% reduction). In most studies, 7% to 10% of patients had positive CTs, considered “clinically important” brain injuries, but typically, < 2% of patients required neurosurgical intervention. The high-risk criteria have consis-tently shown 100% sensitivity at ruling out the latter group..
Ian Stiell, MD, MSc, FRCPC
Susan B. Kirelik, MD, FAAP
Jeffrey J. Bazarian, MD, MPH; Tamara R. Espinoza, MD, MPH, FACEP
September 15, 2019
October 14, 2022
4 AMA PRA Category 1 Credits.™ Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Date of Original Release: September 15, 2019. Date of most recent review: August 31, 2019. Termination date: September 15, 2022.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma credits, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
CME Objectives: Upon completion of this activity, you should be able to: (1) describe the current recommendations for assessment and management of sport-related concussion and mild traumatic brain injury; (2) utilize clinical decision tools to guide the diagnosis of concussive injuries; (3) identify risk factors for prolonged recovery from concussion; and (4) describe the aftercare instructions that should be given to patients with concussion, including guidance for returning to work, school, and sport participation.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Kirelik, Dr. Bazarian, Dr. Espinoza, and their related parties report no relevant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
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