Table of Contents
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Abstract
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Case Presentations
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Introduction
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Critical Appraisal Of The Literature
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Definitions
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Epidemiology
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Morbidity And Mortality
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Pathophysiology
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Prehospital Care
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Transport
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Emergency Department Management
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Initial Evaluation
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History
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Physical Examination
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Neurological Examination
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Glasgow Coma Scale Score
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Cognitive Examination
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Pupillary Reflexes
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Motor And Balance Testing
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Diagnostic Testing
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Laboratory And Bedside Studies
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Radiography
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Plain Skull Radiography
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Computed Tomography
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Postconcussive Syndrome
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Sports-Related Concussion
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Controversies And Cutting Edge
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Biomarkers
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Diffusion-Weighted Imaging
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Neuropsychological And Sideline Testing
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Disposition
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Key Points For Evaluating And Treating Mild Traumatic Brain Injury
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Summary
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Areas In Need Of Future Research
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Risk Management Pitfalls For Mild Traumatic Brain Injury
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Cost-Effective Strategies For Mild Traumatic Brain Injury
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Case Conclusions
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Clinical Pathway For Evaluating The Adult With Mild Traumatic Brain Injury
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Clinical Pathway For Evaluating The Child With Mild Traumatic Brain Injury
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Tables and Figures
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Table 1. Major Guidelines On Mild Traumatic Brain Injury
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Table 2. Glasgow Coma Scale Scoring
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Table 3. Components Of The Sports Concussion Assessment Tool-2 (SCAT2)
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Table 4. Clinical Decision Rules In Mild Traumatic Brain Injury In Adults
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Table 5. Pecarn Clinical Decision Ruke For Children With mild Traumatic Brain Injury
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Table 6. Symptoms Seen In Postconcussive Syndrome
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Table 7. Indications For Computed Tomography In Mild Traumatic Brain Injury
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Figure 1. Diffusion-Weighted Magnetic Resonance Imaging Showing Frontal Injury
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References
Abstract
With over 1.7 million people in the United States seeking medical attention for head injury each year, emergency clinicians are challenged daily to screen quickly for the small subset of patients who harbor a potentially lethal intracranial lesion while minimizing excessive cost, unnecessary diagnostic testing, radiation exposure, and admissions. Whether working at a small, rural hospital or a large inner-city public hospital, emergency clinicians play a critical role in the diagnosis and management of mild traumatic brain injury. This review assesses the burgeoning research in the field and reviews current clinical guidelines and decision rules on mild traumatic brain injury, addressing the concept of serial examinations to identify clinically significant intracranial injury, the approach to pediatric and elderly patients, and the management of patients who are on anticoagulants or antiplatelet agents or have bleeding disorders. The evidence on sports-related concussion and postconcussive syndrome is reviewed, and tools for assessments and discharge are included.
Case Presentations
It’s 8 PM and you are just getting into the groove of your first in a series of several night shifts. After picking up your fourth head injury chart, you think to yourself, “Good grief, are we having a sale on head injury tonight?” Your patients are:
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A 16-year-old boy brought in by his parents after head-butting another player during a soccer game. He was confused for several minutes and now has a headache. His coach told his parents that he had a concussion and should go to the ER to be checked out before he can return to play.
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A 38-year-old woman who was in a low-speed motor vehicle crash. She states that she “blacked out” for a few seconds but feels fine now.
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A 2-month-old brought in by her parents with a bump on her head. They said the babysitter told them the baby rolled off the bed while she was changing her diaper.
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A well-known (to you) alcoholic brought in by the police, intoxicated, with an abrasion on his forehead. He has no idea how he hit his head and is asking for something to eat.
These are 4 cases of what appear to be minor injuries, although you know there is the chance that any of the patients may be harboring a neurosurgical lesion and that all 4 are at risk for sequelae. In your mind, you systematically go through the high-return components of the physical exam of a head-injured patient, the indications for neuroimaging in the ED, and the information needed at discharge to prepare the patients and their families for what might lie ahead. The medical student working with you is very impressed with the complexity of managing these cases, which he thought were so straightforward.
Introduction
Minor head injury, mild traumatic brain injury (TBI, also known as MTBI), and concussion are terms that are often used interchangeably. Regardless of the variation in nomenclature, emergency clinicians can expect to see a number of patients each shift who have sustained some sort of blunt trauma to the head. The clinical approach to these patients varies widely, and, despite the availability of clinical guidelines, most patients will undergo computed tomography (CT) imaging, and the majority will be interpreted as normal. The challenge for emergency clinicians is to quickly screen for the small subset of patients who harbor a potentially lethal intracranial lesion while minimizing excessive costs, admissions, and unnecessary diagnostic testing. Emergency clinicians must accurately document a neurologic baseline for serial examinations and provide discharge instructions that educate patients and families about the potential sequelae of head injury no matter how minor the injury may appear to be.
Further challenges include the rapidly evolving milieu of head injury treatment in the sports arena, with all but 2 states having active or pending laws on return to play for youth sports and full elimination of any same-day return to play after concussive events.1 Furthermore, with up to 50% of nonactive military personnel seeking care outside of the Veterans Health Administration system,2 emergency clinicians can expect to provide care for the increasing numbers of military personnel returning to the United States with postconcussive symptoms. Called the “signature’”injury of the Iraq and Afghanistan Wars, military-related mild TBI has affected close to 200,000 soldiers to date,3,4 with up to 30% suffering continued postconcussive symptoms.5
Critical Appraisal Of The Literature
Appraising the literature is very challenging due to the lack of uniformity—and often impassioned disagreement—regarding the definition of the terms used to describe these injuries. Moreover, studies often lack consistency in the timing of injury assessments, suffer from selection bias, and have conflicting outcome measures. The literature review was performed using PubMed and Ovid MEDLINE® searches for articles on TBI published between 1966 and 2012. Keywords included traumatic brain injury, concussion, head injury, MTBI, neuroimaging, postconcussive syndrome, sports, and second impact syndrome. The articles obtained from these searches provided content and background for further manual literature searches. Over 650 articles were reviewed, and 158 of these are included here for the reader’s reference.
Additionally, major published guidelines regarding mild TBI were evaluated. These included guidelines published by the Centers for Disease Control and Prevention (CDC), the Brain Trauma Foundation, the American College of Emergency Physicians (ACEP), the American Academy of Neurology, the American Academy of Pediatrics, the Advanced Trauma Life Support® (ATLS®) course, and the Eastern Association for the Surgery of Trauma. Website addresses for several guidelines are provided in Table 1.
Risk Management Pitfalls For Mild Traumatic Brain Injury
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“The GCS score was normal. How can he have a head bleed?”
Even in patients with a GCS score of 15, there is a small—but definite—risk for an intracranial lesion. About 6% to 8% of patients with mild TBI and a normal GCS have ICI on CT, and less than 1% will require neurosurgical intervention.13,20,22
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“But I told the patient everything at discharge.”
Patients discharged from the ED after mild TBI can be expected to recall no more than 30% to 50% of verbal instructions, and a significant number will suffer from both short-term and long-term postconcussive symptoms.8,14 This holds true even for those patients who appear completely neurologically intact. Consequently, all discharge instructions should not only be written down, but also told to a responsible third party.
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“But the skull films showed no fracture.”
Numerous studies have demonstrated the low sensitivity of skull films for predicting intracranial lesions. Though the presence of a fracture on a skull film increases the incidence of a traumatic intracranial lesion, the absence of a visible fracture does not decrease the incidence of an intracranial lesion. CT with bone windows is the imaging strategy of choice for patients with suspected TBI.
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“The babysitter initially said that the baby fell down the steps, and then changed her story and said the baby fell off the sofa.”
Child abuse is a frequently reported cause of TBI in infants. Emergency clinicians should be on their guard and recall that an inconsistent history is often associated with child abuse.39 When in doubt, it is best to err on the side of caution and involve the proper child protective services.
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“But the CT was negative.”
CT is an excellent test for identifying lesions in need of neurosurgical intervention, but it is not very good at identifying brain stem lesions, basilar skull fractures, or nonhemorrhagic injuries. In fact, about 25% of focal axonal injuries,69 50% of brain stem lesions,70 and 30% of basilar skull fractures are missed on CT.71 These injuries typically involve a great deal of energy and are therefore not commonly found in a patient with mild TBI or found in isolation.138 It is extremely rare for an initially undetected lesion on CT to evolve into a lesion that requires neurosurgical intervention.139 Patients and families should be given discharge instructions that describe symptoms that require a repeat visit to the ED.
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“The patient is malingering. His CT was negative, and the neurologic examination was normal.”
Many patients diagnosed with mild TBI have deficits on cognitive testing despite a normal CT. Most of these deficits resolve within 3 months of the injury, but some do not. It is very stressful for patients with persistent symptoms that do not seem to be supported by objective evidence. Follow-up with a neurologist can be very helpful to determine the need for further neuroimaging or neuropsychological testing.
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“The coach asked me if he could play in the tournament tomorrow.”
There is no longer any role for same-day return to play, and the assessment for return to play involves the individual evaluation of the player by his or her primary care or sports medicine physician with consideration to the severity of concussion, past injuries, and expected future impact injuries. Discharge instructions must include both physical and cognitive rest until cleared by the player’s physician.
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“I thought the patient was just drunk.”
Alcohol users are at increased risk for TBI, and evaluation is made difficult by their intoxication. These patients require serial neurologic evaluations, and if there are any associated high-risk criteria, a CT is indicated.
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“He didn’t get knocked out. How could he have a subdural hematoma?”
In many cases of mild TBI, there will be no loss of consciousness, and only about 10% of sports TBI is associated with loss of consciousness. A period of unconsciousness or amnesia to the event is not required for ICI, and the absence of loss of consciousness is not protective against ICI or future symptoms of postconcussive syndrome.
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“I know he was on warfarin, but his CT was normal, so I sent him home.”
Delayed hemorrhage is a rare, but important, concern in anticoagulated patients.114,115 All patients on anticoagulants must be educated about the risk of delayed hemorrhage and instructed to return for a repeat CT in the setting of any new or worsening symptoms.
Tables and Figures
References
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 information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Legislatures NCoS. Traumatic brain injury legislation. http://www.ncsl.org/issues-research/health/traumatic-brain-injury-legislation.aspx, July 2012.
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Long JA, Polsky D, Metlay JP. Changes in veterans’ use of outpatient care from 1992 to 2000. Am J Public Health. 2005;95(12):2246-2251. (Survey; 11,645 patients)
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DVBIC. Defense and veterans brain injury center. 2012; http://www.dvbic.org/dod-worldwide-numbers-tbi. Accessed July 17, 2012, 2012.
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Fear NT, Jones E, Groom M, et al. Symptoms of post-concussional syndrome are non-specifically related to mild traumatic brain injury in UK armed forces personnel on return from deployment in Iraq: an analysis of self-reported data. Psychol Med. 2009;39(8):1379-1387. (Secondary analysis; 5869 patients)
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Hoge CW, McGurk D, Thomas JL, et al. Mild traumatic brain injury in US soldiers returning from Iraq. N Engl J Med. 2008;358(5):453-463. (Prospective; 2525 patients)
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* McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med. 2009;43 Suppl 1:i76-i90. (Consensus statement)
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CDC. Injury prevention & control: traumatic brain injury. Centers for Disease Control and Prevention http://www.cdc.gov/concussion/index.html. Accessed May 19, 2012.
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Faul M XL, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
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Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-378. (Review)
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* Cantu RC, Register-Mihalik JK. Considerations for return-to-play and retirement decisions after concussion. Pm R. 2011;3(10 Suppl 2):S440-S444. (Consensus paper)
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Herring SA, Cantu RC, Guskiewicz KM, et al. Concussion (mild traumatic brain injury) and the team physician: a consensus statement--2011 update. Med Sci Sports Exerc. 2011;43(12):2412-2422. (Consensus statement)
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Faux S, Sheedy J, Delaney R, et al. Emergency department prediction of post-concussive syndrome following mild traumatic brain injury--an international cross-validation study. Brain Inj. 2011;25(1):14-22. (Prospective; 107 patients)
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* Pandor A, Goodacre S, Harnan S, et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation. Health Technol Assess. 2011;15(27):1-202. (Meta- analysis; 93 studies)
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Lannsjo M, af Geijerstam JL, Johansson U, et al. Prevalence and structure of symptoms at 3 months after mild traumatic brain injury in a national cohort. Brain Inj. 2009;23(3):213-219. (Secondary analysis; 1262 patients)
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Coronado VG, Xu L, Basavaraju SV, et al. Surveillance for traumatic brain injury-related deaths--United States, 1997-2007. MMWR Surveill Summ. 2011;60(5):1-32. (Secondary analysis; 580,000 patients)
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Chen J, Jin H, Zhang Y, et al. MRS and diffusion tensor image in mild traumatic brain injuries. Asian Pac J Trop Med. 2012;5(1):67-70. (Prospective; 21 patients)
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Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology of concussive brain injury. Clin Sports Med. 2011;30(1):33-48, vii-iii. (Review)
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Stocchetti N, Longhi L. The race for biomarkers in traumatic brain injury: what science promises and the clinicians still expect. Crit Care Med. 2010;38(1):318-319. (Review)
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DeLellis SM, Kane S, Katz K. The neurometabolic cascade and implications of mTBI: mitigating risk to the SOF community. J Spec Oper Med. 2009;9(4):36-42. (Review)
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Haydel MJ, Preston CA, Mills TJ, et al. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343(2):100-105. (Prospective; 1429 patients)
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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; 3121 patients)
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Mower WR, Hoffman JR, Herbert M, et al. Developing a decision instrument to guide computed tomographic imaging of blunt head injury patients. J Trauma. 2005;59(4):954-959. (Prospective; 13,728 patients)
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Delgado Almandoz JE, Kelly HR, Schaefer PW, et al. Prevalence of traumatic dural venous sinus thrombosis in high-risk acute blunt head trauma patients evaluated with multidetector CT venography. Radiology. 2010;255(2):570- 577. (Retrospective; 195 patients)
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Ringer AJ, Matern E, Parikh S, et al. Screening for blunt cerebrovascular injury: selection criteria for use of angiography. J Neurosurg. 2010;112(5):1146-1149. (Prospective; 365 patients)
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Committee on Trauma ACoS. ATLS: Advanced Trauma Life Support program for doctors. 8th ed. Chicago: American College of Surgeons; 2008. (Textbook)
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Mulligan RP, Friedman JA, Mahabir RC. A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures. J Trauma. 2010;68(3):587-592. (Database analysis; 2.7 million patients)
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Badjatia N, Carney N, Crocco TJ, et al. Guidelines for prehospital management of traumatic brain injury, 2nd edition. Prehosp Emerg Care. 2008;12 Suppl 1:S1-S52. (Review)
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Chi JH, Knudson MM, Vassar MJ, et al. Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study. J Trauma. 2006;61(5):1134-1141. (Prospective; 150 patients)
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Warner KJ CJ, Copass MK, et al. The impact of prehospital ventilation on outcome after severe traumatic brain injury. J Trauma. 2007;62:1330-1338. (Prospective; 574 patients)
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Manley G, Knudson MM, Morabito D, et al. Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Arch Surg. 2001;136(10):1118-1123. (Prospective; 107 patients)
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Pearson WS, Ovalle F, Jr., Faul M, et al. A review of traumatic brain injury trauma center visits meeting physiologic criteria from the American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention field triage guidelines. Prehosp Emerg Care. 2012. (Secondary analysis: 114,032 patients)
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Maddocks DL, Dicker GD, Saling MM. The assessment of orientation following concussion in athletes. Clin J Sport Med. 1995;5(1):32-35. (Prospective; 28 patients)
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* Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59(6):460-468. (Prospective; 1064 patients)
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Leventhal JM, Martin KD, Asnes AG. Fractures and traumatic brain injuries: abuse versus accidents in a US database of hospitalized children. Pediatrics. 2010;126(1):e104-e115. (Secondary analysis; 18,822 patients)
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Jagoda AS, Bazarian JJ, Bruns JJ Jr, et al. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008;52:714-748. (Position statement)
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Lee H, Wintermark M, Gean AD, et al. Focal lesions in acute mild traumatic brain injury and neurocognitive outcome: CT versus 3T MRI. J Neurotrauma. 2008;25(9):1049-1056. (Prospective; 52 patients)
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Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009;169(22):2078-2086. (Retrospective; 1119 patients)
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Papa L, Stiell IG, Clement CM, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States level I trauma center. Acad Emerg Med. 2012;19(1):2-10. (Prospective; 431 patients)
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Smits M, Dippel DW, de Haan GG, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA. 2005;294(12):1519-1525. (Prospective; 3181 patients)
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CDC. Injury prevention & control: traumatic brain injury heads-up to clinicians. Centers for Disease Control and Prevention http://www.cdc.gov/concussion/clinician.html. Accessed May 19, 2012.
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Ro YS, Shin SD, Holmes JF, et al. Comparison of clinical performance of cranial computed tomography rules in patients with minor head injury: a multicenter prospective study. Acad Emerg Med. 2011;18(6):597-604. (Prospective; 7131 patients)
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Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005;294(12):1511-1518. (Prospective; 1822 patients)
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Stiell IG, Clement C, Rowe BH, et al. Multicenter prospective validation of the New Orleans Criteria for CT in minor head injury. Acad Emerg Med. 2003;10(5):477. (Prospective; 1733 patients)
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Stiell I, Lesiuk H, Vandemheen K, et al. Obtaining consensus for the definition of “clinically important” brain injury in the CCC study. Acad Emerg Med. 2000;7(5):572-573. (Survey; 129 patients)
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Stiell IG, Lesiuk H, Brison RJ, et al. How valid is the concept of “clinically unimportant” brain injury in patients with minor head injury? Acad Emerg Med. 2001;8(5):487-488. (Prospective; 94 patients)
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* Atzema C, Mower WR, Hoffman JR, et al. Defining “clinically unimportant” CT findings in patients with blunt head trauma. Acad Emerg Med. 2002;9(5):451. (Secondary analysis; 8374 patients)
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* Clement CM, Stiell IG, Schull MJ, et al. Clinical features of head injury patients presenting with a Glasgow Coma Scale score of 15 and who require neurosurgical intervention. Ann Emerg Med. 2006;48(3):245-251. (Secondary analysis; 4551 patients)
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Lima DP, Simao Filho C, Abib Sde C, et al. Quality of life and neuropsychological changes in mild head trauma. Late analysis and correlation with S100B protein and cranial CT scan performed at hospital admission. Injury. 2008;39(5):604-611. (Prospective; 50 patients)
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Sherer M, Stouter J, Hart T, et al. Computed tomography findings and early cognitive outcome after traumatic brain injury. Brain Inj. 2006;20(10):997-1005. (Prospective; 89 patients)
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Smits M, Houston GC, Dippel DW, et al. Microstructural brain injury in post-concussion syndrome after minor head injury. Neuroradiology. 2010;53(8):553-563. (Prospective; 32 patients)
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Lipton ML, Gulko E, Zimmerman ME, et al. Diffusion-tensor imaging implicates prefrontal axonal injury in executive function impairment following very mild traumatic brain injury. Radiology. 2009;252(3):816-824. (Prospective; 40 patients)
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