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RESEARCH TO PRACTICE

Mild Traumatic Brain Injury in the Emergency Department

A Clinical Practice Gap

Tucker, Paula DNP, FNP-BC, ENP-C, FAANP; Safier Frenkel, Tova DNP, APRN, FNP-C

Editor(s): Evans, Dian Dowling PhD, FNP-BC, ENP-C, FAANP, FAAN, Column Editor

Author Information
doi: 10.1097/TME.0000000000000326
  • Free

Abstract

THE CASE

Mr Smith, a 19-year-old, healthy male athlete, presented to the emergency department (ED) accompanied by his basketball coach with reports of “blacking out” and falling to the gym floor after hitting his head against another teammate while playing basketball. According to the basketball coach, Mr Smith was unresponsive for about 45 s. Mr Smith reported a dull headache and dizziness and stated, “I feel foggy” since the incident. He denied any visual changes, weakness, or incontinence. Mr Smith had no significant past medical or surgical history but recalled having a concussion 10 years ago while playing football. He lived on a college campus in a dormitory room and was awarded a full athletic scholarship for basketball. He denied alcohol, tobacco, or illicit drug use. He exercised and completed weight training daily. He ate a well-balanced diet, took no medications, and had no known drug allergies.

On physical examination, vital signs were as follows: temperature: 36.8 °F; pulse: 72 and regular; blood pressure: 120/69 mmHg; and respirations: 18. He appeared well hydrated and in no acute distress. He was alert and oriented to person, place, time, and situation; however, he did not recall the incident with his teammate. His skin was warm, dry, and intact. Mucous membranes were moist and pink, and pupils were equal, round, and reactive to light, with normal conjunctiva. Heart and lungs sounds were normal. Head was normocephalic with mild swelling to the forehead. Neck examination revealed full range of motion with no cervical spine tenderness or carotid bruits. There were no clinical signs of basilar skull fracture such as hemotympanum, periorbital ecchymosis, postauricular ecchymosis, cerebral spinal fluid rhinorrhea, or otorrhea, and he was without meningeal signs. His Glasgow Coma Scale (GCS) score was 15. His neurological examination was nonfocal, with cranial nerves II–XII intact. There was normal cerebellar function and normal gait. His muscle strength was 5/5, with normal perfusion and sensation to upper and lower extremities bilaterally. His abdomen was round, soft, with positive bowel sounds, and nontender.

REVIEW OF THE ARTICLE

Koval, R. R., Zalesky, C. C., Moran, T. P., Moore, J. C., Ratcliff, J. J., Wu, D. T., & Wright, D. W. (2019). Concussion care in the emergency department: A prospective observational brief report. Annals of Emergency Medicine, 75(4), 483–490.

STUDY PURPOSE, DESIGN, AND METHODS

The primary purpose of Koval et al.'s (2019) study was to examine current clinician practice patterns related to the evaluation and management of patients identified as at risk for a sustained mild traumatic brain injury (mTBI). Secondarily, this study sought to describe which mTBI-specific history and physical examination characteristics were documented, the number of patients with mTBI diagnosis who received specific discharge education, and clinical characteristics of those identified as at risk for a sustained mTBI (Koval et al., 2019).

To address the evaluation and management gap surrounding mTBI, Koval et al. (2019) conducted a prospective observational study performed at an academic Level I trauma and emergency care center. The study evaluated patients who answered affirmatively to a two-item identification tool based on the Centers for Disease Control and Prevention (CDC) clinical definition of an mTBI (Gioia & Collins, 2006). The questions included, “Was there a blunt force trauma to the head or did the head move back and forward with a lot of force?” and “Was there a change in mental status or level of consciousness as a result of the event (including fogginess, confusion, disorientation, stunned)?” (Koval et al., 2019, p. 2). The questions were asked by study-trained nurses at triage and entered into the electronic medical record (EMR), so clinicians remained blinded by the responses (Koval et al., 2019).

Koval et al. (2019) enrolled a final subject population of 98 patients, based on specific inclusion criteria, who presented to this particular ED over a 4-week period in 2016. Inclusion criteria included patients who answered affirmatively to both identification questions, were 18 years or older, and presented to the ED following their head injury 7 days or less (Koval et al., 2019). Triage nurses were trained on the process, reminded to perform the screen during the 4-week period, and asked to record the information into the EMR (Koval et al., 2019).

A single trained reviewer abstracted relevant clinical data via a comprehensive chart review. The chart review was restricted to the provider note linked with the patient encounter that generated the positive mTBI screen result (Koval et al., 2019). Information collected during the chart review included patient demographics, specific injury characteristics, observed signs and symptoms, physical examination, and laboratory and imaging results (Koval et al., 2019). These data elements were similar to the National Institute of Neurological Disorders and Stroke Common Data Elements for mTBI. The CDC Acute Concussion Evaluation for the Emergency Department (ACE-ED; Gioia & Collins, 2006), Fifth International Conference on Concussion in Sport (Echemendia et al., 2017), and the Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for the Management of Concussion–Mild Traumatic Brain Injury (VA/DoD, 2016) were used as standards to compare the patient evaluation (Koval et al., 2019).

An mTBI was considered present in the differential diagnosis if clinicians listed the following in their clinical note: “mild traumatic brain injury,” “brain injury,” “head injury,” “traumatic brain injury,” or other associated terms (Koval et al., 2019, p. 3); stated that brain computed tomography (CT) was necessary for the severity or mechanism of injury; or a comment related to brain CT findings (Koval et al., 2019). A diagnosis of mTBI was defined by the presence of the ED diagnosis in the concluding portions of the note or billing code (Koval et al., 2019).

Data were queried on the basis of corresponding patient encounters assigned by the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes (Koval et al., 2019). Koval et al. (2019) utilized guidelines from the Defense and Veterans Brain Injury Center to establish ICD-10 codes corresponding to mTBI diagnosis.

DATA ANALYSIS AND RESULTS

Of the 10,413 patients who presented to the ED during the study period, 7,655 were queried by nurses and 1,033 reported an injury of any type (Koval et al., 2019). On the basis of the two-question identification tool, 116 injury-positive patients were identified as at risk for mTBI and 18 patients were excluded from the study for not meeting the inclusion criteria (Koval et al., 2019). With the remaining 98 patients in this study, Koval et al. (2019) summarized demographic and clinical characteristics of patients with a positive screening result for mTBI. Data included patient age, gender, race, means of ED arrival, trauma level, mechanism of injury, injury complexity, and provider type (Koval et al., 2019).

To compare with recommendations from the CDC ACE-ED (Gioia & Collins, 2006), Fifth International Conference on Concussion in Sport (Echemendia et al., 2017), or the VA/DoD Clinical Practice Guideline for the Management of Concussion–Mild Traumatic Brain Injury (VA/DoD, 2016), documented evaluation components of patients with possible mTBI were stratified by diagnosis such as the presence of observed signs, physical symptoms, cognitive symptoms, emotional symptoms, documented physical examination, ambulatory status, head CT, alcohol level, and urine drug screen (Koval et al., 2019). Finally, Koval et al. (2019) assessed patterns of mTBI inclusion in the differential diagnosis, assigned mTBI-specific ICD-10 codes, provision of mTBI discharge instructions, and patient disposition with a positive screening result for mTBI. Categorical variables were then summarized with percentages of 95% confidence intervals (CIs; Koval et al., 2019).

To support the complexity of injuries among this sample, only 35.7% (95% CI [27.6, 44.9]) of patients who presented with chief complaints or physical examination findings were isolated to the head (Koval et al., 2019). Among the final study population (N = 98), essential components of the mTBI evaluation, including physical, cognitive, and emotional symptoms, were not documented among 54.1% (95% CI [45.9, 62.7]), 98.0% (95% CI [95.9, 100]), and 93.9% (95% CI [89.8, 99%]), respectively, and observed signs were not documented in 52% (95% CI [42.9, 61.2]) of patients (Koval et al., 2019). Head CT was ordered for 62.3%, and when stratified by mTBI diagnosis, 77.7% had a documented diagnosis whereas 52.3% did not (Koval et al., 2019). Among the study population, 37% (95% CI [27.8, 46.7]) received a documented mTBI diagnosis; 13.9% (95% CI [5.6, 22.2]) received an mTBI-specific ICD-10 code, and 41.5% (95% CI [26.7, 57.9]) received mTBI discharge education (Koval et al., 2019).

In addition to the primary data analysis, a secondary data set was created to determine the sensitivity and specificity of the triage identification screening tool to capture patients who received an mTBI-specific ICD-10 code (Koval et al., 2019). The screening tool exhibited specificity of 95%, sensitivity of 10%, a positive predictive value of 1%, and a negative predictive value of 99% (Koval et al., 2019).

STRENGTHS, LIMITATIONS, DISCUSSION, AND CONCLUSION

The primary strength of this study was Koval et al.'s (2019) hypothesis validation. Koval et al. (2019) hypothesized that several patients at risk for mTBI were being missed in the ED. Utilizing a simple two-question screening tool, Koval et al. (2019) successfully demonstrated this assumption through documented evaluation and management findings of patients who screened positive for mTBI. However, several limitations were addressed in this study.

The sensitivity of the screening tool was 10%, considering the majority of patients who screened positive did not receive a corresponding ICD-10 code, which may not indicate the true diagnostic performance of the screening tool (Koval et al., 2019), whereas the specificity of the screening tool was 95%, revealing that the majority of patients with a negative screening result did not receive an mTBI-specific ICD-10 code (Koval et al., 2019). Koval et al. (2019) also acknowledged that a significant limitation of this study was the assumption that documentation was equivalent to consideration, which could be argued that mTBI was considered despite the lack of documentation.

In addition, patient charts were abstracted by a single, unblinded reviewer, which is a potential limitation in the reliability of the data (Koval et al., 2019). Patients were also clustered among providers; for instance, patients treated by the same provider represented nonindependent observations. Because there were too few patients for every provider, Koval et al. (2019) could not account for this clustering. As a result, Koval et al. (2019) admit that the CIs were falsely narrowed. Furthermore, ED best practices surrounding the evaluation and management of mTBI are less clearly defined than in other settings such as sports medicine, primary care, and rehabilitation (Koval et al., 2019). Finally, discharge instructions were only reviewed for patients who were discharged from the ED, rather than in conjunction with admitted patients (Koval et al., 2019).

Koval et al. (2019) discovered that a majority of the evaluation components recommended by the CDC ACE-ED (Gioia & Collins, 2006), Fifth International Conference on Concussion in Sport (Echemendia et al., 2017), and the VA/DoD Clinical Practice Guideline for the Management of Concussion–Mild Traumatic Brain Injury (VA/DoD, 2016) were documented for less than 50% of patients. Of the 36 patients who received a final diagnosis of mTBI, only 41.7% received mTBI discharge education (Koval et al., 2019). These missed opportunities could also impact risk mitigation, treatment, referral, and improvement in mTBI outcomes (Koval et al., 2019). In conclusion, while this was a brief observational study with several limitations, Koval et al. (2019) highlight the need for more provider education and standardization of best practice to increase awareness of patients at risk for mTBI who present to the ED.

PAULA'S COMMENTS

In 2014, nearly 2.5 million ED visits in the United States were linked to TBI, with more than 812,000 cases involving children (CDC, 2019). Together with TBI-related ED visits, estimates reveal that mTBIs comprise 70%–90%, with falls and motor vehicle crashes being the most common mechanisms of injury (Cassidy et al., 2004; CDC, 2003). Given these sobering statistics, still no “gold standard” exists surrounding mTBI care. Emergency department providers typically are first medical contact, and for that reason, essential to the identification, management, and education of patients diagnosed with mTBI. Unfortunately, data and Koval et al.'s (2019) findings support the variability of mTBI care and the lack of consistency among evidence-based mTBI clinical practice guideline implementation across emergency settings (Stern et al., 2017). Furthermore, the ED is unique and faces numerous challenges that prevent a thorough mTBI evaluation. The balance of patient throughput combined with the lack of specific adult ED clinical guidelines intensifies these barriers surrounding appropriate identification and management of patients with suspected mTBI (Koval et al., 2019). As a result, many patients who present to the ED with specific injuries consistent with mTBI do not receive a formal diagnosis, which has led to improper targeted education and recommendations upon discharge (Koval et al., 2019).

The CDC defines mTBI as a head injury caused by blunt trauma or acceleration or deceleration forces resulting in one or more episodes of observed or self-reported: transient confusion, disorientation or impaired consciousness, memory dysfunction near the time of injury or loss of consciousness (LOC) lasting less than 30 min, or signs of neurological or neuropsychological dysfunction (CDC, 2003). Other mTBI definitions have been proposed to include criteria such as an initial GCS score of 13–15 after 30 min of the injury or within 24 hr (Carroll et al., 2004; Head, 1993; VA/DoD, 2016). However, evidence has shown that patients who presented to the ED with suspected or confirmed mTBI and initial GCS scores between 13 and 15 upon arrival were associated with acute intracranial lesions on CT scan (Isokuortti et al., 2018). Therefore, depending exclusively on a single GCS score to diagnose an mTBI is not recommended, and the solution to utilizing the GCS score in patients with mTBI should be for ongoing evaluations, particularly in the setting of limited head CT availability (Jagoda et al., 2008).

Although variabilities within mTBI care are known (Stern et al., 2017), a significant clinical practice gap among ED providers surrounding the evaluation and management of mTBI exists (Koval et al., 2019). Appropriate identification, management, and education conducted by evidence-based clinical practice guidelines are central to mTBI care in the ED to improve patient recovery and decrease the risk of short- and long-term outcomes. The American College of Emergency Physicians (ACEP) and the CDC developed a clinical policy with specific evidence-based recommendations surrounding the management of adult patients with mTBI in the acute care setting such as the ED. These guidelines were updated in 2008 to provide further recommendations surrounding head CT determination and safe discharge for patients with suspected or diagnosed mTBI (Jagoda et al., 2008). This policy also aims to assist providers in the identification, evaluation, and management with proper discharge planning of patients who are neurologically intact with possible intracranial injuries and who are at risk for prolonged postconcussive symptoms (Jagoda et al., 2008). As of recent, the CDC published the first pediatric mTBI guidelines (Lumba-Brown et al., 2018). Other guidelines specifically related to sports concussion management have also been published (Giza et al., 2013; Harmon et al., 2019; McCrory et al., 2017).

Early identification and accurate historical data obtained from the patient or proxy with suspected mTBI are critical to mTBI diagnosis. Patients presenting to the ED with suspected mTBI can be difficult to identify, given the vague and variable symptoms that can often be confused with other causes (Harmon et al., 2019). The compelling results noted in the study by Koval et al. (2019) revealing infrequent documentation of symptoms among the sample call attention to the lack of recognition of mTBI-related symptoms. A two-item identification screening tool administered during triage as in Koval et al.'s (2019) study could improve identification by notifying the ED provider to patients at risk for a sustained mTBI.

Symptoms of mTBI are categorized as physical such as headache and dizziness; cognitive such as feeling “foggy”; emotional such as irritability; and difficulties with sleep (Gioia & Collins, 2006). Loss of consciousness, retrograde amnesia, and posttraumatic amnesia (PTA) may also be present in the setting of an mTBI (Ruff et al., 2009). Focal neurological signs associated with mTBI may include cranial nerve deficits, seizures, vision and speech problems, and gait and balance abnormalities (Ruff et al., 2009). Acute intracranial abnormalities found on CT scan, for example, subdural hematoma, subarachnoid hemorrhage, and contusions, have been shown to occur in mTBI with increasing risk factors such as older age, falls, and being struck by a car (Ganti et al., 2019). Therefore, the ED provider should assess for “red flag” signs and symptoms such as declining level of consciousness and neurological examination, worsening headache, slurred speech, pupillary asymmetry, repeated vomiting and seizures (VA/DoD, 2016), and basilar skull fracture (Jagoda et al., 2008).

Ultimately, establishing the mechanism of injury is the first critical step in evaluating an mTBI (Silverberg et al., 2020). Second, the provider should ask about signs and symptoms such as LOC, PTA, and confusion (Silverberg et al., 2020) and seek to identify confounding factors such as alcohol or drug intoxication that could be the cause for the change in mental status (Silverberg et al., 2020). It is also important to identify risk factors that are associated with prolonged mTBI recovery such as previous concussion, headache, and developmental and psychiatric history (CDC, 2009). Several tools have been developed to assist providers in the appropriate identification and management of mTBI in children and adults, for example, the ACE-ED and the ACE Care Plan (Gioia & Collins, 2006; Gioia, Collins, & Isquith, 2008) are made available on the CDC website, titled HEADS UP to Health Care Providers (https://www.cdc.gov/headsup/providers/index.html). Another tool that can be used in the ED or as an option on the field, the Sport Concussion Assessment Tool—Fifth Edition (SCAT 5), developed by the Concussion in Sports Group, provides a standardized method to concussion assessment that includes athlete background, symptom evaluation, cognitive screening (Standardized Assessment of Concussion); neurological screening, which includes balance assessment (modified Balance Error Scoring System); delayed recall; and decision making (Echemendia et al., 2017). Both the ACE-ED and SCAT 5 lack measurement of vestibular or ocular motor function.

A priority step to the concussion-focused examination is to rule out a neurosurgical emergency (Woods & Raukar, 2020). Therefore, ED providers should assess for possible cervical spine injury and examine the neck for motion and tenderness, signs of airway trauma, and sensory motor deficits (Silverberg et al., 2020). A detailed neurological examination should also include assessment of cranial nerves II–XII, manual muscle testing and reflexes, balance and coordination examination, and vestibular-ocular motor examination (Matuszak, McVige, McPherson, Willer, & Leddy, 2016). The vestibular-ocular motor screening assessment (VOMS) was developed to identify vestibular ocular motor dysfunction in sports-related concussion (Mucha et al., 2014). The VOMS requires 5–10 min to perform and includes five domains: smooth pursuit, horizontal and vertical saccades, convergence, horizontal and vertical vestibular ocular reflexes, and visual motion sensitivity (Mucha et al., 2014). A positive objective finding or symptom aggravation such as a change in headache, dizziness, nausea, and fogginess with any assessment domain indicates dysfunction and should prompt the provider to refer the patient for a more detailed assessment and rehabilitation management (Mucha et al., 2014). Duke Neurology (2016) has published a YouTube video demonstrating how to perform the VOMS (available at: https://youtu.be/CJF6kJcFGqE).

The decision to obtain a CT scan in the patient with suspected mTBI is described in the ACEP/CDC guidelines (Jagoda et al., 2008). The CT should not be used to diagnose an mTBI. Specific clinical decision rules have been developed to standardize and safely rule out intracranial injuries warranting neurosurgical intervention to ultimately improve emergency care of patients with minor head injury. The Canadian CT Head Rule was validated for use among patients 16 years and older (Stiell et al., 2001), the New Orleans Head CT Rule has been validated in patients 3 years and older (Haydel et al., 2000), and the Pediatric Emergency Care Applied Research Network (PECARN) was validated specifically for children younger than 2 years and 2 years and older (Kuppermann et al., 2009).

Patient education at discharge is critical to improve symptom recovery following an mTBI and a very important component to the management of mTBI. The lack of appropriate discharge instructions revealed in Koval et al.'s (2019) study was a missed opportunity. Although mTBIs do not appear to be life-threatening, studies demonstrate persistent postconcussive symptoms even after 1 year of the injury (McMahon et al., 2014; Theadom et al., 2016). Therefore, it is important that patients are educated on the risk of reinjury and importance of physical and cognitive rest and receive appropriate follow-up and tailored discharge instructions regarding expected postconcussive symptoms, sleep hygiene, and return to learn, work, activity, sports, and play plans (CDC, 2020). In 2010, the CDC developed the HEADS UP to Health Care Providers (https://www.cdc.gov/headsup/providers/index.html) initiative as an online resource for health care providers and parents on appropriate discharge instructions for sports-related concussion (CDC, 2020).

CASE REVISITED

The emergency nurse practitioner (ENP) considers a list of differential diagnoses that include but are not limited to mTBI, cervical spine injury, cerebral contusion, intracranial hemorrhage, and skull fracture. On the basis of the ACEP/CDC Clinical Policy on Neuroimaging Level A recommendations, the ENP orders a noncontrast head CT scan, which is indicated in patients with head trauma with LOC or PTA in the setting of headache (Jagudo et al., 2008). The head CT scan was negative for acute intracranial lesions. On the basis of the ACEP/CDC Clinical Policy (Jagudo et al., 2008), Mr Smith was cleared for discharge because he presented with an isolated mTBI and a normal neurological evaluation and a normal CT scan. Prior to discharge, the nurse practitioner educated Mr Smith on the common signs and symptoms following an mTBI, for example, difficulty concentrating, headache, dizziness, lack of energy, irritability, and disturbances in sleep (CDC, 2020). The ENP reassured Mr Smith that symptoms usually require no treatment and will resolve with time; however, if symptoms persist after 1 week, the ENP advised Mr Smith to seek care with a concussion specialist (CDC, 2020). The ENP also advised Mr Smith to get plenty of rest and sleep, which helps the brain to heal, and to avoid activities that require physical and cognitive demands, such as sports, exercising, and playing video games, and that he should gradually return to his normal routine once he starts feeling better (CDC, 2020). Mr Smith asked the ENP, “When can I return to playing basketball?” The ENP emphasized to Mr Smith that a repeat concussion that occurs prior to the brain completely healing can be extremely dangerous, slowing recovery, and increasing one's risk of long-term problems such as second-impact syndrome and postconcussive syndrome; therefore, he should not return to recreational activities or contact sports until he is cleared by the team doctor, a primary care provider with experience in concussion, or a concussion specialist (CDC, 2020). Mr Smith was advised to return to the ED if he developed serious symptoms such as LOC or difficulty staying awake, confusion, repeated vomiting, severe or worsening headache, seizures, weakness, or vision changes (CDC, 2020). Prior to discharge, the ENP provided Mr Smith with the CDC HEADS UP Return to School Letter and Discharge Instructions and a list of community resources specializing in concussion care including sports medicine, neurology, physiatry, and neuropsychology. Mr Smith was advised to follow up with his primary care provider within 48 hr and provided the CDC's website on concussion. Mr Smith verbalized understanding of the discharge instructions and was agreeable to the plan of care.

CONCLUSION

Mild traumatic brain injury is a public health concern. Unfortunately, no “gold standard” for treatment exists. Because of broad mTBI definitions and various clinical practice guidelines that are not specific to the ED, this has resulted in inconsistencies in mTBI care. Even though these variabilities exist, it is essential for ED providers to use evidence-based clinical practice guidelines and tools to improve symptom recovery and prevent long-term outcomes among patients who are diagnosed with an mTBI. Dissemination and implementation of high-quality evidence into clinical practice will help close this clinical practice gap surrounding mTBI care in the ED. Ultimately, provider education, standardization of guidelines, and implementation practices are strategies for increasing the uptake of care in the ED for patients presenting with mTBI.

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        Keywords:

        concussion; emergency; mild traumatic brain injury

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