ABSTRACT
Objective
Among patients discharged from the ED after mild traumatic brain injury (mTBI), 16%–25% experience post‐concussive symptoms for up to 3 months after injury. However, the assessment of mTBI in the ED is variable. A common tool for the assessment of mTBI in Australia is the Abbreviated Westmead Post‐Traumatic Amnesia Scale (A‐WPTAS). The aim of this study was to report the proportion of patients who were detected to have post‐traumatic amnesia (PTA) following a head injury and whether this varied by reported loss of consciousness (LOC), age, Glasgow Coma Scale (GCS) and mechanisms of injury.
Methods
This was a single‐centre, retrospective cohort study. Data were extracted from patients' electronic medical records. All patients presenting to the ED between 1 January 2019 and 31 December 2021 with a head injury, documented results of A‐WPTAS, and aged ≥ 18 years were included for analysis.
Results
There were 6259 patients included, and 5746 (91.8%, 95% CI: 91.1%–92.5%) passed the A‐WPTAS. ‐PTA was more frequent among patients who presented with GCS 13 or 14, male patients, those with low falls and presenting after hours. Among patients with documented LOC, the pass rate was 90.6% (95% CI: 88.8%–92.4%), and among those without LOC, it was 92% (95% CI: 91.3%–92.8%); p = 0.13.
Conclusion
PTA was detected in a small proportion of patients tested in the ED. PTA was associated with low initial GCS, but not with reported LOC. Among patients discharged from the ED, follow‐up for persistent post‐concussion symptoms is indicated.
Keywords: concussion, emergency medicine, traumatic brain injury
1. Introduction
It is estimated that 69 million individuals globally are diagnosed with a traumatic brain injury (TBI) annually [1]. Concussion, used interchangeably with mild traumatic brain injury (mTBI), results from physical injury to the head, causing a transient alteration in neurological function due to an acute physiological disruption of brain function [2]. The term ‘mild’ refers to initial changes in consciousness.
Following a normal CTB, the assessment for mTBI in EDs is variable [3, 4]. A commonly used tool is the Abbreviated Westmead Post‐Traumatic Amnesia Scale (A‐WPTAS) [5]. The A‐WPTAS provides an objective measure for post‐traumatic amnesia and cognition. It allows for rapid, standardised testing in the ED and has been associated with decreased length of stay (LOS) and decreased hospital admissions, with subsequent cost savings to the hospital [6].
Independent of the presence of amnesia, however, the symptoms of concussion may continue, where patients experience debilitating symptoms that include neurological deficits, balance impairment, behavioural changes, cognitive impairment and sleep/wake disturbances, labelled persistent post‐concussional symptoms (PPCS) [7]. There have been a small number of studies that have reported on the frequency of PPCS after mTBI in the ED population, ranging from 16% to 25% [8, 9, 10, 11, 12, 13]. Among patients that sustain head injury in the setting of sports, the rate of PPCS has been reported to be higher [14]. PPCS can negatively impact quality of life and prolong the return to regular activities [15, 16]. Therefore, it is important for ED clinicians to diagnose mTBIs and refer patients at risk of PPCS to appropriate services for ongoing treatment and support.
The most prominent variables associated with PPCS are acute cognitive symptoms, history of anxiety and/or depression or of sleep disorders, and the presence of clinical signs (loss of consciousness [LOC] or amnesia) [17]. While commonly used for the assessment of sports‐related concussion, cognitive symptoms are uncommonly assessed in the ED setting, and the history of anxiety, depression or sleep disorders may not be apparent during ED assessment. Thus, the assessment of amnesia is often the only objective measure to identify patients with mTBI who may be at risk of ongoing post‐concussive symptoms, including PPCS.
The aim of this study was to report the proportion of patients with suspected mTBI who had deficits detected on the A‐WPTAS. We compared patients who failed the A‐WPTAS to those that passed the test to assess whether it could discriminate between patients who had a LOC or lower Glasgow Coma Scale (GCS) on arrival. Therefore, we also identified the proportion of patients who are discharged with no evidence of PTA, but who may have ongoing symptoms requiring community follow‐up.
2. Methods
2.1. Setting
This was a retrospective cohort study conducted at The Alfred Hospital, Victoria, Australia. The Alfred Emergency & Trauma Centre receives 65,000 patients per year and admits more than 7500 trauma patients. It incorporates an adult level one trauma centre.
2.2. The Abbreviated Westmead Post Traumatic Amnesia Scale
The A‐WPTAS is a PTA screening tool primarily used in the ED setting. It is derived from the Westmead Post‐Traumatic Amnesia Scale (WPTAS) and Revised Westmead Post‐Traumatic Amnesia Scale (R‐WPTAS). These PTA screening tools provide greater validity than GCS for the identification of TBIs. The A‐WPTAS has been previously validated against the R‐WPTAS [18]. The components and scoring structure of the A‐WPTAS are shown in Table 1.
TABLE 1.
Abbreviated Westmead Post‐Traumatic Amnesia Scale [18].
| Initial assessment | Subsequent assessment | |
|---|---|---|
| Motor | ||
| Obeys commands | 6 | 6 |
| Localises | 5 | 5 |
| Withdraws | 4 | 4 |
| Abnormal flexion | 3 | 3 |
| Extension | 2 | 2 |
| None | 1 | 1 |
| Eyes | ||
| Spontaneous | 4 | 4 |
| Verbal | 3 | 3 |
| Pain | 2 | 2 |
| None | 1 | 1 |
| Verbal | ||
| Orientated (must achieve all) | 5 | 5 |
| Person | ||
| Place | ||
| Reason for admission | ||
| Month | ||
| Year | ||
| Confused | 4 | 4 |
| Inappropriate words | 3 | 3 |
| Incomprehensible sounds | 2 | 2 |
| None | 1 | 1 |
| Total GCS score (part A) | /15 | /15 |
| Picture recognition | ||
| Picture 1—cup | Show three pictures | 1 |
| Picture 2—keys | 1 | |
| Picture 3—bird | 1 | |
| Total picture recognition score (part B) | n/a | /3 |
| Total A‐WPTAS score (part A + part B) | /15 | /18 |
2.3. Inclusion and Exclusion Criteria
All patients presenting to the ED aged ≥ 18 years old between 1 January 2019 and 31 December 2021 were eligible for this study. Participants included those who presented to the ED with a head injury and had a documented A‐WPTAS score. Participants were excluded if they had only the initial A‐WPTAS documented or if the three picture tasks were not assessed or documented. Alfred Health's policy required the A‐WPTAS to be commenced on patients with GCS 13–15 with impact to the head resulting in confusion, disorientation, anterograde and/or retrograde amnesia, or brief LOC.
2.4. Exposure Variables
The primary exposure variables were reported LOC, GCS at the time of assessment, age and mechanism of injury.
2.5. Data Extraction
Data were extracted from the hospital's clinical information system and included dates of presentation, age, sex, ED LOS, injury cause and A‐WPTAS score. LOC was determined by searching triage notes and all data were supplemented using explicit chart review. Arrival after hours was defined as arrival to ED between 5 p.m. and 9 a.m.
2.6. Statistical Analysis
Continuous variables were summarised using mean (standard deviation) and compared using Student's t‐test. Categorical variables were compared using the χ 2 test. The primary outcome was reported using proportion and 95% confidence intervals. All analyses were performed using SPSS v.29. A p‐value of < 0.05 was considered to be statistically significant.
2.7. Ethics
The study was approved by the Alfred Human Research and Ethics Committee (Project ID 489/22). The requirement to seek informed consent from patients was waived.
3. Results
There were 8253 patients who had an A‐WPTAS started during the study period. Of these, 47 patients had a GCS < 13 at the time of testing and were excluded from analysis. We also excluded patients with incomplete data (n = 1947), with 6259 patients retained for analysis (Figure 1). Among all patients, 5746 (91.8%, 95% CI: 91.1%–92.5%) passed the A‐WPTAS and 513 patients failed the test. Among included patients, there were 1036 who had LOC and 505 patients had a GCS < 15. Patient characteristics, compared by failure of A‐WPTAS, are listed in Table 2.
FIGURE 1.
Patient selection.
TABLE 2.
Patient characteristics.
| Passed A‐WPTAS (n = 5746) | Failed A‐WPTAS (n = 513) | p | |
|---|---|---|---|
| Age, mean (SD) | 48.8 (20.4) | 50.0 (22.3) | 0.08 |
| Sex (%) | 0.009 | ||
| Female | 2007 (34.9) | 150 (29.2) | |
| Male | 3739 (65.1) | 363 (70.8) | |
| After hours arrival time (%) | 3550 (61.8) | 341 (66.5) | 0.04 |
| Injury cause (%) | 0.012 | ||
| Fall ≤ 1 m | 1496 (26.0) | 161 (31.4) | |
| Motorcycle crash | 372 (6.5) | 26 (5.1) | |
| Motor vehicle crash | 815 (14.2) | 83 (16.2) | |
| Fall > 1 m | 739 (12.9) | 49 (9.6) | |
| Struck by person | 482 (8.4) | 44 (8.6) | |
| Struck by object | 294 (5.1) | 16 (3.1) | |
| Pedal bike crash | 580 (10.1) | 38 (7.4) | |
| Struck by vehicle | 190 (3.3) | 16 (3.1) | |
| Unspecified | 167 (2.9) | 15 (2.9) | |
| Unknown | 611 (10.6) | 65 (12.7) | |
| Initial Glasgow Coma Scale (%) | < 0.001 | ||
| 13 | 0 | 176 (34.3) | |
| 14 | 0 | 329 (64.1) | |
| 15 | 5746 (100) | 8 (1.6) | |
| Loss of consciousness (%) | 939 (16.3) | 97 (18.9) | 0.13 |
Patients who failed the A‐WPTAS had a lower initial GCS (median 14, IQR 13–14) than those who passed (median 15, IQR 15–15, p < 0.001). There was no statistically significant difference in age between those who passed (mean 48.41, SD 20.4) and failed (mean 50.0, SD 22.3, p = 0.08). Patients who failed the A‐WPTAS had longer LOS in the ED (mean 6:53 h, SD 5:23) when compared to the ED LOS in patients who passed the A‐WPTAS (mean 6:11 h, SD 4:58, p = 0.002). Among patients with LOC, the pass rate was 90.6% (95% CI: 88.8%–92.4%), and among those without LOC, it was 92% (95% CI: 91.3%–92.8%; p = 0.13).
4. Discussion
In this contemporaneous sample of patients with suspected mTBI presenting to a tertiary adult ED, 6259 underwent A‐ WPTAS screening, with a failure rate of 8.2%. Patients with lower initial GCS, male patients, after‐hours presentations and those with low falls had higher rates of failure. The association between lower GCS and A‐WPTAS failure, however, should be interpreted with caution, as GCS forms part of the A‐WPTAS scoring system. In contrast, reported LOC was not associated with detection of PTA on the A‐WPTAS. These findings highlight the heterogeneous clinical features of patients who present with suspected mTBI and highlight the need for ongoing assessment of patients discharged from the ED, who continue to be at risk of PPCS.
The depth and duration of PTA has long been considered one of the best indicators of injury severity and outcome following TBI [19]. However, the A‐WPTAS provides an objective means of defining PTA duration only, which is one of the myriad of symptoms possible in the setting of mTBI. There are many effects of concussion that may not be detected by assessment of PTA. Emotional and behavioural changes are often the first missed signs, including increased irritability, anxiety, depression, agitation or becoming more emotional. Cognitive fog and slowdown may not show up as overt amnesia. Persistent physical symptoms may develop or be recognised later and include dizziness and headaches. Sensory sensitivity, such as photophobia or phonophobia, and sleep disturbances are often delayed responses. In addition, subtle cognitive deficits such as concentration may be missed if only gross memory (amnesia) is tested [20]. Reflecting on the high proportion of patients with mTBI who are reported to have concussion and PPCS—estimated to be up to around 20% [21]—the findings further highlight that screening using A‐WPTAS alone is insufficient to exclude PPCS. Accordingly, appropriate follow‐up should be arranged from the ED.
In the absence of capacity to conduct detailed neuro‐cognitive assessments, the diagnosis and management of concussion in the ED setting remain challenging. Biomarkers such as GFAP and UCH‐L1 have been identified as potentially valuable diagnostic tools in the evaluation of head injury patients presenting to the ED [22, 23]. However, biomarkers have yet to demonstrate the ability to effectively predict concussion recovery duration [24]. While biomarkers may be beneficial in screening and diagnosing concussion, there is currently no reliable method to predict duration of recovery or PPCS, thus preventing ED clinicians from providing tailored recovery and treatment plans. Improving the identification of concussion and risk factors for prolonged recovery will assist ED clinicians with appropriate management strategies.
A recently implemented management strategy is the referral of patients with mTBI to concussion clinics. Multidisciplinary interventions provided at specialised concussion clinics have been associated with reduced symptom burden in patients experiencing PPCS [25]. Early referral to concussion clinic specialists is vital as it was found that patients who presented to a concussion clinic earlier tended to experience shorter duration of symptoms [26]. Despite concussion clinics being easily accessible, many patients with mTBI will not see a medical practitioner after discharge from the ED or hospital [27]. Therefore, the ideal assessment for concussion after discharge from the ED may require routine community follow‐up, either through the patient's general practitioner or specialised concussion services. The effectiveness of such strategies requires further evaluation.
This study has several limitations. First, it is limited in assessing patients from a single centre that manages adults in a tertiary referral setting. It is likely that patients with potential mTBI were not assessed with A‐WPTAS and hence not included in this study. On the other hand, the low rate of PTA, compared to previous studies, suggests that A‐WPTAS testing was not restricted to the population that satisfied the World Health Organization criteria for mTBI [4]. We did not conduct long‐term follow‐up of patients, and thus, the rate of PPCS in this population remains unknown. Finally, symptoms such as LOC were self‐reported and thus subject to recall bias, but represent realistic conditions during assessment of patients in the ED.
5. Conclusions
A small proportion of patients have persistent amnesia when tested using A‐WPTAS in the ED. Patients presenting with lower GCS, male patients, patients injured after low falls, and those presenting after‐hours had higher rates of persistent amnesia. LOC, however, was not a discriminating variable. The potential for PPCS remains, regardless of PTA, and requires follow‐up after discharge from the ED.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgements
Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australasian University Librarians.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
- 1. Dewan M. C., Rattani A., Gupta S., et al., “Estimating the Global Incidence of Traumatic Brain Injury,” Journal of Neurosurgery 130, no. 4 (2018): 1080–1097, 10.3171/2017.10.JNS17352. [DOI] [PubMed] [Google Scholar]
- 2. Silverberg N. D., Iverson G. L., Cogan A., et al., “The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury,” Archives of Physical Medicine and Rehabilitation 104, no. 8 (2023): 1343–1355, 10.1016/j.apmr.2023.03.036. [DOI] [PubMed] [Google Scholar]
- 3. Lunter C. M., Carroll E. L., Housden C., et al., “Neurocognitive Testing in the Emergency Department: A Potential Assessment Tool for Mild Traumatic Brain Injury,” Emergency Medicine Australasia 31, no. 3 (2019): 355–361, 10.1111/1742-6723.13163. [DOI] [PubMed] [Google Scholar]
- 4. Pozzato I., Meares S., Kifley A., et al., “Challenges in the Acute Identification of Mild Traumatic Brain Injuries: Results From an Emergency Department Surveillance Study,” BMJ Open 10, no. 2 (2020): e034494, 10.1136/bmjopen-2019-034494. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Ponsford J., Willmott C., Rothwell A., Kelly A. M., Nelms R., and Ng K. T., “Use of the Westmead PTA Scale to Monitor Recovery of Memory After Mild Head Injury,” Brain Injury 6 (2004): 603–614, 10.1080/02699050310001646152. [DOI] [PubMed] [Google Scholar]
- 6. Watson C. E., Clous E. A., Jaeger M., and D'Amours S. K., “Introduction of the Abbreviated Westmead Post‐Traumatic Amnesia Scale and Impact on Length of Stay,” Scandinavian Journal of Surgery 4 (2017): 356–360, 10.1177/1457496917698642. [DOI] [PubMed] [Google Scholar]
- 7. McCrory P., Meeuwisse W., Dvorak J., et al., “Consensus Statement on Concussion in Sport—The 5th International Conference on Concussion in Sport Held in Berlin, October 2016,” British Journal of Sports Medicine 51, no. 11 (2017): 838–847, 10.1136/bjsports-2017-097699. [DOI] [PubMed] [Google Scholar]
- 8. Fried E., Balla U., Catalogna M., et al., “Persistent Post‐Concussive Syndrome in Children After Mild Traumatic Brain Injury Is Prevalent and Vastly Underdiagnosed,” Scientific Reports 12 (2022): 4364, 10.1038/s41598-022-08302-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Le Sage N., Chauny J.‐M., Berthelot S., et al., “Post‐Concussion Symptoms Rule: Derivation and Validation of a Clinical Decision Rule for Early Prediction of Persistent Symptoms After a Mild Traumatic Brain Injury,” Journal of Neurotrauma 39, no. 19–20 (2022): 1349–1362, 10.1089/neu.2022.0026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Ponsford J., Nguyen S., Downing M., et al., “Factors Associated With Persistent Post‐Concussion Symptoms Following Mild Traumatic Brain Injury in Adults,” Journal of Rehabilitation Medicine 51, no. 1 (2019): 32–39, 10.2340/16501977-2492. [DOI] [PubMed] [Google Scholar]
- 11. Savola O. and Hillbom M., “Early Predictors of Post‐Concussion Symptoms in Patients With Mild Head Injury,” European Journal of Neurology 10, no. 2 (2008): 175–181, 10.1046/j.1468-1331.2003.00552.x. [DOI] [PubMed] [Google Scholar]
- 12. Varner C., Thompson C., de Wit K., Borgundvaag B., Houston R., and McLeod S., “Predictors of Persistent Concussion Symptoms in Adults With Acute Mild Traumatic Brain Injury Presenting to the Emergency Department,” Canadian Journal of Emergency Medicine 23 (2021): 365–373, 10.1007/s43678-020-00076-6. [DOI] [PubMed] [Google Scholar]
- 13. Ingebrigtsen T., Waterloo K., Marup‐Jensen S., Attner E., and Romner B., “Quantification of Post‐Concussion Symptoms 3 Months After Minor Head Injury in 100 Consecutive Patients,” Journal of Neurology 245 (1998): 609–612, 10.1007/s004150050254. [DOI] [PubMed] [Google Scholar]
- 14. Rowe B. H., Yang E. H., Gaudet L. A., et al., “Sports‐Related Concussions in Adults Presenting to Canadian Emergency Departments,” Clinical Journal of Sport Medicine 32, no. 5 (2022): 469–477, 10.1097/JSM.0000000000001005. [DOI] [PubMed] [Google Scholar]
- 15. Ahman S., Saveman B. I., Styrke J., Björnstig U., and Stålnacke B. M., “Long‐Term Follow‐Up of Patients With Mild Traumatic Brain Injury: A Mixed‐Method Study,” Journal of Rehabilitation Medicine 45, no. 8 (2013): 758–764, 10.2340/16501977-1182. [DOI] [PubMed] [Google Scholar]
- 16. Hiploylee C., Dufort P. A., Davis H. S., et al., “Longitudinal Study of Postconcussion Syndrome: Not Everyone Recovers,” Journal of Neurotrauma 34, no. 8 (2017): 1511–1523, 10.1089/neu.2016.4677. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. McIntosh S. J., Vergeer M. H., Galarneau J., Eliason P. H., and Debert C. T., “Factors Associated With Persisting Symptoms After Concussion in Adults With Mild TBI: A Systematic Review and Meta‐Analysis,” JAMA Network Open 8, no. 6 (2025): e2516619, 10.1001/jamanetworkopen.2025.16619. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Meares S., Shores E. A., Taylor A. J., Lammél A., and Batchelor J., “Validation of the Abbreviated Westmead Post‐Traumatic Amnesia Scale: A Brief Measure to Identify Acute Cognitive Impairment in Mild Traumatic Brain Injury,” Brain Injury 25, no. 12 (2011): 1198–1205, 10.3109/02699052.2011.608213. [DOI] [PubMed] [Google Scholar]
- 19. Roberts C. M., Spitz G., and Ponsford J. L., “Retrospective Analysis of the Recovery of Orientation and Memory During Posttraumatic Amnesia,” Neuropsychology 29, no. 4 (2015): 522–529, 10.1037/neu0000178. [DOI] [PubMed] [Google Scholar]
- 20. Rao V., Syeda A., Roy D., Peters M. E., and Vaishnavi S., “Neuropsychiatric Aspects of Concussion: Acute and Chronic Sequelae,” Concussion 2, no. 1 (2017): CNC29, 10.2217/cnc-2016-0018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Heslot C., Azouvi P., Perdrieau V., Granger A., Lefèvre‐Dognin C., and Cogné M., “A Systematic Review of Treatments of Post‐Concussion Symptoms,” Journal of Clinical Medicine 11, no. 20 (2022): 6224, 10.3390/jcm11206224. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Jalali R., Bałuch M., Malinowska J., et al., “GFAP/UCH‐L1 as a Biomarker for Rapid Assessment of Mild TBI in Emergency Departments,” Medical Science Monitor 31 (2025): e948353, 10.12659/MSM.948353. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Bazarian J. J., Biberthaler P., Welch R. D., et al., “Serum GFAP and UCH‐L1 for Prediction of Absence of Intracranial Injuries on Head CT (ALERT‐TBI): A Multicentre Observational Study,” Lancet Neurology 17, no. 9 (2018): 782–789, 10.1016/S1474-4422(18)30231-X. [DOI] [PubMed] [Google Scholar]
- 24. Swaney E. E. K., Cai T., Seal M. L., and Ignjatovic V., “Blood Biomarkers of Secondary Outcomes Following Concussion: A Systematic Review,” Frontiers in Neurology 14 (2023): 989974, 10.3389/fneur.2023.989974. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Janak J. C., Cooper D. B., Bowles A. O., et al., “Completion of Multidisciplinary Treatment for Persistent Postconcussive Symptoms Is Associated With Reduced Symptom Burden,” Journal of Head Trauma Rehabilitation 32, no. 1 (2017): 1–15, 10.1097/HTR.0000000000000202. [DOI] [PubMed] [Google Scholar]
- 26. Barnhart M., Bay R. C., and Valovich McLeod T. C., “The Influence of Timing of Reporting and Clinic Presentation on Concussion Recovery Outcomes: A Systematic Review and Meta‐Analysis,” Journal of Sports Medicine 51, no. 7 (2021): 1491–1508, 10.1007/s40279-021-01444-7. [DOI] [PubMed] [Google Scholar]
- 27. Seabury S. A., Gaudette É., Goldman D. P., et al., “Assessment of Follow‐Up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK‐TBI Study,” JAMA Network Open 1, no. 1 (2018): e180210, 10.1001/jamanetworkopen.2018.0210. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.