Skip to main content
PMC home page
Emergency Medicine Journal : EMJ logoLink to Emergency Medicine Journal : EMJ
. 2005 Jul;22(7):473–477. doi: 10.1136/emj.2004.019273

Emergency department management of mild traumatic brain injury in the USA

J Bazarian 1, J McClung 1, Y Cheng 1, W Flesher 1, S Schneider 1
PMCID: PMC1726852  PMID: 15983080

Abstract

Objective: To describe the emergency department (ED) management of isolated mild traumatic brain injury (TBI) in the USA and to examine variation in care across age and insurance types.

Methods: A secondary analysis of ED visits for isolated mild TBI in the National Hospital Ambulatory Medical Care Survey 1998–2000 was performed. Mild TBI was defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes for skull fracture, concussion, intracranial injury (unspecified), and head injury (unspecified). Available ED care variables were analysed by patient age and insurance categories using multivariate logistic regression.

Results: The incidence of isolated mild TBI cases attending ED was 153 296 per year, or 56.4/100 000 people. Of the patients with isolated mild TBI, 44.3% underwent computed tomography, 23.9% underwent other non-extremity, non-chest x rays, 17.1% received wound care and 14.1% received intravenous fluids. However, only 43.8% had an assessment of pain. Of those with documented pain, only 45.5% received analgesics in the ED. Nearly 38% were discharged without recommendations for specific follow up. Several aspects of ED care varied by age but not by insurance type.

Conclusion: Substantial ED resources are devoted to the care of isolated mild TBI. The present study identified deficiencies in and variation around several important aspects of ED care. The development of guidelines specific for mild TBI could reduce variation and improve emergency care for this injury.

Full Text

The Full Text of this article is available as a PDF (80.1 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bazarian J. J., Atabaki S. Predicting postconcussion syndrome after minor traumatic brain injury. Acad Emerg Med. 2001 Aug;8(8):788–795. doi: 10.1111/j.1553-2712.2001.tb00208.x. [DOI] [PubMed] [Google Scholar]
  2. Bazarian J. J., Wong T., Harris M., Leahey N., Mookerjee S., Dombovy M. Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. Brain Inj. 1999 Mar;13(3):173–189. doi: 10.1080/026990599121692. [DOI] [PubMed] [Google Scholar]
  3. Bazarian J., Hartman M., Delahunta E. Minor head injury: predicting follow-up after discharge from the Emergency Department. Brain Inj. 2000 Mar;14(3):285–294. doi: 10.1080/026990500120754. [DOI] [PubMed] [Google Scholar]
  4. Blostein Paul, Jones Susan J. Identification and evaluation of patients with mild traumatic brain injury: results of a national survey of level I trauma centers. J Trauma. 2003 Sep;55(3):450–453. doi: 10.1097/01.TA.0000038545.24879.4D. [DOI] [PubMed] [Google Scholar]
  5. Bohnen N., Twijnstra A., Jolles J. Post-traumatic and emotional symptoms in different subgroups of patients with mild head injury. Brain Inj. 1992 Nov-Dec;6(6):481–487. doi: 10.3109/02699059209008145. [DOI] [PubMed] [Google Scholar]
  6. Borczuk P. Mild head trauma. Emerg Med Clin North Am. 1997 Aug;15(3):563–579. doi: 10.1016/s0733-8627(05)70318-7. [DOI] [PubMed] [Google Scholar]
  7. Borg Jörgen, Holm Lena, Cassidy J. David, Peloso Paul M., Carroll Linda J., von Holst Hans, Ericson Kaj, WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury Diagnostic procedures in mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004 Feb;(43 Suppl):61–75. doi: 10.1080/16501960410023822. [DOI] [PubMed] [Google Scholar]
  8. Carroll Linda J., Cassidy J. David, Peloso Paul M., Borg Jörgen, von Holst Hans, Holm Lena, Paniak Chris, Pépin Michel, WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004 Feb;(43 Suppl):84–105. doi: 10.1080/16501960410023859. [DOI] [PubMed] [Google Scholar]
  9. Cassidy J. David, Carroll Linda J., Peloso Paul M., Borg Jörgen, von Holst Hans, Holm Lena, Kraus Jess, Coronado Victor G., WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury Incidence, risk factors and prevention of mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004 Feb;(43 Suppl):28–60. doi: 10.1080/16501960410023732. [DOI] [PubMed] [Google Scholar]
  10. Chambers J., Cohen S. S., Hemminger L., Prall J. A., Nichols J. S. Mild traumatic brain injuries in low-risk trauma patients. J Trauma. 1996 Dec;41(6):976–980. doi: 10.1097/00005373-199612000-00006. [DOI] [PubMed] [Google Scholar]
  11. Dikmen S. S., Temkin N. R., Machamer J. E., Holubkov A. L., Fraser R. T., Winn H. R. Employment following traumatic head injuries. Arch Neurol. 1994 Feb;51(2):177–186. doi: 10.1001/archneur.1994.00540140087018. [DOI] [PubMed] [Google Scholar]
  12. Fabbri A., Servadei F., Marchesini G., Morselli-Labate A. M., Dente M., Iervese T., Spada M., Vandelli A. Prospective validation of a proposal for diagnosis and management of patients attending the emergency department for mild head injury. J Neurol Neurosurg Psychiatry. 2004 Mar;75(3):410–416. doi: 10.1136/jnnp.2003.016113. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Guru V., Dubinsky I. The patient vs. caregiver perception of acute pain in the emergency department. J Emerg Med. 2000 Jan;18(1):7–12. doi: 10.1016/s0736-4679(99)00153-5. [DOI] [PubMed] [Google Scholar]
  14. Ingebrigtsen T., Romner B., Kock-Jensen C. Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. J Trauma. 2000 Apr;48(4):760–766. doi: 10.1097/00005373-200004000-00029. [DOI] [PubMed] [Google Scholar]
  15. Ingebrigtsen T., Romner B. Management of minor head injuries in hospitals in Norway. Acta Neurol Scand. 1997 Jan;95(1):51–55. doi: 10.1111/j.1600-0404.1997.tb00068.x. [DOI] [PubMed] [Google Scholar]
  16. Jager T. E., Weiss H. B., Coben J. H., Pepe P. E. Traumatic brain injuries evaluated in U.S. emergency departments, 1992-1994. Acad Emerg Med. 2000 Feb;7(2):134–140. doi: 10.1111/j.1553-2712.2000.tb00515.x. [DOI] [PubMed] [Google Scholar]
  17. Jagoda Andy S., Cantrill Stephen V., Wears Robert L., Valadka Alex, Gallagher E. John, Gottesfeld Steven H., Pietrzak Michael P., Bolden Jason, Bruns John J., Jr, Zimmerman Robert. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2002 Aug;40(2):231–249. doi: 10.1067/mem.2002.125782. [DOI] [PubMed] [Google Scholar]
  18. Jay G. W., Goka R. S., Arakaki A. H. Minor traumatic brain injury: review of clinical data and appropriate evaluation and treatment. J Insur Med. 1996 Summer;27(4):262–282. [PubMed] [Google Scholar]
  19. Jorge R. E., Robinson R. G., Starkstein S. E., Arndt S. V. Influence of major depression on 1-year outcome in patients with traumatic brain injury. J Neurosurg. 1994 Nov;81(5):726–733. doi: 10.3171/jns.1994.81.5.0726. [DOI] [PubMed] [Google Scholar]
  20. Klassen T. P., Reed M. H., Stiell I. G., Nijssen-Jordan C., Tenenbein M., Joubert G., Jarvis A., Baldwin G., St-Vil D., Pitters C. Variation in utilization of computed tomography scanning for the investigation of minor head trauma in children: a Canadian experience. Acad Emerg Med. 2000 Jul;7(7):739–744. doi: 10.1111/j.1553-2712.2000.tb02260.x. [DOI] [PubMed] [Google Scholar]
  21. Levin H. S., Mattis S., Ruff R. M., Eisenberg H. M., Marshall L. F., Tabaddor K., High W. M., Jr, Frankowski R. F. Neurobehavioral outcome following minor head injury: a three-center study. J Neurosurg. 1987 Feb;66(2):234–243. doi: 10.3171/jns.1987.66.2.0234. [DOI] [PubMed] [Google Scholar]
  22. Mittenberg W., Canyock E. M., Condit D., Patton C. Treatment of post-concussion syndrome following mild head injury. J Clin Exp Neuropsychol. 2001 Dec;23(6):829–836. doi: 10.1076/jcen.23.6.829.1022. [DOI] [PubMed] [Google Scholar]
  23. Petrack E. M., Christopher N. C., Kriwinsky J. Pain management in the emergency department: patterns of analgesic utilization. Pediatrics. 1997 May;99(5):711–714. doi: 10.1542/peds.99.5.711. [DOI] [PubMed] [Google Scholar]
  24. Phillips D. M. JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA. 2000 Jul 26;284(4):428–429. doi: 10.1001/jama.284.4.423b. [DOI] [PubMed] [Google Scholar]
  25. Ponsford J., Willmott C., Rothwell A., Cameron P., Ayton G., Nelms R., Curran C., Ng K. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001 Dec;108(6):1297–1303. doi: 10.1542/peds.108.6.1297. [DOI] [PubMed] [Google Scholar]
  26. Seelig J. M., Becker D. P., Miller J. D., Greenberg R. P., Ward J. D., Choi S. C. Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. N Engl J Med. 1981 Jun 18;304(25):1511–1518. doi: 10.1056/NEJM198106183042503. [DOI] [PubMed] [Google Scholar]
  27. Stiell I. G., Wells G. A., Vandemheen K., Laupacis A., Brison R., Eisenhauer M. A., Greenberg G. H., MacPhail I., McKnight R. D., Reardon M. Variation in ED use of computed tomography for patients with minor head injury. Ann Emerg Med. 1997 Jul;30(1):14–22. doi: 10.1016/s0196-0644(97)70104-5. [DOI] [PubMed] [Google Scholar]
  28. Vos P. E., Battistin L., Birbamer G., Gerstenbrand F., Potapov A., Prevec T., Stepan Ch A., Traubner P., Twijnstra A., Vecsei L. EFNS guideline on mild traumatic brain injury: report of an EFNS task force. Eur J Neurol. 2002 May;9(3):207–219. doi: 10.1046/j.1468-1331.2002.00407.x. [DOI] [PubMed] [Google Scholar]
  29. Wade D. T., King N. S., Wenden F. J., Crawford S., Caldwell F. E. Routine follow up after head injury: a second randomised controlled trial. J Neurol Neurosurg Psychiatry. 1998 Aug;65(2):177–183. doi: 10.1136/jnnp.65.2.177. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. von Holst Hans, Cassidy J. David. Mandate of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004 Feb;(43 Suppl):8–10. doi: 10.1080/16501960410023633. [DOI] [PubMed] [Google Scholar]
  31. von Wild K., Terwey S. Diagnostic confusion in mild traumatic brain injury (MTBI). Lessons from clinical practice and EFNS--inquiry. European Federation of Neurological Societies. Brain Inj. 2001 Mar;15(3):273–277. doi: 10.1080/026990501300005712. [DOI] [PubMed] [Google Scholar]

Articles from Emergency Medicine Journal : EMJ are provided here courtesy of BMJ Publishing Group

RESOURCES