Early Discharge versus 6-hour Observation in Mild Traumatic Brain Injury with Normal Brain CT Scan; a Comparative Pilot study of Outcomes
Archives of Academic Emergency Medicine,
Vol. 12 No. 1 (2024),
1 January 2024
,
Page e50
https://doi.org/10.22037/aaem.v12i1.2245
Abstract
Introduction: Early discharge from the emergency department (ED) or a 6-hour observation in the ED are two methods for management of patients with mild traumatic brain injury (mTBI) with normal brain computed tomography (CT) scan. This study aimed to compare the outcomes of the two management options.
Methods: This study is a single-center, open-label, pilot randomized case control study conducted in the ED of Ramathibodi Hospital from June 2022 to September 2023. Eligible participants included all individuals with mTBI who had negative findings on Brain CT scans. They were randomly assigned to either the early ED discharge or 6-hour ED observation group and compared regarding the outcomes (rate of 48-hour ED revisits; occurrence of post-concussion syndrome (PCS) 1 day, 1 month, and 3 months after the initial injury; and 3-month mortality).
Results: 122 patients with the mean age of 74.62 ± 14.96 (range: 25-99) years were consecutively enrolled (57.37% female). No significant differences were observed between the early discharge and observation groups regarding the severity of TBI (p=0.853), age (p=0.334), gender (p=0.588), triage level (p=0.456), Glasgow Coma Scale (GCS) score (p=0.806), comorbidities (p=0.768), medication usage (p=0.548), mechanism of injury (p=0.920), indication for brain CT scan (p=0.593), time from TBI onset to ED arrival (p=0.886), and time from ED triage to brain CT scan (p=0.333). Within 48 hours after randomization, the incidence of revisits was similar between the two groups (1.57% vs. 3.23%; p = 1.000). There were no statistically significant differences in the incidence of PCS between the early discharge and observation groups at 1 day (33.90% vs. 35.48%, p = 0.503), at 1 month (12.07% vs. 13.11%, p = 0.542), and at 3 months (1.92% vs. 5.56%, p = 0.323) after randomization. After a three-month follow-up period, four patients in the early discharge group, had expired (none of the deaths were associated with TBI).
Conclusion: It seems that, in mTBI patients with normal initial brain CT scan and the absence of other injuries or neurological abnormalities, early discharge from the ED without requiring observation could be considered safe.
- brain injury
- trauma
- emergency department
- revisit
- post-concussion syndrome
How to Cite
References
Skandsen T, Nilsen TL, Einarsen C, Normann I, McDonagh D, Haberg AK, et al. Incidence of Mild Traumatic Brain Injury: A Prospective Hospital, Emergency Room and General Practitioner-Based Study. Front Neurol. 2019;10:638.
Carroll LJ, Cassidy JD, Holm L, Kraus J, Coronado VG. Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004(43 Suppl):113-25.
Flanagan SR. Invited Commentary on "Centers for Disease Control and Prevention Report to Congress: Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation". Arch Phys Med Rehabil. 2015;96(10):1753-5.
Yuksen C, Sittichanbuncha Y, Patumanond J, Muengtaweepongsa S, Sawanyawisuth K. Clinical predictive score of intracranial hemorrhage in mild traumatic brain injury. Ther Clin Risk Manag. 2018;14:213-8.
Yuksen C, Sittichanbuncha Y, Patumanond J, Muengtaweepongsa S, Aramvanitch K, Supamas A, et al. Clinical Factors Predictive for Intracranial Hemorrhage in Mild Head Injury. Neurol Res Int. 2017;2017:5385613.
Aramvanitch K, Yuksen C, Jenpanitpong C, Nuanprom P, Phootothum Y, Phontabtim M, et al. Validity of mild TBI risk score to predict intracranial hemorrhage in cases of mild traumatic brain injury in Thailand. Trauma Surg Acute Care Open. 2020;5(1):e000453.
Wintermark M, Sanelli PC, Anzai Y, Tsiouris AJ, Whitlow CT. Imaging evidence and recommendations for traumatic brain injury: conventional neuroimaging techniques. J Am Coll Radiol. 2015;12(2):e1-14.
Jagoda AS, Bazarian JJ, Bruns JJ, Jr., Cantrill SV, Gean AD, Howard PK, et al. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008;52(6):714-48.
Choudhry OJ, Prestigiacomo CJ, Gala N, Slasky S, Sifri ZC. Delayed neurological deterioration after mild head injury: cause, temporal course, and outcomes. Neurosurgery. 2013;73(5):753-60; discussion 60.
Isokuortti H, Luoto TM, Kataja A, Brander A, Siironen J, Liimatainen S, et al. Necessity of monitoring after negative head CT in acute head injury. Injury. 2014;45(9):1340-4.
Covino M, Manno A, Della Pepa GM, Piccioni A, Tullo G, Petrucci M, et al. Delayed intracranial hemorrhage after mild traumatic brain injury in patients on oral anticoagulants: is the juice worth the squeeze? Eur Rev Med Pharmacol Sci. 2021;25(7):3066-73.
Afaneh A, Ford J, Gharzeddine J, Mazar A, Hayward RD, Buck J. Head injury on Warfarin: likelihood of delayed intracranial bleeding in patients with negative initial head CT. BMC Res Notes. 2018;11(1):183.
Chauny JM, Marquis M, Bernard F, Williamson D, Albert M, Laroche M, et al. Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. J Emerg Med. 2016;51(5):519-28.
Santing JAL, Lee YX, van der Naalt J, van den Brand CL, Jellema K. Mild Traumatic Brain Injury in Elderly Patients Receiving Direct Oral Anticoagulants: A Systematic Review and Meta-Analysis. J Neurotrauma. 2022;39(7-8):458-72.
Verschoof MA, Zuurbier CCM, de Beer F, Coutinho JM, Eggink EA, van Geel BM. Evaluation of the yield of 24-h close observation in patients with mild traumatic brain injury on anticoagulation therapy: a retrospective multicenter study and meta-analysis. J Neurol. 2018;265(2):315-21.
Nearing KI, Tsao JW. Head injury while on anticoagulation: Small numbers, big risks. Neurol Clin Pract. 2017;7(4):280-2.
Cipriano A, Pecori A, Bionda AE, Bardini M, Frassi F, Leoli F, et al. Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists. Intern Emerg Med. 2018;13(7):1077-87.
Savioli G, Ceresa IF, Luzzi S, Gragnaniello C, Giotta Lucifero A, Del Maestro M, et al. Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists. Medicina (Kaunas). 2020;56(6).
Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A. Long-term outcomes after uncomplicated mild traumatic brain injury: a comparison with trauma controls. J Neurotrauma. 2011;28(6):937-46.
Levin HS, Diaz-Arrastia RR. Diagnosis, prognosis, and clinical management of mild traumatic brain injury. Lancet Neurol. 2015;14(5):506-17.
Tapia RN, Eapen BC. Rehabilitation of Persistent Symptoms After Concussion. Phys Med Rehabil Clin N Am. 2017;28(2):287-99.
Laborey M, Masson F, Ribéreau-Gayon R, Zongo D, Salmi LR, Lagarde E. Specificity of postconcussion symptoms at 3 months after mild traumatic brain injury: results from a comparative cohort study. J Head Trauma Rehabil. 2014;29(1):E28-36.
Tator CH, Davis HS, Dufort PA, Tartaglia MC, Davis KD, Ebraheem A, et al. Postconcussion syndrome: demographics and predictors in 221 patients. J Neurosurg. 2016;125(5):1206-16.
Menon DK, Schwab K, Wright DW, Maas AI. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil. 2010;91(11):1637-40.
Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.
Fabbri A, Servadei F, Marchesini G, Dente M, Iervese T, Spada M, et al. Which type of observation for patients with high-risk mild head injury and negative computed tomography? Eur J Emerg Med. 2004;11(2):65-9.
Marincowitz C, Gravesteijn B, Sheldon T, Steyerberg E, Lecky F. Performance of the Hull Salford Cambridge Decision Rule (HSC DR) for early discharge of patients with findings on CT scan of the brain: a CENTER-TBI validation study. Emerg Med J. 2022;39(3):213-9.
Marincowitz C, Lecky FE, Allgar V, Hutchinson P, Elbeltagi H, Johnson F, et al. Development of a Clinical Decision Rule for the Early Safe Discharge of Patients with Mild Traumatic Brain Injury and Findings on Computed Tomography Brain Scan: A Retrospective Cohort Study. J Neurotrauma. 2020;37(2):324-33.
Marincowitz C, Lecky FE, Townend W, Borakati A, Fabbri A, Sheldon TA. The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis. J Neurotrauma. 2018;35(5):703-18.
Thiruppathy SP, Muthukumar N. Mild head injury: revisited. Acta Neurochir (Wien). 2004;146(10):1075-82; discussion 82-3.
Tangkulpanich P, Yuksen C, Kongchok W, Jenpanitpong C. Clinical Predictors of Emergency Department Revisits within 48 Hours of Discharge; a Case Control Study. Arch Acad Emerg Med. 2021;9(1):e1.
keeratipornruedee p, Potipwong W, Rojsaengroeng R. Revisits for Traumatic Brain Injury in Emergency Department, Samut Sakhon Hospital. Thai Journal of Emergency Medicine. 2022;4(1):15-35.
Hsia RY, Markowitz AJ, Lin F, Guo J, Madhok DY, Manley GT. Ten-year trends in traumatic brain injury: a retrospective cohort study of California emergency department and hospital revisits and readmissions. BMJ Open. 2018;8(12):e022297.
Krishnamoorthy V, Chaikittisilpa N, Kiatchai T, Vavilala M. Hypertension After Severe Traumatic Brain Injury: Friend or Foe? J Neurosurg Anesthesiol. 2017;29(4):382-7.
- Abstract Viewed: 304 times
- pdf Downloaded: 633 times