EAST 2014: TBI Evaluation In The ED

Concussion evaluation is a very common reason for presentation to the ED. Many centers discharge patients from the ED with a normal GCS and a normal head CT. But is this enough? How many of these patients would benefit from further outpatient evaluation and possible treatment?

Another study from Grant Hospital in Columbus looked at a subset of mild TBI patients from the ED who also underwent more robust neurocognitive evaluation within 48 hours of their discharge.

Here are the factoids:

  • of the 6000+ trauma patients seen over a 17 month period, only 396 met the inclusion criteria (age >13, GCS 15, normal head CT, blunt trauma, no psych issues) and had a neurocognitive eval within 48 hours
  • 41% were cleared for discharge without any followup or supervision. 88% of these had known or suspected loss of consciousness.
  • 25% required outpatient therapy or were not safe for discharge. 81% of these had possible LOC. 
  • Only 28% of patients who required ongoing therapy would have met traditional ED discharge guidelines

Bottom line: First, this abstract is very poorly written. The concept comes across (barely), but is presented badly. Obviously, loss of consciousness is not much of an indicator of anything. The question is, how can we more reliably determine if a patient will need further cognitive evaluation or therapy? Gross GCS and head CT results do not seem to be enough. One solution may be to have ED nurses administer a basic cognitive screen to identify more subtle problems. The Short Blessed Test is ideal for this, and takes only a few minutes of time. And the key is to have some type of TBI clinic available to refer these patients to if they fail the test!

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Reference: You can’t go home: routine concussion evaluation is not enough. EAST 2014, poster abstract #12.

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