84 Accid Emerg Med 1998;15:84-88

REVIEW

The management of minor traumatic brain injury

P J A Hutchinson, P J Kirkpatrick, J Addison, S Jackson, J D Pickard

UniversityDepartment ofNeurosurgery,Addenbrooke'sHospital, Cambridge,UKP J A HutchinsonP J KirkpatrickJ AddisonS JacksonJ D Pickard

Correspondence to:P J A Hutchinson FRCS,University Department ofNeurosurgery, Box 167,Addenbrooke's Hospital,Cambridge CB2 2QQ, UK.

Accepted for publication13 August 1997

The past two decades have seen increasedinterest in the management of major headinjury. The introduction of advanced traumalife support' courses within the United King-dom has made a significant contribution to theinitial treatment of patients with severe braintrauma, and addresses the major concerns ofearly correction of hypoxia and hypotension.However, a working party organised by theTraumatic Brain Foundation acknowledges thedifficulties in providing evidence based guide-lines for these patients.2

In contrast, minor injury attracts muchless publicity, despite affecting many morepatients and demanding important manage-ment decisions. In this review we aim todiscuss the management of minor traumaticbrain injury, particularly the exclusion of majorinjury.3'4The significance of the problem relates to

the one million patients who annually attendaccident and emergency (A&E) departmentswith a head injury in the United Kingdom.' Ofthese, 800 000 have a minor or mild injury, and80 000 are admitted to hospital. The inpatienthospital cost incurred is therefore consider-able. Prolonged time off work as a result ofpersistent postconcussion symptoms adds tothe national burden resulting from minor trau-matic brain injury.The definition of minor traumatic brain

injury is unsatisfactory for two reasons.Firstly, traditionally the term "head injury"has been applied, but the term "traumaticbrain injury" is now often used. Secondly,there is confusion regarding the term "minor."In the past head injuries have been dividedaccording to the Glasgow coma scale (GCS)6as minor (GCS 13-15), moderate (GCS9-12), and severe (GCS 3-8).7 However, thereis a difference in the rate of complicationsbetween those patients with GCS 15 (theoverwhelming majority8 ) versus those withGCS 13/14.9-" Some investigators thereforesubdivide this group of brain injured patientsinto minor (GCS 15) and mild (GCS13-14).12In this review, we shall use the term "minor

traumatic brain injury" to define patients withGCS 13-15. This term simplifies theclassification of severity and indicates the aeti-ology of the injury and that the brain is theaffected organ.

Management in the accident andemergency departmentThe initial management decisions about pa-tients with minor traumatic brain injury aremade by junior doctors within the A&Edepartment. The aim is to detect those patientsat risk of deterioration of consciousness,mainly as a result of the development of anintracranial haematoma.'3 14. The major riskfactors for this complication are decreasedlevel of consciousness and the presence of askull fracture.9 The risk of an intracranial hae-matoma is one in 120 in patients who are con-fused but have no fracture, one in 30 in thosewho are fully conscious with a skull fracture,and one in four if both decreased level of con-sciousness and a fracture are present. A studyof 183 patients who presented to hospital withGCS 15 but subsequently underwent surgeryfor acute intracranial haematoma highlightsthese factors.'4 A history of altered conscious-ness, or symptoms of headache and vomiting,was present in 61% of the patients. A skullfracture was shown radiographically in 60% ofpatients. However, in addition to intracranialhaematoma, other causes of deterioration canoccur'5 including seizures.16As a result of these studies, guidelines in the

form of criteria have been drawn up to aid themanagement of patients with traumatic braininjury.10 '7 Recently, there has been consider-able interest in the production of guidelines inall branches of medicine, particularly inrelation to evidence based medicine. Headinjury guidelines were the subject of the BayerSatellite Symposium to the J Douglas Millermemorial meeting held in October 1996 inEdinburgh. Guidelines have been proposedcovering all aspects of brain injury manage-ment, but those most applicable to minor trau-matic brain injury are criteria for skull films,criteria for admission to hospital, and criteriafor computed tomography. Problems havearisen in relation to the basis of guidelines, towhat extent clinical practice should be gov-erned by guidelines, and whether they can beeffectively implemented. We have shown thatimprovements in documentation and the pro-vision of proformas have not improved theimplementation of head injury guidelines inEast Anglia.'" Most guidelines are based on aconsensus of opinion of experts, but with theincreased interest in evidence based medicineit is clear that additions and modificationsshould be based on a combination of expert

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Minor traumatic brain injury

Table 1 Criteria for skull x ray after recent head injury

Loss of consciousness or amnesia suspected at any timeNeurological symptoms or signs (including headache and/or vomiting more than twice)Return visitsCerebrospinal fluid or blood from the nose or ear

Suspected penetrating injuryScalp bruising, swelling, or laceration down to the boneChildren (<5 years): falls from >60 cm or onto a hard surface; tense fontanelle;suspected non-accidental injury (refer to paediatrician)Difficulty in assessing the patient (eg, alcohol intoxication, epilepsy, children);inadequate or suspicious history

Note: Skull x ray not necessary if computed tomography to be performed immediately or if anabusive patient is to be admitted immediately.

opinion and high quality evidence. Ideally,guidelines should be governed by standardswhich in turn should be based on hardevidence. As in other branches of medicine,this would require randomised control trials. Itwill also be necessary to provide mechanismsfor evaluating the distribution, implementa-tion, and effectiveness of guidelines.There are aspects of brain injury suitable for

guidelines and the symposium addressed theagenda for future work. The guidelines quotedin this review are those currently in use in theEast Anglian Region, and were derived fromthe national neurosurgical guidelines,'0 17 withinput from a number of specialties includingneurosurgery, accident and emergency medi-cine, and general surgery. These are largelybased on expert opinion and current practice,not on randomised controlled trials.

Criteria for skulil x ray after recent headinjuryThis has been a source of great controversy inBritain, with some radiologists criticisingliberal policies on skull radiography whichresult in large numbers of negative skullfilms.'9 20 However, if a skull fracture isdetected, the risk of an intracranial haematomais increased, particularly if the patient isdisorientated.9" Thus skull films may be con-sidered to direct the decision as to whether toperform computed tomography.

In order to establish guidelines for skullradiography following brain injury, a group ofneurosurgeons and radiologists met in Harro-gate in 1983 and drew up the Harrogate crite-ria for skull films after brain trauma.22 In EastAnglia criteria for skull films after recent braininjury have been formulated as part of regionalhead injury guidelines (table 1). In addition,clinical judgement is necessary for assessingthe force of injury, which requires an accuratehistory.

Table 2 Criteria for admission to hospital

Confusion or any other depression of the level of consciousness at the time ofexamination. If <5 years, at any time following the injuryNeurological symptoms or signs even if minor, particularly in children (eg, headache or

vomiting more than twice)Skull fracture on skull x ray or clinical signs of basal skull fracture includingcerebrospinal fluid rhinorrhoea / otorrhoeaDifficulty in assessing the patient (eg, suspected drugs, alcohol, non-accidental injury,epilepsy, attempted suicide)Other medical conditions (eg, coagulation disorders)Patient's social conditions or lack of a responsible adult / relative

In contrast to our policy, certain investiga-tors have advocated that skull films only needto be performed if the decision has been madeto discharge the patient.2' If the patient fulfilsthe criteria for admission, an immediate skullfilm is not necessary as the patient will undergoadmission for clinical observation. If thepatient does not fulfil the clinical criteria foradmission and discharge is planned, an imme-diate skull film is performed. If this reveals a

fracture, the patient is deemed at increased riskof developing a haematoma and is then admit-ted. The exception is where a depressedfracture is suspected and then early skull filmshould be performed."4 25 We do not advocatethis approach, as skull radiography may detectan unsuspected depressed fracture, and if a

fracture is diagnosed there is a strong argumentfor proceeding to computed tomography. Thediscovery of a fracture will also heighten theawareness of the inpatient team regardingfrequency of neurological observations andlength of admission.The East Anglian criteria attempt to balance

fracture detection (and therefore risk ofhaematoma formation) versus economy in theuse of, and risk from, radiographs. We do notadvocate skull films in all head injury attend-ances, but tailor their use to well defined clini-cal criteria based on expert opinion.There has also been concern regarding the

ability of casualty officers to detect fractures onskull films. A study from Glasgow has shownthis to be largely unfounded."6 Of 2730radiographs of the skull, radiologists reported45 fractures, with casualty officers failing todetect only six.Of additional concern is the number of other

injuries that are missed in a patient with a

minor head injury. Gautam and Leonardpresented a series of 100 patients with minortraumatic brain injury.27 Of these, 30 had frac-tures in addition to a minor traumatic braininjury. These predominantly affected the facialskeleton (43%), skull (20%), forearm (10%),and spine (10%), and 27% of these fractureswere not diagnosed in the A&E department. Avery high index of suspicion is required forextracranial injuries.

Criteria for admission to hospitalThe East Anglian regional guidelines criteriafor admission to hospital are listed in table 2. Itis again important to stress that the criteria are

an adjunct to clinical judgement. In addition,the mechanism of injury is an important factor.There should be a low threshold for admissionfor patients who have sustained high velocityinjuries. A paper from Denmark has stressedthe importance of agitation (defined as unusu-

ally troubled behaviour) as a predictor ofintracranial pathology.'8

Criteria for computed tomographyscanning in general hospitals

The controversy regarding skull films andminor traumatic brain injury in Britain hasbeen matched by that over computed tomogra-phy and minor traumatic brain injury in theUSA. Stein and Ross express concern that

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Note: (a) Post-traumatic amnesia (< 2 min) or transient unconsciousness with full recovery arenot necessarily indications for admission, but if in doubt the patient should be admitted; (b)patients who are sent home should be accompanied by a responsible adult who should receivewritten advice to return immediately if there is any deterioration.

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Table 3 Criteria for computed tomography (CT) in general hospitals

234

Confusion (GCS <13-14) or worse, persisting after initial assessment and resuscitationUnstable systemic state precluding transfer to neurosurgery

Diagnosis uncertainFully conscious but with a skull fracture or following a first fit admit and consider CT

GCS, Glasgow coma score.

clinical assessment alone is not adequate29 andrecommend that any patient who has sufferedloss of consciousness or amnesia followingtraumatic brain injury should have urgent cra-nial computed tomography.30 Of 1538 patientswith minor traumatic brain injury who werescanned, 265 (17.2%) had an abnormal scan,with 131 fractures and 209 intracranial abnor-malities; 58 patients underwent surgery; 40%of patients with a GCS 13 had abnormalitieson tomography.31 Mohanty et al, however,argue that routine computed tomography forminor traumatic brain injury is unnecessaryand an inefficient use of personnel andequipment.32 Of 348 patients scanned, only 12had abnormal scans with no neurological defi-cit, and all of these had an uneventful hospitaldischarge. The reason for the difference inresults of these retrospective studies is not clearbut may be explained by Stein and Ross usingGCS 13-15 for inclusion in their study, andMohanty et al, GCS 14-15. Different ages,injury aetiology, and timing of scans may alsoaccount for the discrepancy. Mohanty et al rec-ognise the need for better prospective studies.There is also debate regarding hospital admis-sion of patients with normal tomographicfindings.33 Shackford et al advocate computedtomography in all patients with minor trau-matic brain injury, and discharge those inwhom the scan is negative.34 It is wellrecognised, however, that intracranial lesionsmay take several hours to develop and can bemissed on an early scan.35

In the United Kingdom the criteria for com-puted tomography have changed over the pastfew years with the increasing availability ofscanners in district general hospitals. Teasdaleet allo now advocate scanning patients who arefully conscious but have a skull fracture, andthis recommendation has been incorporatedinto the criteria for computed tomography ingeneral hospitals (table 3).

Criteria for consultation with theneurosurgical unitThe indications for neurosurgical consultationare given in table 4. Following consultation,approximately 5% of admitted patients withhead injury are transferred to neurosurgical

Table 4 Criteria for consultation with neurosurgical unit

(a) Without preliminary CT1 Coma (not obeying commands) continuing after resuscitation-even if no skull fracture2 Deterioration in level of consciousness or progressive neurological deficits3 Open injury: depressed fracture, penetrating injury, or suspected basal skull fracture4 Tense fontanelle5 Patient fulfils criteria for CT in general hospital but this cannot be performed within a

reasonable time (eg, 3-4 hours)

(b) After CT in general hospital1 Abnormal CT (preferably after neurosurgical opinion on images transferred

electronically)2 CT normal but patient's progress considered unsatisfactory

CT, computed tomography.

units.5 In the United Kingdom, the absoluterisk of traumatic intracranial haematoma re-quiring neurosurgery in adult patients attend-ing A&E departments with no altered con-sciousness and no skull fracture is 1:31 370,and for those with no altered consciousness butwith a skull fracture it is 1:81.10 The proportionof patients transferred following neurosurgicalconsultation requires further study.

Inpatient management ofminortraumatic brain injuryIf a patient satisfies the criteria for admissiontheir destination depends on the hospitalinvolved. In the United Kingdom, patients withminor traumatic brain injury are admitted toA&E observation wards, surgical wards, ortho-paedic wards, and, rarely, neurosurgical units.

In observation wards the patient usuallyremains under the care of the A&E staff.36 Thishas the advantage of ease of admission withoutinvolving other teams, and is particularlysuitable if the patient's social circumstances arethe only indication for admission. In some hos-pitals, these wards are only open at certaintimes (for example, weekdays). A study fromGuy's Hospital has shown that this influencesthe decision as to whether the patient isadmitted.37 When the observation ward wasopen 51 of 76 patients (67%) with admissioncriteria were admitted, but when it was closedand the patient required an inpatient surgicalbed only 15/51 patients (29%) were admitted.Another problem with observation wards isthat in the event of deterioration, the generalsurgical or orthopaedic team is unlikely to haveseen the patient before, impairing their assess-ment of the change of level of consciousness.

In the United Kingdom in the past, patientswith minor traumatic brain injury were admit-ted under the care of general or orthopaedicsurgeons. However, as the specialty of A&Eexpands it is likely that more patients will beadmitted under the care ofA&E consultants inobservation wards. This approach has theadvantage that the initial consultation and sub-sequent review is made by the same medicalteam. The neurosurgical unit in Cambridge isunusual in that we admit all patients withminor traumatic brain injury under our care.This has the advantage that computed tomog-raphy is readily available and the delay tosurgery is minimised.

Following admission, there are several fac-tors to be considered. Neurological observa-tions are performed in order to detect deterio-ration. There is no consistent pattern to theirfrequency and duration. Because of the rigidnature of the skull, intracranial bleeding canlead to rapid deterioration in level of con-sciousness, ending in coning. There are noguidelines for the frequency of observations,but we would recommend halfhourly monitor-ing of the variables listed in table 5. The GCSis the most important observation, as a declinein level of consciousness is the first sign ofdeterioration, with changes in the other vari-ables occurring late. During this time thepatient should not receive anything by mouthand may therefore require an intravenous infu-

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Minor traumatic brain injury

sion. The majority of intracranial haematomasthat require urgent evacuation develop withinthe first 12 hours. Patients should therefore beadmitted for at least this time.Drugs given to patients with minor trau-

matic brain injury include analgesics, anti-emetics, and antibiotics. Codeine phosphate isthe most appropriate analgesic. It avoids theneurological and respiratory depression associ-ated with the strong opiates and the depressionof platelet function induced by the non-steroidal anti-inflammatory drugs. Prochlor-perazine is a suitable anti-emetic. The routineuse of antibiotics is no longer advised forpatients with a base of skull fracture.38 Thosewith cerebrospinal fluid leaks should always beadmitted and referred to neurosurgeons.

Discharge and follow upFollowing discharge from the A&E departmentor the ward, patients are routinely given headinjury instruction cards. Ward et al haveassessed the benefits of these cards.39 Theycontacted patients who had been dischargedfrom hospital following a minor traumaticbrain injury. More than one third had no recol-lection of receiving a head injury instructioncard. Possible explanations for this are thatcards are not issued, that relatives receivingcards did not inform the patient, or that thepatient had memory loss for this aspect of theirmanagement. The authors postulated the latteras the main explanation. However, only sevenof 1546 patients stated that the verbal andinjury card advice was reassuring or that thesymptoms were not bad enough to warrantfurther reassurance.

Although there is no proven benefit for theuse of head injury cards, they are still standardpractice. Medicolegal implications may con-tribute to their continued use. Clear verbalinstructions to the carer of the individualshould be given irrespective of the use of headinjury cards.

The postconcussion syndromeThe follow up of patients with minor traumaticbrain injury is not consistent. Most patients areadvised to return to the hospital or visit theirgeneral practitioner if they require furthertreatment. Routine follow up is rarely offered.However, within three months of minortraumatic brain injury over 50% of patientshave post-traumatic symptoms. These togethercomprise the postconcussion syndrome, a

neglected area in the management of minortraumatic brain injury.Although the aim of this review is to focus on

the acute management of apparently minortraumatic brain injury and the exclusion ofmajor injury, we will give a brief outline of thepostconcussion syndrome, along with adviceon treatment aimed at doctors who treat thesepatients acutely. There are several detailedreviews on the postconcussion "unirnmt.4043The postconcussion syndrome comprises a

large number of symptoms that may occur

alone or in combination following minor trau-matic brain injury. They include headache,dizziness, fatigue, irritability, anxiety, insom-

nia, noise sensitivity, and loss of memory.

There are two theories of aetiology: (1) theorganic theory, which proposes that thesyndrome is due to neuronal damage; and (2)the neurosis theory, which suggests that thesymptoms are not due to any organic conditionbut result from an underlying personalitydisorder. These are addressed in the reviewscited above.

Resolution occurs in most patients withinthree to six months, but some are affected formany years. There is no specific treatment forthe postconcussion syndrome. Education, neu-ropsychological treatment, and drug treatmenthave all been used. Education in the form ofsupport, reassurance, and encouraging thepatient to return to a normal lifestyle is themost useful form of treatment. Neuropsycho-logical assessment may be useful in determin-ing cognitive impairment. There is no goodevidence for the use of drugs, but simple anal-gesics such as paracetamol may help some

patients.From the perspective ofA&E staff and other

doctors who treat patients acutely with minortraumatic brain injury, it is essential to excludeunderlying pathology, for example frontal con-

tusions, and to convey information to the gen-eral practitioner regarding the nature of theinjury and the condition of the patient on dis-charge. Patients whose symptoms persist afterone week should not return to work, and thosestill symptomatic at one month require furtherattention." Advice on management may beobtained from head injury rehabilitation unitsand a neuropsychology opinion may be appro-priate. A&E medicine may have a role byestablishing minor traumatic brain injuryfollow up clinics. "Headway" is a charitableorganisation which supports patients with headinjury and produces an information pack forrelatives." The aims of Headway are to givesupport, encourage research, provide infor-mation, and increase awareness.

The futureThe future for the management of minor trau-matic brain injury lies with training of medicaland nursing staff in the form of formalseminars, the introduction of computerisedteaching aids, and implementing and auditingguidelines. More emphasis needs to be placedon the prevention of traumatic brain injury, forexample promoting the use of cycle helmets. Agreater understanding of the pathophysiologyof, and improved treatment of, the postconcus-sion syndrome represents a further challengeto reducing the morbidity that results fromminor traumatic brain injury.

SummaryMinor traumatic brain injury accounts for themajority of the one million head traumaattendances at A&E departments in the UnitedKingdom. Guidelines have been establishedlisting criteria for skull films, admission to hos-pital, computed tomography, and neurosurgi-cal consultation. These are currently undergo-ing revision and were the subject of a satellitesymposium to the J Douglas Miller memorial

Table 5 Neurologicalobservations

1 Glasgow coma score2 Pupil responses3 Pulse4 Blood pressure5 Limb movement

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88 Hutchinson, Kirkpatrick, Addison, et al

meeting held in October 1996 in Edinburgh. Inthe East Anglia Region the current guidelineshave been issued as memo-cards for A&Eofficers.The aim of admission is to observe for dete-

rioration, predominantly caused by intracranialhaematomas. The indicators for the develop-ment of such lesions are an impaired level ofconsciousness and presence of a skull fracture.Such patients should therefore undergo regularand frequent neurological observations, and beadmitted for at least 12 hours. Followingdischarge, routine follow up should be consid-ered to identify and treat patients withpostconcussion symptoms and signs.The possible way forward for the manage-

ment of these patients is adopting a greateremphasis on preventative aspects, and estab-lishing, implementing, and auditing evidencebased guidelines. Improved teaching in theform offormal induction seminars and compu-terised teaching aids is required, and a betterunderstanding of the aetiology and treatmentof the postconcussion syndrome.

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