Breaking
Through Barriers
IN mTBI Care

Research Has Identified Numerous Challenges Associated With Managing mTBI In The ED

Patient Assessment Challenges

Patient Assessment Challenges

  • Current tools not specifically targeted for mTBI assessment.
  • Reliance on CT to rule out injury.
Patient Care Challenges

Patient Care Challenges

  • mTBI can be associated with long-term functional impairments.1,2
  • Patients may receive limited education at discharge.3
  • Patients may not receive follow-up care.3

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CHALLENGES

9%

OF CT SCANS FOR PATIENTS WITH SUSPECTED TBI INDICATE INTRACRANIAL BLEEDING AND/OR SKULL FRACTURE.4

 

“The number of negative head CT scans represents
high-volume, high-cost, but low-value testing—not to
mention increasingly recognized radiation risk.”4
–  Korley et al. 

27%

OF mTBI PATIENTS WITH NORMAL HEAD CT SCANS HAD TRAUMA-RELATED ABNORMALITIES ON MAGNETIC RESONANCE IMAGES.5

 

“[CT-occult injuries] without significant hemorrhage but that nevertheless correlate with a range of clinical deficits… can cause chronic sequelae and impairment, and pose unique challenges to TBI diagnosis and severity stratification.”5
– Yuh et al.

REVIEWERS CAUTION AGAINST CT SCAN AS INDEPENDENT INDICATOR OF BRAIN INJURY7

Researchers advise that non-invasive tests based on physical signs—including identifying signs of brain injury on a CT scan—are not sufficiently sensitive to identify increased intracranial pressure (ICP) and should not be used independently to rule out the condition.

”Novel diagnostic tests are needed to improve ED diagnosis and management of TBI, offering the
potential to boost performance metrics without relying on head CT scans.”4
– Korley et al.
 

Current TBI Evaluation Options


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  • Low sensitivity or specificity
  • Designed to assess level of consciousness 
  • Can be impeded by several patient factors—eg, intoxication, shock, sedation
  • Limited capability beyond identification of vascular brain injury (hemorrhage) and incapable of identifying parenchymal injury associated with mTBI, including gliding contusions and axonal shear injury.5,6
  • 91% negative in TBI assessment.4
  • A head CT and related steps as part of mTBI evaluation in the ED takes 151 minutes which adds time to the visit and requires additional resources.10
  • Exposes patients to harmful radiation, effectively a dose of 2 mSv.
    • The radiation dose of head CT is equivalent to 100 times the radiation dose of a single skull X-ray. 11,12
  • Clinical decision rules (e.g. Canadian CT Head Rule (CCHR) New Orleans criteria, National Emergency X-Radiography Utilization Study II) were developed to help physicians determine which minor head injury patients need head CT imaging or neurological intervention.
  • With 95% sensitivity and 65% specificity for clinical significant head CT findings,13 the CCHR has been cited as the most researched clinical decision rule, with consistent performance enabling effective utilization for minor head injury patients.14
  • Despite expectations that CCHR adherence could substantially decrease CT use, studies reporting use of clinical decision rules, including the CCHR, reveal mixed findings and cannot be used with all patients:15-19
    • The CCHR did not eliminate imaging or increase diagnostic yield.18,19
    • The CCHR excludes patients on oral anticoagulation and anti-platelet agents.14

PATIENT CARE CHALLENGES

2019, JAMA NEUROLOGY: “Most patients with mTBI presenting to US level I trauma centers report persistent, injury-related life difficulties at 1-year postinjury, suggesting the need for more systematic follow-up of patients with mTBI to provide treatments and reduce the risk of chronic problems after mTBI.”1

  • More than half of patients with mTBI who present to the ED do not receive any TBI diagnosis.20
  • In addition, more than half (58%) of patients receive no educational materials at discharge from the ED.3
  • After injury, 56% of mTBI patients receive no follow-up care from a physician even when they experience post-concussive symptoms.3
     

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References: 
1. Nelson LD, Temkin NR, Dikmen S, et al. Recovery after mild traumatic brain injury in patients presenting to US level I trauma centers. JAMA Neurol. 2019;76(9):1049.
2. Zhou Y, Kierans A, Kenul D, et al. Mild traumatic brain injury: longitudinal regional brain volume changes. Radiology. 2013;267(3):880-890.
3. Seabury SA, Gaudette E, Goldman DP, 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 Netw Open. 2018;1(1):e180210.
4. Korley FK, Kelen GD, Jones CM, et al. Emergency department evaluation of traumatic brain injury in the united states, 2009–2010. J Head Trauma Rehabil. 2015;31(6):379-387.
5. Yuh EL, Mukherjee P, Lingsma HF, et al. MRI improves 3-month outcome prediction in mild traumatic brain injury. Ann Neurol. 2013;73(2):224-235. doi:10.1002/ana.23783.
6. Yue JK, Yuh EL, Korley FK, et al. Association between plasma GFAP concentrations and MRI abnormalities in patients with CT-negative traumatic brain injury in the TRACK-TBI cohort: a prospective multicentre study. Lancet Neurol. 2019;18(10):953-961. doi: 10.1016/S1474-4422(19)30282-0.
7. Anon. Individual non-invasive tests not sufficient to diagnose important complication of brain injury. BMJ Website. Available at: https://www.bmj.com/company/newsroom/individual-non-invasive-tests-not-sufficient-to-diagnose-important-complication-of-brain-injury/. [Accessed Sept 13, 2019].
8. Nurse.org. (2019). Understanding the Glasgow Coma Scale. Available at: https://nurse.org/articles/glasgow-coma-scale/. [Accessed Sept 18, 2019].
9. Moppett I. Traumatic brain injury: assessment, resuscitation and early management. Br J Anaesth. 2007;99(1):18-31.
10. Michelson EA, Huff JS, Loparo M, et al. Emergency department time course for mild traumatic brain injury workup. West J Emerg Med. 2018;19(4):635-640.
11. U.S. Food and Drug Administration. (2019). What are the Radiation Risks from CT? Available at: https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/what-are-radiation-risks-ct. [Accessed Sept 13,2019].
12. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357:2277-2284.
13. Bouida W, Marghli S, Souissi S, et al. Prediction value of the Canadian CT Head Rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multicenter external validation study. Ann Emerg Med. 2013;61(5): 521-527.
14. Harnan SE, Pickering A, Pandor A, et al. Clinical decision rules for adults with minor head injury: a systematic review. J Trauma. 2011;71:245-251. 
15. Melnick ER, Szlezak CM, Bentley SK, et al. CT overuse for mild traumatic brain injury. Jt Comm J Qual Patient Saf. 2011;38(11):483-489.
16. Sharp AL, Nagaraj G, Rippberger EJ, et al. Computed tomography use for adults with head injury: describing likely avoidable emergency department imaging based on the Canadian CT Head Rule. Acad Emerg Med. 2017;24(1):22-30.
17. Korley FK, Morton MJ, Hill PM, et al. Agreement between routine emergency department care and clinical decision support recommended care in patients evaluated for mild traumatic brain injury. Acad Emerg Med. 2013;20:463-469. 
18. Stiell IG, Clement CM, Grimshaw JM, et al. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. Can Med Assoc J. 2010;182:1527-1532.
19. Boyle A, Santarius L, Maimaris C. Evaluation of the impact of the Canadian CT Head Rule on British practice. Emerg Med J. 2004;21:426-428. 
20. Powell JM, Ferraro JV, Dikmen SS, et al. Accuracy of mild traumatic brain injury diagnosis. Arch Phys Med Rehabil. 2008;89:1550-1555.