mTBI in the ED:
uncovering challenges
and opportunities

about-tbi
about-tbi
about-tbi

LONG-term consequences and what eds can do to improve outcomes

The Emergency Department is on the front line of mTBI.

The workload and accountability of TBI patient management lies predominately with the ED physician.1,2

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LONG-TERM CONSEQUENCES OF mTBI

mTBI CARE STRATEGIES 

HEAD INJURY NOMENCLATURE

 

Head injury nomenclature: “TBI”, “concussion”, and “post-concussion syndrome”

The terms “concussion” and “TBI” are often used interchangeably, both in medical literature and in clinical practice. Some clinicians may prefer the term “concussion” when communicating with patients and caregivers since it suggests a transient condition and avoids the stigma associated with brain damage or brain injury. 15,16

“mTBI” is described as a diagnosis made in the period immediately following injury from a traumatic event resulting in disruption of consciousness, memory, mental clarity, or other normal neurologic function. “Concussion” is often used to describe the constellation of signs and symptoms following such an injury. 16

 

Approximately one third of mTBI patients experience a variety of cognitive, emotional, psychosocial, and behavioral post-concussion symptoms. When a cluster of these symptoms persists for more than 3 months they are often classified as “post-concussion syndrome” (PCS).17

most tbi cases are mild and categorized by microscopic injury to nerve fibers

MOST ARE MILD
  • It has been reported that 94.5% of all TBI cases are mild.1
mTBI: associated with microscopic injury
  • Patients with mTBI rarely have intracranial hemorrhage; however, the absence of hemorrhage does not exclude TBI. Instead they are categorized by microscopic injury to nerve fibers.3,4
MORE SEVERE: acategorized by bruising and/or diffuse axonal injury 
  • More severe forms of TBI often involve bruising and/or diffuse axonal injury. Subdural or extradural hemorrhage and swelling in or around the brain may also occur.3

LONG-term consequences of mild tbi

The latest research on the clinical, social, and financial impact of TBI demonstrates many patients can have serious consequences from mild TBI, contradicting the common misconception that most TBI cases are resolved without long-term consequences.5,7
A SINGLE mTBI CAN LEAD TO PROLONGED OR PERMANENT FUNCTIONAL IMPAIRMENT
  • 52.8% of mTBI patients reported functional limitations at 12 months post-injury.7
  • Measurable structural changes to the brain can be present 1 year after a single concussive episode, even for mild injury.8
  • Patients who experience lingering functional deficits are at particular risk for emotional health difficulties.9
PATIENTS WHO HAVE SUSTAINED mTBI ARE AT RISK OF ANOTHER AND MAY TAKE LONGER TO RECOVER THE SECOND TIME10
  • Patients sustaining a second injury, particularly within weeks of the first, may be more vulnerable to serious consequences including death, even if the second impact is less intense.11
  • Degree of initial injury also affects outcome of second injury.
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THE NUMBER OF PREVALENT CASES OF TBI GLOBALLY WAS ESTIMATED TO BE 55.5 MILLION IN 201612
  • In the US, an estimated 5.3 million Americans are living with TBI-related disabilities, including long-term cognitive and psychological impairment.10,13
  • Some of the conditions associated with TBI are CTE (chronic traumatic encephalopathy), depression/MDD, anxiety, sleep disorders, and PTSD.10, 14

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ADVANCING mTBI CARE IN THE ED

Acute care Acute care Acute care

 

 

“Increased efforts are warranted to raise
ED clinician awareness of the importance of
follow-up care to prevent morbidity and
disability.” 5

-Seabury, et al

FOLLOW-up care and providing educational materials at discharge can improve long-term patient outcomes 

  • Providing educational materials to patients with mTBI is associated with improved outcomes.5
  • A number of studies support the efficacy of providing a clinical encounter soon (eg, 1 week) after injury to offer accurate and reassuring information about the expected symptoms and recovery course from mTBI.7
LEARN MORE ABOUT THE BARRIERS TO mTBI CARE IN THE ED

References: 
1.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.
2.Coronado VG, Haileyesus T, Cheng TA, et al. Trends in sports-and recreation-related traumatic brain injuries treated in US emergency departments: the national electronic injury surveillance system-all injury program (NEISS-AIP) 2001-2012. J Head Trauma Rehabil. 2015;30(3):185-197.
3.American Society of Neuroradiology Website. Available at: https://www.asnr.org/patientinfo/conditions/tbi.shtml [Accessed Sept 18, 2019].
4.Anon. Traumatic Brain Injury. Johns Hopkins Medicine Website. Available at: www.hopkinsmedicine.org/health/conditions-and-diseases/traumatic-brain-injury [Accessed Sept 13,2019].
5.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. 
6.Yue JK, Cnossen MC, Winkler EA, et al. Pre-injury comorbidities are associated with functional impairment and postconcussive symptoms at 3- and 6-months after mild traumatic brain injury: a TRACK-TBI study. Front Neurol. 2019;10:343.
7.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.
8.Zhou Y, Kierans A, Kenul D, et al. Mild traumatic brain injury: longitudinal regional brain volume changes. Radiology. 2013;267(3):880-890.
9.Zahniser E, Temkin NR, Machamer J, et al. The functional status examination in mild traumatic brain injury: a TRACK-TBI sub-study. Arch Clin Neuropsychol. 2019;34(7):1165-1174. 
10.Centers for Disease Control and Prevention (CDC) Website. Available at: https://www.cdc.gov/headsup/pdfs/providers/facts_about_concussion_tbi-a.pdf [Accessed Sept 18, 2019] and at https://www.cdc.gov/traumaticbraininjury/outcomes.html [Accessed June 3, 2020].
11.Bey T, Ostick B. Second impact syndrome. West J Emerg Med. 2009;10(1):6-10.
12.GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18:56-87.
13.Wang KK, Yang Z, Zhu T, et al. An update on diagnostic and prognostic biomarkers for traumatic brain injury. Expert Rev Mol Diagn. 2018;18(2):165-180.
14.Stein MB, Jain S, Gia JT, et al. Risk of posttraumatic stress disorder and major depression in civilian patients after mild traumatic brain injury: a TRACK-TBI study. JAMA Psychiatry. 2019;76(3):249-258. doi:10.1001/jamapsychiatry.2018.4288.
15.The Management of Concussion-mild Traumatic Brain Injury Working Group, VA/DoD Clinical Practice Guidelines for the Management of Concussion-Mild Traumatic Injury, Version 2.0, 2016
16.Sussman ES, Pendhark AV, Ho AL, et al. Mild traumatic brain injury and concussion: terminology and classification. Handbook of Clinical Neurology. 2018; Vol. 158, Chapter 3.
17.Voormolen DC, Cnossen MC, Polinder S. Divergent Classification Methods of Post-Concussion Syndrome after Mild Traumatic Brain Injury: Prevalence Rates, Risk Factors, and Functional Outcome. Journal of Neurotrauma. 2018; 35: 1233-1241.

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