Mild traumatic brain injury treatment [Neurosurgery Wiki]

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====== Mild traumatic brain injury treatment ======

===== Guideline =====
see [[Mild traumatic brain injury guideline]].


----



Admitting orders for minor head injury (GCS≥14)

1. activity: BR with HOB elevated 30–45°

2. neuro checks q 2 hrs (q 1 hr if more concerned; consider ICU for these patients). Contact physi-
cian for neurologic deterioration

3. NPO until alert; then clear liquids, advance as tolerated

4. isotonic IVF (e.g. NS+20 mEq KCl/L) run at maintenance: ≈ 100 cc/hr for average size
adult (peds: 2000 cc/m2/d). Note: the concept of “running the patient dry” is considered obsolete

5. mild analgesics: acetaminophen (PO,or PRifNPO),codeine if necessary

6. anti-emetic: give infrequently to avoid excessive sedation, avoid phenothiazine anti-emetics
(which lower the seizure threshold); e.g. use trimethobenzamide (Tigan®) 200 mg IM q 8 hrs PRN for adults
----

Even though admitting a patient with a [[mild traumatic brain injury]] (TBI) to the [[ICU]] might be the appropriate [[decision]] to ensure proper [[intervention]]s in the case of secondary neurological worsening, existing data do not support this
((Nishijima DK, Sena MJ, Holmes JF: Identification of low-risk patients with traumatic
brain injury and intracranial hemorrhage who do not need intensive care unit admission. The
Journal of trauma 70:E101-107, 2011))
((Washington CW, Grubb RL, Jr.: Are routine repeat imaging and intensive care unit
admission necessary in mild traumatic brain injury? Journal of neurosurgery 116:549-557,
2012)).

Because of the low risk of intracranial damage, a [[head computed tomography]] or hospital admission is not always necessary in these patients. To estimate the risk of intracranial abnormalities in mild TBI, various prediction rules and guidelines have been developed, for example the [[Canadian CT head rule]], National Institute for Health and Care Excellence (NICE) guidelines for head injury and [[CHIP prediction rule]]
((Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, McKnight
RD, Verbeek R, Brison R, Cass D, Eisenhauer ME, Greenberg G, Worthington J. The
Canadian CT Head Rule for patients with minor head injury. Lancet. 2001 May
5;357(9266):1391-6. PubMed PMID: 11356436.
))
((Smits M, Dippel DW, Steyerberg EW, de Haan GG, Dekker HM, Vos PE, Kool DR,
Nederkoorn PJ, Hofman PA, Twijnstra A, Tanghe HL, Hunink MG. Predicting
intracranial traumatic findings on computed tomography in patients with minor
head injury: the CHIP prediction rule. Ann Intern Med. 2007 Mar
20;146(6):397-405. PubMed PMID: 17371884.))
((Borg J, Holm L, Cassidy JD, Peloso PM, Carroll LJ, von Holst H, Ericson K; WHO
Collaborating Centre Task Force on Mild Traumatic Brain Injury. Diagnostic
procedures in mild traumatic brain injury: results of the WHO Collaborating
Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004 Feb;(43
Suppl):61-75. Review. PubMed PMID: 15083871.
)).


Implementation of a selective neurosurgical consultation policy reduced neurosurgical consultations without any impact on patient outcomes, suggesting that trauma surgeons can effectively manage these patients
((Overton TL, Shafi S, Cravens GF, Gandhi RR. Can trauma surgeons manage mild
traumatic brain injuries? Am J Surg. 2014 Apr 28. pii: S0002-9610(14)00179-2.
doi: 10.1016/j.amjsurg.2014.02.012. [Epub ahead of print] PubMed PMID: 24933668.
))
((Joseph B, Aziz H, Sadoun M, Kulvatunyou N, Tang A, O'Keeffe T, Wynne J, Gries 
L, Green DJ, Friese RS, Rhee P. The acute care surgery model: managing traumatic 
brain injury without an inpatient neurosurgical consultation. J Trauma Acute Care
Surg. 2013 Jul;75(1):102-5; discussion 105. doi: 10.1097/TA.0b013e3182946667.
PubMed PMID: 23778447.
)).

Patients with the constellation of [[traumatic subarachnoid hemorrhage]] and/or intraparenchymal hemorrhage IPH and mTBI do not require neurosurgical consultation, and these findings should not be used as the sole criteria to justify transfer to [[tertiary center]]s
((Ditty BJ, Omar NB, Foreman PM, Patel DM, Pritchard PR, Okor MO. The
nonsurgical nature of patients with subarachnoid or intraparenchymal hemorrhage
associated with mild traumatic brain injury. J Neurosurg. 2014 Dec 19:1-5. [Epub 
ahead of print] PubMed PMID: 25526270.)).

Since 2000, center's standard practice has been to obtain a repeat head computed tomography (CT) at least 6 hours after initial imaging. Patients are eligible for discharge if clinical and CT findings are stable. Whether this practice is safe is unknown.

Discharge after a repeat head CT and brief period of observation in the ED allowed early discharge of a cohort of mild TBI patients with traumatic ICH without delayed adverse outcomes. Whether this justifies the cost and radiation exposure involved with this pattern of practice requires further study
((Kreitzer N, Lyons MS, Hart K, Lindsell CJ, Chung S, Yick A, Bonomo J. Repeat
neuroimaging of mild traumatic brain-injured patients with acute traumatic
intracranial hemorrhage: clinical outcomes and radiographic features. Acad Emerg 
Med. 2014 Oct;21(10):1083-91. doi: 10.1111/acem.12479. PubMed PMID: 25308130.)).

===== Criteria for observation at home =====

1. head CT scan not indicated, or CT scan normal if indicated

2. initial GCS ≥ 14

3. patient is now neurologically intact (amnesia for the event is acceptable)

4. there is a responsible, sober adult that can observe the patient

5. the patient has reasonable access to return to the hospital E/R if needed

6. no “complicating” circumstances (e.g., no suspicion of domestic [[violence]], including [[child abuse]])
===== Research =====

[[Mild traumatic brain injury treatment Research]]