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Minor Traumatic Brain Injury


Partnership with Trauma Surgery with respect to ownership of patients is essential in this pathway



Transfer Criteria

  • Meets BIG 1 criteria (see table)
    • Normal neurological examination
    • Not clinically intoxicated
    • Not on anticoagulation (including Aspirin, Clopidogrel, Warfarin, Enoxaparin or DOACs)
    • Preliminary read of non-contrast head CT with
      • No skull fracture
      • No Epidural Hematoma or Intraventricular Hemorrhage
      • Subdural Hematoma </= 4mm
      • Intraparenchymal hemorrhage </= 4mm in 1 location only
      • Trace subarachnoid hemorrhage only
  • Patient has spine cleared or is in Aspen Collar and is able to ambulate without assistance
  • No other traumatic injuries that need continued evaluation or treatment. Splinted extremities are acceptable provided the patient is able to ambulate
  • Pt not having intractable pain/vomiting
  • Stable vital signs
  • Consultation in ED by Trauma Surgery and Neurological Surgery teams as deemed appropriate by ED attending

Exclusion Criteria

  • Failure to meet even 1 aspect of BIG 1 criteria
    • Evidence of clinical intoxication
    • Any anticoagulation
    • Presence of skull fracture, Epidural Hematoma or intraventricular hemorrhage
    • More than trace Subarachnoid Hemorrhage
    • Subdural or Intraparenchymal hemorrhage > 4mm
  • Other injuries that still need evaluation/treatment
  • Inability to ambulate
  • Intractable pain/vomiting
  • Unstable vital signs (persistent tachycardia; tachypnea; hypotension)
  • Other indications for admission

Potential Interventions

  • Serial neurologic exams including vital signs every 2 hours
  • 6-23 hour observation for change in neurological status
  • Advance diet as tolerated
  • Antiemetics/analgesics as needed
  • Repeat CT scan as indicated

Decision Points/Acute Interventions

  • STAT repeat CT head and call to neurosurgery and trauma residents on call for
    • Decreased mental status
    • Seizure
    • Focal neurologic deficits
  • STAT trauma evaluation for:
    • Development of abnormal vital signs
    • Intractable pain
    • Inability to ambulate

Discharge Criteria

Home

    • Acceptable VS
    • Normal serial neurologic exams
    • Tolerating diet
    • Able to ambulate and perform ADLs without assistance


Admit

    • Deterioration in clinical condition
    • Development of any exclusion criteria – including over read of initial CT head that includes BIG 2 or 3 criteria




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