An Under Appreciated Diagnosis: A Prospective Cross-Sectional Study Examining the Documented Evaluation and Management of Patients with a Possible Mild Traumatic Brain Injury at an Urban Level 1 Emergency Department Open Access

Abstract

Background: Annually, 2.5 million Traumatic Brain Injuries (TBI) occur with nearly 75% classified as mild TBI (mTBI), also known as a concussion. Mild TBI can be subtle, and detection requires a high index of suspicion and a regimented evaluation process. This study was done to determine the proportion of patients, at high risk for an mTBI, who were evaluated for an mTBI at a high volume urban academic trauma center.

 

Methods: A prospective cross-section of patients was identified using a 3-question screen at the time of triage: did an injury occur; was the mechanism consistent with mTBI; and was there a period of altered mental status. Patients who screened positive were thought to meet a minimum threshold for the evaluation of mTBI. Information about mTBI specific evaluation, management, and education was obtained from the patient’s charts.

 

Results: 38,621 patients were screened over 16 weeks, of whom 441(1.14%) were identified as being high risk for having an mTBI and met inclusion criteria. The most significant findings revealed that recommended portions of an mTBI specific evaluation occurred in fewer than 50% of the study population.In total, 98 were diagnosed with mTBI, and 49 received mTBI discharge instructions. Logistic modeling, for a subgroup of patients who had documented criteria sufficient for diagnosis, estimated that having isolated head injury increased a patient's odds of having a documented diagnosis by 2.1 times (95% CI 1.3 – 3.4).

 

Conclusions: Many patients with a possible mTBI did not have significant portions of an mTBI evaluation documented and roughly half of patients with a documented mTBI diagnosis did not receive discharge education. Changes in Emergency Medicine providers’ approach to mTBI must occur to increase the proportion of patients receiving an appropriate evaluation, management, and education.

Table of Contents

INTRODUCTION 1

BACKGROUND 3

Importance 7

METHODS 9

Specific Aims 9

Study Design and Setting 12

Selection of participants 13

Measurements 13

Outcomes 16

Analysis 17

RESULTS 19

Aim 1 19

Aim 2 20

Aim 3 20

Identification 20

Physical Exam and Management 21

DISCUSSION 22

Strengths and Limitations 22

Conclusion 23

REFERENCES 29

TABLES AND FIGURES 32

APPENDIX 41

About this Master's Thesis

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School	Laney Graduate School
Department	Clinical Research
Degree	M.S.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Medicine and Surgery
Keyword	Emergency Medicine mTBI Concussion
Committee Chair / Thesis Advisor	David Wright, Emory University
Committee Members	Mitch Klein, Emory University Beau Bruce, Emory University

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