Emergency

EMERGENCY MEDICINE PRACTICE
.
EMPRACTICE NET
AN EVIDENCE-BASED APPROACH TO EMERGENCY MEDICINE

Mild Traumatic Brain Injury:
What To Do When There Is
Nothing (Obviously) Wrong
It is 1:00 in the morning, and the ED is quite busy when paramedics roll through
the door with a woman who had tripped and fallen on the pavement, was temporarily “out for the count,” but now states that she isdoing okay. Your exam finds
the patient has a GCS of 15, with an unremarkable neurological examination. The
woman does admit to “having a few drinks” over the course of the evening, but she
is not clinically intoxicated. While the patient is getting dressed to go home, she
vomits once. She tells you that maybe she just drank a little too much, but feels better, and really has to be going soon,because her baby-sitter needs to get home. Both
the radiologist and CT technician are on call, but asleep at home.... Sound familiar?

I

T would seem there is hardly a shift that passes in which the emergency
physician does not encounter the dilemma of what to do with the patient
who has sustained a mild traumatic brain injury (TBI). The question of
whether to observe, discharge, or imageis addressed with each encounter,
yet there is considerable variation in the approach to this quandary amongst
practicing clinicians.1,2 Dramatic cautionary tales regarding patients who
“talk and die” abound, yet such occurrences are uncommon and frequently
based on no more solid literature than case reports. The emergency medicine
practitioner is charged with the task of quickly identifyingthe small subset
of head-injured patients who may harbor a potentially serious or lethal
intracranial lesion, while at the same time minimizing costs and excessive
diagnostics, and speeding ED throughput times.
A central question that must be addressed daily is which patients
with mild TBI need a CT scan. Experts in many fields argue from different
vantage points over this question, andsupporting literature can be found
to endorse a wide variety of approaches. Proponents of routine scanning
will argue that cranial CT scans, even in those with mild injury, show a
surprisingly high incidence of intracranial abnormalities that would not
have otherwise been detected. Alternatively, champions of selective scanning
readily acknowledge that, while a small percentage of patients mayindeed
Editor-in-Chief
Andy Jagoda, MD, FACEP,
Professor and Vice-Chair of
Academic Affairs, Department
of Emergency Medicine;
Residency Program Director;
Director, International Studies
Program, Mount Sinai School of
Medicine, New York, NY.

Associate Editor
John M Howell, MD, FACEP,
Clinical Professor of Emergency
Medicine, George Washington
University, Washington, DC;
Directorof Academic Affairs,
Best Practices, Inc, Inova Fairfax
Hospital, Falls Church, VA.

Editorial Board
William J Brady, MD, Associate
Professor and Vice-Chair,
Department of EM, University of

Virginia, Charlottesville, VA.
Peter DeBlieux, MD, LSUHSC
Professor of Clinical Medicine;
Director of Faculty and Resident
Development, LSU Health
Science Center, New Orleans,
LA.
Wyatt WDecker, MD, Chair
and Associate Professor,
Department of EM, Mayo Clinic
College of Medicine, Rochester,
MN.
Francis M Fesmire, MD, FACEP,
Director, Heart-Stroke Center,
Erlanger Medical Center;
Assistant Professor of Medicine,
UT College of Medicine,
Chattanooga, TN.
Valerio Gai, MD, Professor and
Chair, Department of EM,
University of Turin, Italy.

Michael J Gerardi, MD, FAAP,FACEP, Clinical Assistant
Professor, Medicine, UMDNJ;
Director, Pediatric EM,
Children’s Medical Center,
Atlantic Health System;
Department of EM, Morristown
Memorial Hospital, NJ.
Michael A Gibbs, MD, FACEP,
Chief, Department of EM, Maine
Medical Center, Portland, ME.
Steven A Godwin, MD, FACEP,
Assistant Professor and
Residency Director, Department
of EM, University of Florida HSC/...