Assessment of mTBI “Concussion” in the ED

The assessment of mTBI in the ED varies widely form patient to patient and depends largely on the experience of the attending clinician. A recent audit looking at minor head injury cases in my ED revealed no standardised assessment between patients and only 20% getting useful advice following discharge (more on that in my next post!).

So, what should we be asking and looking for when we assess a patient with a potential mTBI? I believe we can learn a lot in the ED from the world of Sports and Exercise Medicine, specifically how elite athletes with concussions are assessed and managed in their clubs. As with all conditions an accurate history of the event (mechanism) is crucial, followed by the symptoms they are now experiencing (headache, dizziness, nausea etc.). The patient’s past medical history including past concussion history should be elicited. The latter is really important when deciding on appropriate follow up.

When examining a patient with a suspected mTBI, I believe as a minimum we should be looking at assessing their cognition and concentration (immediate and delayed recall of words, reciting lists of numbers backwards or the months in reverse order etc.). We should also be performing a neurological examination (including an assessment of balance) on all of these patients. The absence of patient’s normal baselines to these tests could be considered a problem, but there is data available showing what would constitute a failed assessment in the general population without a baseline.

If the clinician’s experience plays such an important role in making a good assessment of mTBI, then it stands to reason if we create a standardised assessment tool that can be used on all patients with suspected concussion, this will take some of that need for experience away. Below is the assessment proforma we created and use in my ED.

One final thought. Currently there is no routine investigation that helps in the diagnosis of mTBI. CT scanning is almost always normal and MRI scanning whilst again likely to be normal is also hard to obtain quickly. Recently the first neuro biomarker tests (GFAP and UCH-L1) have been approved by the FDA in the US, this might help physicians in the diagnosis of mTBI . This has the potential to take some of the non-standardised assessment and clinician inexperience difficulties away in the ED.

Next up is how we should manage patients with potential concussions in the ED.