A look at the evidence behind discharge instructions post mild head injury.

Juliette SacksPGY3, CCFP-EM Grand RoundsDecember 7, 2006

Objectives

Review the literature with respect to discharge instructions in the context of mild head injury

Assess how we are doing in clinical practice

Make some recommendations for improving our clinical practice

Epidemiology

~2 million head injuries per annum in US

80% are considered “mild” head injuries with GCS 13-15

5% of mild head injuries have abnormalities on neuroimaging

1% of these require acute neurosurgical intervention

Why be concerned?

Post mild head injury disability: Cognitive Psychological Physical Social

Leads to long-term disability and unemployment

50% suffer from post concussion symptoms at 1/12 and 15-25% at 1 yr post mild head injury

Second impact syndrome can potentiate symptoms and disability

Classification of Concussion in Sportfrom the Vienna and Prague International Conferences on Concussion in Sport (2001, 2004)

Categorized for management purposes as simple or complex

Simple:Injury resolves without complication over

7-10 daysNo role for formal neuropsychological

testingMental status screening Rest until asymptomatic and then a

gradual return to play recommended

Complex Concussion

Persistent symptoms at rest and with exertion

Specific sequelae:Concussive seizuresProlonged LOC >1 minuteProlonged cognitive impairment

Repeated concussions occur with less force Formal neurological and neuropsychological

testing required

SCATfrom the Vienna and Prague International Conferences on Concussion in Sport (2001, 2004)

Standardized assessment tool Combination of many of the existing

assessment modalities including:Maddocks questions: to test memory

and orientationStandard time, place, person testing is

unreliable in sporting situation Discharge advice included in tool

Post Concussion Advice as per SCAT

Post Concussion Advice from the Prague International Conference on Concussion in Sport Recovery rates vary: days – weeks – years Domains of speed of information processing, reaction

times, planning, disturbances of new learning and memory are all affected and take time to recover

Slowed thinking and inability to process information quickly leads to suboptimal performance and increased risk of reinjury

Should not drive Return to work dependent on job Education re expectations of recovery and possible post

concussion symptoms may reduce period of disability Clear management plan: work, school, driving, other

activities Full clinical and cognitive recovery prior to resumption of

sports Medical follow up required

So, what about discharge instructions to patients who have not incurred their head injuries from sports?

Can patients with minor head injury be safely discharged home?

Taheri et al. Arch Surg. Mar 1993; 128(3): 289-292. Review of 407 consecutive patients with head injuries in

regional trauma center 310 had GCS of 15/15 in ED All were admitted 5 had intracranial abnormalities requiring intervention

(skull fractures +/- neurological deficits) Discharge criteria:

GCS of 15 No deficit except amnesia No signs of intoxication No evidence clinically or radiologically of basilar fracture

Conclusion: safe discharge is possible and cost efficient No mention of discharge instructions

Minor head injury: predicting follow-up after discharge from the Emergency Department.Bazarian et al. Brain Injury. 2000;14(3): 285-294.

Prospective, observational study of mild head injury patients presenting to the ED in NY

70 patients with mild head injury (MHI) who arrived within 24h of injury and were later discharged from ED were included

MHI definition: blow to the head with brief loss of consciousness (<10 minutes) or amnesia, a GCS score of 15 at presentation in the ED, no focal neurological findings, no physical evidence of skull fracture.

Bazarian et al cont’d

Discharged from ED with written instructions to follow up in 1-2/52 with a doctor

Contacted at 1/12 to determine status of follow-up: 43.7% MHI vs 52.5% control group

3 factors were significant positive predictors of follow up: Female gender Laceration Head CT done in ED

African American race was a negative predictor for follow up

Why did they follow up?

Reasons +FU MHI (31)

Controls (31)

p

Thought it was important 51.6% 41.9% 0.45

Told to do so by ED discharge instructions

64.5% 83.9% 0.08

Still have symptoms 38.7% 61.3% 0.08

Insurance paid for visit 9.7% 6.5% 0.64

Reasons -FU MHI (12)

Controls (9)

Didn’t think it was important 41.7% 22.2% 0.6

Not told to do so by ED discharge instructions

41.7% 55.6% 0.67

Symptoms gone 75% 66.7% 1.00

Conclusion

Follow up may be influenced more by patient perception of injury than actual neurological injury itself

Suggested: Neurobehavioural testing (NBT): to demonstrate

degree of injury and predict post concussion syndrome (PCS)

Educate about MHI and PCS. Provide written instructions.

Have the patient see a consultant with whom they will follow up.

Telephone follow up for high risk patients. Community based MHI resource clinic for follow up.

Emergency department management of mild traumatic brain injury in the USA.Bazarian et al. Emerg Med J. 2005;22:473-477.

Using the National Hospital Ambulatory Medical Care Survey database (NHAMCS) for 1998-2000

Extracted from 70900 ED visits 878 for MTBI and 306 for isolated mild MTBI

Extrapolated that this meant 460000 visits for isolated MTBI in US with 153000/yr

Demographics: 58% male; mean age 21 years.

Assessed pain management, mental status, diagnostic tests and discharge instructions

Discharge Deficiencies

Recognition and characteristics of concussions in the emergency department population.Delaney et al. J Emerg Med. 2005;29(2):189-197.

Anonymous survey over 6/12 from ED 572/700 patients responded 20.1% had had symptoms of a concussion in

preceding 12 months after being hit in the head Of these 88.6% did not know they had had a

concussion 28.2% were engaging in an activity at high risk

for further head injury Conclusion: patients have a poor understanding

of concussion and its ramifications

A proposal for an evidence-based emergency department discharge form for mild traumatic brain injury.Fung et al. Brain Injury. 2006; 20(9):889-894.

Literature review to determine risk factors that were considered to be predictive for intracranial pathology or hemorrhage post MTBI

Include: GCS <15 Amnesia Headache Vomiting Neurologic deficit Seizure

Fung et al.

Rated discharge instruction sheets for patients with MTBI from 5 hospitals in Southern Ontario and 10 hospitals in Western New York

Rated by 2 reviewers for the inclusion of above mentioned predictors of neurologic complications

Rated for the readability and ability to be understood by general public

Results

Of 15 forms reviewed:One contained all 6 itemsGCS <15 and vomiting were included on

all 15 forms50-83% of 6 items were included in 14

formsAmnesia was least frequently included

There is no consensus on which factor is most predictive of neurological complications following MTBI.

Fung et al concluded that:

Patient discharge sheets are important because of the potential for deterioration post MTBI

Patients are given over to caregivers for observation

Of the forms reviewed, not one mentioned that observation of the patient was to monitor for neurological decline

Instructions need to be clear, precise and relevant

Suggested discharge form as per Fung et al.

Post-Concussion Syndrome

PCS is a clinical state as defined by DSM-IV where 3 or more symptoms persist for more than 3/12 post head injury

Headache, fatigue, memory deficits, anxiety and depression are common

Up to 50% of patients have symptoms at 1 year

Ability to predict those at risk for PCS would decrease long term disability, facilitate early intervention and return to work and decrease health care costs

Emergency department assessment of mild traumatic brain injury and prediction of post-concussion symptoms at one month post injury.Sheedy et al. J Clin Exp Neuropsych. 2006;28:755-772.

Australian study which investigated the ability to predict post-concussion symptoms using neuropsychological testing, balance deficits and pain severity as factors.

Small study: 29 concussed individuals and 30 controls Assessed in ED at presentation and then at 1/12 by

telephone 6 factors assessed:

Tests of immediate and delayed memory Speed of sentence comprehension Orientation Digit symbol substitution test Pain scores Balance scores

PCS prediction: Sheedy et al cont’d

Patients: were less oriented had impaired verbal recall slower speed of language comprehension and

information processing had short term memory deficits

Pain and balance deficits in ED correlated with post concussion symptoms at 1/12 post MHI: 92% sensitivity and 92% specificity

Limitations: small sample size, underpowered, not long enough to assess development of PCS

Complications of Concussion

Tonic posturing or convulsive movements within seconds of concussion; usually benign

Seizures: may occur days to months post MHI; require seizure management and prophylaxis

Second Impact Syndrome (SIS): Concussion with less force producing

symptoms in patient who remains symptomatic from prior MHI

Increased risk of persistent cognitive impairment and disability

Increased risk of intracranial abnormality with subsequent injury

CHR patient education sheet…for pediatrics only!

Your child should be seen right away if she/he shows any of the following signs:

Your child is younger than 6 months of age. There is a loss of consciousness. Any memory loss or unable to remember the event. Throwing up more than three times, or if he/she starts to throw up more

than 6 hours after the injury . Irritability or excessive crying more than 10 minutes after the injury, or is

unable to settle down. Seizures or convulsions. Complaining of a severe headache, blurred vision or slurred speech. Strange behaviour, like being confused, irritable, lethargic, or continues to

be sleepy, or is difficult to wake up from sleep. Neck pain. Swelling of the side of the head (temple) or behind the ear. Drainage of blood or fluid from nose or ears. In these situations, call 911 (if necessary) or go to the Emergency

Department.

The evidence suggests:

Discharge instructions post MHI are very important Best evidence for expectations of symptomatology,

duration, limitations and return to normal functioning come from Sports Medicine

Sports Medicine guidelines may not be transferable i.e. NBT resources and multidisciplinary team management is not readily available to general public

Need to include driving, return to work, cognitive and physical rest into education about MHI

Complications of MHI need to be discussed and follow up arranged

Written instructions in non-medical English is very important

Literature shows that the above may decrease disability and burden on health care system

More research is needed

How are we doing?

We are good at telling patients what symptoms are worrisome and should necessitate a return to the ED.

We are not so good at: explaining the meaning and importance of these signs

and symptoms discussing duration of symptoms, complications and

possible development of PCS and SIS giving explicit instructions re: return to work, driving,

activities Follow up:

We recommend following up with GP A dedicated clinic with access to neurobehavioral

testing and the ability to follow patients is postulated to reduce disability over time but is it practical?

Take home points:

1. Most MHI symptoms resolve in 7-10 days.2. Cognitive as well as physical rest is an important part

of the recovery.3. The impact of educating patients about concussions

and the need for medical follow up cannot be overstated.

4. Cognitive deficits may affect a patient’s ability to recall discharge instructions, therefore, written instructions should be clear, precise and easily understood.

5. Return to driving, work, activities should be addressed.6. Serious complications of MHI should also be reviewed

with patient and caregiver.

Thank you.

References

American College of Sports Medicine. Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement. Med Sci Sports Exerc. 2006;38(2)395-9.

Aubry M et al. Summary and agreement statement of the first International Conference on concussion in Sport, Vienna 2001. Br J Sports Med. 2002;36:6-10.

Bazarian JJ et al. Minor head injury: predicting follow-up after discharge from the Emergency Department. Brain Injury. 2000;14(3):285-294.

Bazarian JJ et al. Emergency department management of mild traumatic brain injury in the USA. J Emerg Med. 2005;22:473-477.

Canadian Academy of Sports Medicine Concussion Committee. Guidelines for Assessment and Management of Sport-Related Concussion. Clin J Sport Med. 2000;10:209-211.

Carson J et al. New guidelines for concussion management: based on the second International Conference on Concussion in Sport. Canadian Family Physician. 2006;52:756-7.

Delaney JS et al. Recognition and characteristics of concussions in the emergency department population. J Emerg Med. 2005;29(2):189-197.

Delaney JS, Frankovitch R. Discussion Paper: Head injuries and concussions in soccer. CASM 2004.

Fung M et al. A proposal for an evidence-based emergency department discharge form for mild traumatic brain injury. Brain Injury. 2006;20(9):889-894.

Haydel MJ et al. Indications for computed tomography in patients with minor head injury. NEJM. 2000;343(2):100-105.

References

McCrory P et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med. 2005;15(2):48-57.

McCrory P. What advice should we give to athletes postconcussion? Br J Sports Med. 2002;36:316-8.

Patel DR et al. Management of Sports-Related Concussion in Young Adults. Sports Med. 2005; 35(8):671-684.

Perry JJ, Steill IG. Impact of clinical decision rules on clinical care if traumatic injuries to the foot and ankle, knee, cervical spine and head. Injury, Int J Care Injured. 2006;37:1157-65.

Sheedy J et al. emergency department assessment of mild traumatic brain injury and prediction of post-concussion symptoms at one month post injury. J Clin Exp Neuropsych. 2006;28:755-772.

Steill IG et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in Patients with Minor Head Injury. JAMA. 2005;294(12):1511-8.

Steill IG et al. The Canadian CT Head Rule for patients with minor head injury. The Lancet. 2001;357(5):1391-6.

Taheri PA et al. Can patients with minor head injuries be safely discharged home? Arch Surg. 1993;128(3):289-292.

Return to Play Protocol

The athlete requires physical and cognitive rest in period post injury

Activities that require concentration may slow recovery and exacerbate symptoms

Stepwise process:1. No activity; complete rest. Once asymptomatic proceed

to (2)2. Light aerobic activity; no resistance training.3. Sport specific exercise.4. Non contact training drills5. Full contact training after medical clearance.6. Game play 7. If any symptoms occur, return to above level x 24h

before proceeding through the steps.

Bazarian et al cont’d

Exclusion criteria: Prior head injury requiring hospitalization Alcohol/drug use within last 24h Chronic alcohol/drug use Medical/psychiatric illness impairing cerebral

functioning Design:

25 minute neurobehavioural test battery 90 questions to establish baseline personal distress Educational, occupational, marital status data Perception of blame and intention to pursue

litigation

Bazarian et al.

Assessment of management included:Pain managementMental status examDiagnostic testsDischarge instructions

Delaney et al cont’d

Headache was most reported symptom Nausea > LOC was the symptom that caused patients

to seek out medical attention LOC lead most often to ED

What does it all mean?

So why are they watching the patient? For how long?

What is mental confusion? What does neurological deficits mean? What about waking the patient

throughout the night? Is the form easy to read and to

understand?