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{ "pk": 14686, "title": "Management of Minor Traumatic Brain Injury in an ED Observation Unit", "subtitle": null, "abstract": "Introduction:\n Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress.\nMethods:\n This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention. \nResults:\n There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention. \nConclusion: \nPatients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.", "language": "en", "license": { "name": "Creative Commons Attribution 4.0", "short_name": "CC BY 4.0", "text": "Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\r\n\r\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.", "url": "https://creativecommons.org/licenses/by/4.0" }, "keywords": [ { "word": "Observation Medicine" }, { "word": "Traumatic Brain Injury" } ], "section": "Trauma", "is_remote": true, "remote_url": "https://escholarship.org/uc/item/2tp5c5rb", "frozenauthors": [ { "first_name": "Matthew", "middle_name": "A.", "last_name": "Wheatley", "name_suffix": "", "institution": "Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia", "department": "None" }, { "first_name": "Shikha", "middle_name": "", "last_name": "Kapil", "name_suffix": "", "institution": "Georgetown University School of Medicine, Department of Emergency Medicine, Washington, District of Columbia", "department": "None" }, { "first_name": "Amanda", "middle_name": "", "last_name": "Lewis", "name_suffix": "", "institution": "Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia", "department": "None" }, { "first_name": "Jessica", "middle_name": "", "last_name": "Walsh O'Sullivan", "name_suffix": "", "institution": "Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia", "department": "None" }, { "first_name": "Joshua", "middle_name": "", "last_name": "Armentrout", "name_suffix": "", "institution": "Atlanta Medical Center, Department of Emergency Medicine, Atlanta, Georgia", "department": "None" }, { "first_name": "Tim", "middle_name": "P.", "last_name": "Moran", "name_suffix": "", "institution": "Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia", "department": "None" }, { "first_name": "Anwar", "middle_name": "", "last_name": "Osborne", "name_suffix": "", "institution": "Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia", "department": "None" }, { "first_name": "Brooks", "middle_name": "L.", "last_name": "Moore", "name_suffix": "", "institution": "Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia", "department": "None" }, { "first_name": "Bryan", "middle_name": "", "last_name": "Morse", "name_suffix": "", "institution": "Maine Medical Center, Department of Surgery and Surgical Critical Care, Portland, Maine", "department": "None" }, { "first_name": "Peter", "middle_name": "", "last_name": "Rhee", "name_suffix": "", "institution": "Westchester Medical Center, Department of Surgery, Trauma Surgery, and Surgical Critical Care, Valhalla, New York", "department": "None" }, { "first_name": "Faiz", "middle_name": "", "last_name": "Ahmad", "name_suffix": "", "institution": "Emory University School of Medicine, Department of Neurosurgery, Atlanta, Georgia", "department": "None" }, { "first_name": "Hany", "middle_name": "", "last_name": "Atallah", "name_suffix": "", "institution": "Jackson Health System, Miami, Florida", "department": "None" } ], "date_submitted": "2020-10-26T23:04:31+05:30", "date_accepted": "2020-10-26T23:04:31+05:30", "date_published": "2021-07-16T07:19:52+05:30", "render_galley": null, "galleys": [ { "label": "", "type": "pdf", "path": "https://journalpub.escholarship.org/westjem/article/14686/galley/7482/download/" } ] }