Lit Matters 3: Can we help reduce long-term symptoms from mild TBI?

Mild traumatic brain injury is common in the ED, and persistent post-concussive symptoms remain hard to predict and harder to prevent. Current evidence supports the Canadian CT Head Rule for imaging decisions, safe discharge after a single negative CT in selected anticoagulated patients, and targeted follow-up rather than routine repeat testing.

Mild TBI risk stratification

• ACEP mild TBI definition: ACEP defines mild TBI as GCS 14-15, improving to 15 within 2 hours if initially 14, with or without loss of consciousness, amnesia, or disorientation, presenting within 24 hours of injury.
• Preferred head CT rule: The Canadian CT Head Rule carries the strongest ACEP recommendation for identifying adults with minor head injury who do not need CT, with NEXUS Head CT and New Orleans Criteria trailing in specificity.
• Anticoagulation decision-rule limitation: Clinical decision tools should not be used to rule out CT in patients taking anticoagulants or antiplatelet agents other than aspirin, a distinction that matters at the bedside and comes up in the episode.
• Single negative CT discharge: For anticoagulated or antiplatelet-treated patients with a normal exam and no hemorrhage on initial CT, routine repeat imaging, admission, and prolonged observation are not recommended.
• Post-concussion risk factors: Higher post-concussive symptom risk clusters around female sex, prior psychiatric history, GCS below 15, assault, intoxication, loss of consciousness, and pre-injury anxiety or depression.

What may improve outcomes

• Weak signal overall: The intervention literature is heterogeneous and noisy, with far more uncertainty than protocol-ready answers despite the frequency of mild TBI in emergency practice.
• Predictive model promise: Prediction tools showed the most consistent signal for identifying patients at highest risk of post-concussive syndrome, with recurrent features including prior TBI, headache, and memory impairment.
• Discharge instruction reality: Routine ED concussion instructions are often weak in both content and readability, while add-ons like booklets, videos, electronic handouts, and telephone counseling have not shown durable benefit.
• Rest versus exercise uncertainty: Advice on strict rest versus early exercise remains unsettled, with mixed study results rather than a clear winner. We get into the practical uncertainty in the chapter.
• Protocol and function findings: Observation-unit pathways mainly improved throughput metrics like shorter length of stay and fewer admissions, while one social-work intervention improved community functioning at 3 months.
• Immediate reinjury avoidance: The clearest practical message is that a second head injury during early recovery is bad, even as the rest of the prevention literature still offers more noise than signal.