Concussive Symptoms in Emergency Department Patients Diagnosed with Minor Head Injury

Background: Evidence-based protocols exist for Emergency Department (ED) patients diagnosed with minor head injury. These protocols focus on the need for acute intervention or in-hospital management. The frequency and nature of concussive symptoms experienced by patients discharged from the ED are not well understood. Objectives: To examine the prevalence and nature of concussive symptoms, up to 1 month post-presentation, among ED patients diagnosed with minor head injury. Methods: Eligible and consenting patients presenting to Kingston EDs with minor head injury (n = 94) were recruited for study. The Rivermead Post-Concussion Symptoms Questionnaire was administered at baseline and at 1 month post-injury to assess concussive symptoms. This analysis focused upon acute and ongoing symptoms. Results: Proportions of patients reporting concussive symptoms were 68/94 (72%) at baseline and 59/94 (63%) at follow-up. Seventeen percent of patients (18/102) were investigated with computed tomography scanning during their ED encounter. The prevalence of somatic symptoms declined between baseline and follow-up, whereas some cognitive and emotional symptoms persisted. Conclusion: The majority of patients who present to the ED with minor head injuries suffer from concussive symptoms that do not resolve quickly. This information should be incorporated into discharge planning for these patients.     

Tools for the Measurement of Outcome after Minor Head Injury in Children: Summary from the Ambulatory Pediatric Association/EMSC Outcomes Research Conference

This article summarizes discussions held during a conference on outcomes research in emergency medical services for children. It provides detailed information on existing outcome measures for pediatric minor head injury. Benefits and/or limitations in their applicability for use in pediatric emergency medicine and pediatric minor head injury research are highlighted.     

S100b Immunoassay: An Assessment of Diagnostic Utility in Minor Head Trauma

Background

Over 1.4 million patients present annually to United States (US) emergency departments with minor head trauma. Many undergo unnecessary head computed tomography (HCT).

Objectives

We sought to determine the diagnostic accuracy of S100B, a central nervous system peptide, to screen for HCT+ head injury.

Methods

This study was a prospective observational study of adults with minor head trauma. Patients presenting within 6 h of injury and undergoing HCT for evaluation were eligible. All HCTs were blindly reviewed for presence of a priori defined intracranial injury (HCT+). Quantitative S100B levels were determined by enzyme-linked immunosorbent assay.

Results

A total of 346 patients were enrolled over 12 months, mean age 48 years (± 23 years), 62% male. Twenty-two (6.4%) were HCT+. Vomiting, headache, anterograde amnesia, Glasgow Coma Scale score < 15, nausea, and loss of consciousness were associated with HCT+ results. Median S100B levels were significantly elevated in HCT+ (115 ng/dL) vs. HCT− (56.0 ng/dL) patients (p = 0.032). Receiver operator characteristic analysis demonstrated an area under the curve of 0.643. Sensitivity and specificity were 86% (95% confidence interval [CI] 67–96) and 37% (95% CI 29–45%) at 42 ng/dL, 91% (95% CI 72–98%) and 24% (95% CI 17–31%) at 32 ng/dL, and 96% (95% CI 78–100%) and 13% (95% CI 9–20%) at 24 ng/dL, respectively.

Conclusion

The study demonstrates that S100B may be a sensitive but non-specific marker of HCT+ injury.     

Failure of the Miller Criteria to Predict Significant Intracranial Injury in Patients with a Glasgow Coma Scale Score of 14 after Minor Head Trauma

Objective: To determine the utility of the Miller criteria (presence of headache, nausea, vomiting, and signs of depressed skull fracture) for predicting the need for CT in patients with minor head trauma and a Glasgow Coma Scale score (GCS) of 14.
Methods: The study was a prospective, consecutive series of all patients undergoing head CT scans with a GCS of 14 following head trauma. A data sheet was completed for all patients prior to obtaining a head CT scan.
Results: 264 patients were entered into the study and 35 patients were found to have traumatic abnormalities on head CT scan. The use of the Miller criteria to select those patients who would require head CT scan would have resulted in missing 17 of the 35 abnormal scans, including 2 patients who required neurosurgical intervention. These 2 patients were markedly intoxicated upon presentation.
Conclusion: The use of the Miller criteria as the only criteria for screening patients with a GCS of 14 after minor head trauma who require a head CT scan is not recommended. While the authors have identified ethanol intoxication as one confounding factor, further refinement of this risk-stratification tool is required.