Concussive Symptoms in Emergency Department Patients Diagnosed with Minor Head Injury

doi:10.1016/j.jemermed.2008.08.017

The Journal of Emergency Medicine

Volume 40, Issue 3, March 2011, Pages 262-266

https://doi.org/10.1016/j.jemermed.2008.08.017 Get rights and content

Abstract

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.

Introduction

Patients with minor head injury commonly present to the Emergency Department (ED). Minor head injuries are common in all age groups, accounting for 85% of all brain injuries (1). These injuries are debilitating and costly to the victims and to the medical care system (2, 3).

Clinical management of minor head injuries in the ED has been the subject of recent study (4). Efforts to improve ED treatment protocols for the head-injured patient include formulation of clinical decision rules to identify patients who require imaging, hospitalization, or neurosurgical intervention (5). In addition, consensus-based clinical practice guidelines for the management of minor head injuries in the ED have been developed (6). These initiatives focus on acute medical diagnosis, emergency treatment, and evidence-based decisions surrounding patient disposition (4, 5, 6). However, after acute and life-threatening events are ruled out, patients are often discharged without specific plans for follow-up care (4, 5, 6). Little is known about the disabling effects of minor head injuries seen in EDs beyond the acute medical encounter.

Epidemiological and neuropsychological studies suggest the persistence of a range of concussive symptoms in the weeks and months after minor head injury, including cognitive, physical, and emotional or behavioral effects (7, 8, 9, 10, 11, 12, 13). This evidence comes from the concussion literature and has been observed in patients in other clinical settings (e.g., sports medicine, neurology) (14, 15). In Canada, the annual incidence of patients who are treated in a hospital or clinic for minor head injury each year is 150 per 100,000 population (16). Similar annual rates have been reported for the United States (130 per 100,000), the United Kingdom (200–300 per 100,000), and for multiple countries by the World Health Organization (100–300 per 100,000, with higher rates among teenagers and adults) (16, 17, 18, 19, 20). The prevalence of reported post-concussive symptoms ranges from 34% to 84% in studies that followed patients for 3 months to 1 year (21, 22). Few clinical studies have investigated the frequency and severity of post-concussive symptoms in general populations of ED patients.

In this study, we prospectively followed a series of patients diagnosed with minor head injury who presented to the general EDs in Kingston, Ontario. Our objective was to describe the prevalence and patterns of concussive symptoms reported up to 1 month post-presentation.

Section snippets

Clinical Setting

The study population consisted of consecutive patients diagnosed with minor head injury (Glasgow Coma Scale [GCS] score of 15) presenting to either of the two EDs serving the city of Kingston, Ontario, Canada. Minor head injury was defined conceptually as any acute traumatic head injury with a transient loss of brain function (see operational definition below). Patients were enrolled at the Kingston General Hospital or Hotel Dieu Hospital between October 2005 and April 2006. Both are large,

Sample

There were 163 potential subjects identified during the recruitment period. Forty-one could not be contacted within 72 h, 8 had untraceable telephone numbers or addresses, 2 had language barriers that limited communication, and 10 refused participation. A total of 102 participants completed the baseline interview; of these, 8 were lost to follow-up at the second interview, leaving a total of 94 completed patient files. Table 1 describes demographic and injury-related characteristics of these

Discussion

The major finding from this prospective case series is that large proportions of patients discharged from EDs with a diagnosis of minor head injury continued to experience a range of concussive symptoms at 1 month post-injury. Most of these patients were discharged from the ED with no referral for follow-up care. Somatic symptoms of headache, fatigue, and dizziness were highest in frequency, and other types of cognitive and emotional symptoms persisted. Minor head injury, therefore, should be

Conclusion

This prospective case series demonstrates that most patients who present to the ED with minor head injury suffer from a range of concussive symptoms that do not resolve quickly. This fact may not be widely recognized by health care professionals who provide acute care to these patients. The high likelihood of ongoing concussive symptoms should be incorporated into discharge planning and instructions for these patients.

Acknowledgments

We thank Kathy Bowes and Fenni Loye of the Department of Emergency Medicine, Queen's University for data collection efforts.

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If the sport-related concussion patient has already experienced concussions, the emergency physician should introduce the idea that continued exposure to head impacts might be dangerous for long-term neurologic health. Multiple studies have demonstrated variability or inadequacy of ED discharge instructions for patients with concussion,91-96 as well as poor compliance with recommendations.97,98 Discharge instructions have been shown to be maximally effective when they provide educational material about expected postconcussion symptoms, guidelines for return to activity, time-frame for follow-up, and recommendations for when to seek specialist care.96
Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.
Neurosensory diagnostic techniques for mild traumatic brain injury
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Though the neuropsychological symptoms and signs of mild traumatic brain injury (mTBI) are mostly subtle and transient, the sequelae can be persistent even after mTBI. Thus, it is important to raise the possibility of the diagnosis of mTBI among the patients complaining vague neurosensory symptoms; however, current research investigating the diagnosis/screening of mTBI has yet to produce accepted diagnostic criteria and no single assessment can identify all mTBI patients. Recently, a multifaceted approach to mTBI, focusing on the use of objective assessment tools to obtain information about clinical symptoms, signs, cognitive dysfunction, and physical problems has been employed. It is not recommended to diagnose mTBI or monitor the recovery solely with cognitive and balance evaluation. However, these measures can be used in conjunction with clinical examinations and a symptom checklist. This section reviews the update of screening tools for the diagnosis of mTBI in the literatures.
A population-based study of sport and recreation-related head injuries treated in a Canadian health region
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This proportion is higher than that reported by a previous study in the same health region where 24% of HIs were due to SR-activities7; however, the present study included more severe HIs (i.e., haemorrhage). Other studies, which have limited inclusion to school aged children15 and minor head injuries16 have reported that 32% and 42% of HIs are due to SR-activities, respectively; however, direct comparisons between these studies are cautioned due to different inclusion criteria. A small number of SR-activities (e.g., hockey, cycling, skiing/snowboarding/sledding, soccer, and football) accounted for 59% of the SR-HIs treated in EDs.
To report the rates of SR-related HIs presenting to EDs in a Canadian population-based sample.
Descriptive epidemiology study.
Using administrative data, sport and recreation-related emergency department presentations for persons 0–35 years of age, from April 1997 through March 2008, were obtained from the Edmonton Zone (formerly the Capital Health Region), Alberta Health Services through the Ambulatory Care Classification System.
Of the 3,230,890 visits to the emergency departments of the five hospitals in Edmonton, 63,219 sport and recreation-related injury records and 4935 sport and recreation-head injury records were identified. Head injuries were most frequently treated for the activities of hockey (20.7%), cycling (12.0%), and skiing/snowboarding/sledding. Males accounted for 71.9% (n = 3546) and patients less than 18 years of age sustained 3446 (69.8%) sport and recreation-head injuries.
Sport and recreation-related head injuries most frequently treated in emergency departments involve common activities such as hockey, cycling, skiing/snowboarding/sledding, and soccer. Males and those less than 18 years of age sustain the majority of sport and recreation-related head injuries treated in emergency departments. These findings underscore the importance of sport-specific policies and safety promotion for the prevention of head injuries, in sports and recreational activities.
Risk of suicide after a concussion
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We distinguished each case as a weekend concussion (midnight Friday to midnight Sunday) or a weekday concussion (remaining 5 days and nights of the week).50 Differentiating a weekend from a weekday concussion was based on the date of medical care, which closely corresponds to the date of injury.51,52 For patients with multiple concussions, we used the date of the first concussion, such that each person was counted once in the analyses; repeat concussions were tracked for separate secondary analyses.
Head injuries have been associated with subsequent suicide among military personnel, but outcomes after a concussion in the community are uncertain. We assessed the long-term risk of suicide after concussions occurring on weekends or weekdays in the community.
We performed a longitudinal cohort analysis of adults with diagnosis of a concussion in Ontario, Canada, from Apr. 1, 1992, to Mar. 31, 2012 (a 20-yr period), excluding severe cases that resulted in hospital admission. The primary outcome was the long-term risk of suicide after a weekend or weekday concussion.
We identified 235 110 patients with a concussion. Their mean age was 41 years, 52% were men, and most (86%) lived in an urban location. A total of 667 subsequent suicides occurred over a median follow-up of 9.3 years, equivalent to 31 deaths per 100 000 patients annually or 3 times the population norm. Weekend concussions were associated with a one-third further increased risk of suicide compared with weekday concussions (relative risk 1.36, 95% confidence interval 1.14–1.64). The increased risk applied regardless of patients’ demographic characteristics, was independent of past psychiatric conditions, became accentuated with time and exceeded the risk among military personnel. Half of these patients had visited a physician in the last week of life.
Adults with a diagnosis of concussion had an increased long-term risk of suicide, particularly after concussions on weekends. Greater attention to the long-term care of patients after a concussion in the community might save lives because deaths from suicide can be prevented.
Diagnostic performance of S100B as a rule-out test for intracranial pathology in head-injured patients presenting to the emergency department who meet NICE Head Injury Guideline criteria for CT-head scan
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: This study was supported by the Canadian Hospital Injury Reporting and Prevention Program (RJ Brison, Kingston medical director) funded by the Child Injury Section of the Public Health Agency of Canada; and the Ontario Neurotrauma Foundation (Grant # 2003-PREV-MS-03).

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Original contributionConcussive Symptoms in Emergency Department Patients Diagnosed with Minor Head Injury

Abstract

Introduction

Section snippets

Clinical Setting

Sample

Discussion

Conclusion

Acknowledgments

Six-month recovery from mild to moderate traumatic brain injury: the role of the APOE-e4 allele

Brain

Mild traumatic brain injury: the silent epidemic

Can J Public Health

The incidence and economic burden of injuries in the United States

Emergency department management of mild traumatic brain injury in the USA

Emerg Med J

Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and economic analysis)

Ann Emerg Med

Critical evaluation of the existing guidelines on mild traumatic brain injury

J Rehabil Med

Outcomes following childhood head injury: a population study

J Neurol Neurosurg Psychiatry

Neurobehavioral outcome following minor head injury: a three-center study

J Neurosurg

Neuropsychological and psychosocial consequences of minor head injury