Chester County Medicine Summer 2018 - 10

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MILD TRAUMATIC BRAIN INJURY
BY RENÉE M. CASSIDY, MD, FAAP, FACP

@ReneeCassidyMD

Background
Traumatic brain injury (TBI)
may be defined as any disruption
to brain function caused by direct
contact or acceleration/deceleration
forces to the head. Concussion is
synonymous with the term mild
TBI. Mild TBI occurs following
biomechanical forces that cause a constellation of signs and
symptoms as a direct result of the trauma. Primary care physicians
and specialists in emergency medicine, sports medicine, and
neurology will not be surprised to find that traumatic brain injury
is common and increasing. The Centers for Disease Control and
Prevention (CDC) reports recent rates of combined emergency
department visits, hospitalizations, and deaths of 823.7 per
100,000 and available evidence suggests that numerous incidents
of minor head injury, for example 2/3 of health-care visits for
pediatric traumatic brain injury, are handled in outpatient visits.
Although surveillance is not as robust as the medical and public
health communities would like, efforts are underway to improve
data collection and prevention efforts. Sports-related concussions
were once thought to be nothing more than a "bump to the
head" or having your "bell rung" with no consequences. The
movie "Concussion" and news about TBI risk in many different
sports are beginning to increase awareness. However, the public
still seems unaware that a substantial number of head injuries are
caused by falls, motor vehicle collisions, military injuries, being
struck by objects, and other causes. Evidence-based prevention
efforts such as "A Matter of Balance" (a falls prevention program
for older adults) and broad public health efforts to decrease child
abuse, violence, motor vehicle collisions, and other causes of injury
and death can also be understood as TBI prevention efforts.

10 CHESTER COUNT Y Medicine | SUMMER 2018

Clinical Features
TBI is frequently categorized as mild, moderate, or severe
based on Glasgow Coma Scale scores of 13 to 15, 9 to 12, and
8 or less, respectively. Some experts feel that GCS scores of 13
show prognosis closer to moderate TBI and should be reclassified.
Moderate and severe TBI will generally be managed in the
emergency department and hospital settings and will not be
addressed in this article.
Children and adults have a lot of overlap in the signs and
symptoms of mild TBI. Anyone may have memory problems,
such as amnesia for the event; loss of consciousness; headache;
confusion; dizziness; nausea or vomiting; attention problems;
inappropriate emotions; or difficulty with speech, coordination,
or gait. Findings can appear immediately or over the minutes,
hours, or days following the injury. Numerous standardized
examinations have been developed to assist in the diagnosis of
mild traumatic brain injury, including Standardized Assessment
of Concussion, Westmead Post-traumatic Amnesia Scale, Sport
Concussion Assessment Tool, and many others. While these are
useful instruments to ensure thorough and consistent evaluation,
of course they are not a substitute for clinical judgement or a
replacement for a complete examination. When selecting an
evaluation to use in your practice, be sure to check the age groups
in which the tool has been studied. For example, the SCAT5 is
used for athletes ages 13 and up, and children ages 5 to 12 require
the Child SCAT5 version.

Do I need to order a CT scan of the head?
Concussions are not diagnosed using CT scans, but imaging
may be needed to evaluate for skull fractures, hematomas, or other
significant brain injury. Key historical factors help identify children
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