SYMPTOMS and DIAGNOSTIC FACTORS

• Common symptoms of a mild TBI include: fatigue , headaches , visual disturbances , memory loss , poor attention/concentration , sleep disturbances , dizziness/loss of balance , irritability-emotional disturbances , feelings of depression , and/or seizures.
• These symptoms may not be present or noticed at the time of injury. They may be delayed days or weeks before they appear. The symptoms are often subtle and are often missed by the injured person, family and doctors.
• Medicine defines a mild traumatic brain injury as a patient “who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following: 1) any period of loss of consciousness; 2) any loss of memory for events immediately before or after the accident; 3) any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused); and 4) focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following: a) loss of consciousness approximately 30 minutes or less; b) after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and c) post-traumatic amnesia (PTA) not greater than 24 hours.

PATIENT JOURNEY

• The person looks normal and often moves normal in spite of not feeling or thinking normal. This makes the diagnosis easy to miss. Family and friends often notice changes in behavior before the injured person realizes there is a problem. Frustration at work or when performing household tasks may bring the person to seek medical care.
• Mild TBI has been termed a “silent epidemic,” because many patients do not have visible physical signs. Rather, many patients possess disabling cognitive, psychological, and/or behavioral impairments and employment disabilities that are often unnoticed or misdiagnosed.
• Individuals seeking medical attention generally receive a standard history and physical exam. Further, imaging such as a head Computerized Tomography (CT) or possibly Magnetic Resonance Imaging (MRI) will usually be obtained if the patient has loss of consciousness, post traumatic amnesia, focal neurological deficits, physical signs of a skull fracture, or was involved in a dangerous mechanism of injury, or are older than the age of 65. The current diagnostic tests are neither sensitive nor specific enough to identify individuals who have sustained a mild TBI. Individuals therefore may not be receiving the proper diagnosis, and without a diagnosis, it is difficult to provide precise and appropriate clinical management. Accurate diagnosis would also be of immense assistance in distinguishing those that truly suffer from mild TBI sequelae as opposed to those with malingering symptoms.
• The current difficulty in the definitive diagnosis of mild TBI can be partly attributed to the fact that when patients are evaluated with imaging tests, it is done with CT or MRI, which are mainly aimed at identifying macroscopic lesions. However, these conventional imaging tests are limited in their capacity to assess microscopic white matter injury associated with DAI. DAI is caused by acceleration and deceleration forces or rotation forces acting on the head, leading to shearing of the brain tissue.
• Both the Both CDC and ACEP have developed a discharge instruction sheet and wallet card for patients. These materials help patients and caregivers to understand the facts about concussion, information on what to expect and post concussive symptoms, when to return to the emergency department and also include a customizable section for physician instructions.

LEADERS in DEVELOPING TREATMENT GUIDELINES

• The convened an expert panel to develop an Updated Mild Traumatic Brain Injury Management Guideline for Adults. This management guideline is based on ACEP’s 2008 Clinical Policy for adult mild traumatic brain injury (MTBI)External, which revises the previous 2002 Clinical Policy. The policy focuses on identifying neurologically intact patients who have potentially significant intracranial injuries, and identifying patients with risk for prolonged post concussive symptoms to ensure proper discharge planning.
• The CDC Pediatric mTBI Guideline consists of 19 sets of clinical recommendations that cover diagnosis, prognosis, and management and treatment. These recommendations are for healthcare providers working in: inpatient, emergency, primary, and outpatient care settings.
• The American Academy of Pediatrics (AAP) has developed new guidelines for mild traumatic brain injuries to help families understand the recovery process.