Scope of Application
This guideline is intended for physicians working in emergency departments (EDs).

Inclusion Criteria
The guideline is intended for adults with blunt head injury (Q1/Q2), or adults diagnosed with mild traumatic brain injury or concussion (Q3).

Exclusion Criteria
This guideline is not intended for patients with a history of a bleeding disorder, pregnant patients, patients with a primary presentation of a seizure disorder, pediatric patients, patients with an obvious open or penetrating head injury, or patients with unstable vital signs with multisystem trauma.

Critical Questions

1. In the adult ED patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head CT?
   
   Level A Recommendation:
   
   Use the Canadian CT Head Rule (CCHR) to provide decision support and improve head CT utilization in adults with a minor head injury.
   
   Level B Recommendation:
   
   Use the National Emergency X-Radiography Utilization Study (NEXUS) Head CT decision tool (NEXUS Head CT) or the New Orleans Criteria (NOC) to provide decision support in adults with minor head injury; however, the lower specificity of the NEXUS Head CT and NOC compared with CCHR may lead to more unnecessary testing.
   
   Level C Recommendation:
   
   Do not use clinical decision tools to reliably exclude the need for head CT in adult patients with a minor head injury on anticoagulation therapy or antiplatelet therapy exclusive of aspirin.
   
   
   
2. In the adult ED patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head CT?
   
   Level B Recommendations:
   
   Do not routinely perform repeat imaging in patients after a minor head injury who are taking anticoagulants or antiplatelet medication and are at their baseline neurologic examination, provided the initial head CT showed no hemorrhage.
   
   Do not routinely admit or observe patients after a minor head injury who are taking anticoagulants or antiplatelet medications, who have an initial head CT without hemorrhage, and who do not meet any other criteria for extended monitoring.
   
   Level C Recommendations:
   
   Provide instructions at discharge that include the symptoms of rare, delayed hemorrhage after a head injury [CDC Adult Mild mTBI and Concussion] [CDC Adults mTBI]. (Consensus recommendation)
   
   Consider outpatient referral for assessment of both fall risk and risk/benefit of anticoagulation therapy [CDC Algorithm for Fall Risk Screening] [CDC Fall Prevention Materials] [CDC Stay Independent Brochure]. (Consensus recommendation)
   
   
   
3. In the adult ED patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome (PCS) or to identify patients with delayed sequelae after ED discharge?
   
   Level C Recommendations:
   
   Consider referral for patients with PCS and the following potential risk factors: female sex; previous preconcussive psychiatric history; GCS score <15; etiology of assault, acute intoxication; loss of consciousness; and preinjury psychological history such as anxiety/depression.
   
   Do not use current diagnostic tools (including biomarkers) to reliably predict which patients are at risk for PCS.
   
   Provide concussion-specific discharge instructions and selected outpatient referrals of patients at high risk for prolonged PCS. (Consensus recommendation)
   
   
   

Disclaimer
Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician's judgment and patient preferences.