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A prospective cross-sectional study examining the documented evaluation of patients at high risk for mild traumatic brain injury

The American Journal of Emergency Medicine Mar 02, 2020

Zalesky CC, Moran TP, Koval RR, et al. - Via this study, researchers investigated the proportion of patients, who were deemed high risk for a mild traumatic brain injury (mTBI), that had documentation of an mTBI evaluation. Using a 3-question screen, they identified a prospective cross-section of patients at the time of triage: did an injury occur; was the mechanism consistent with mTBI; and was there a period of altered mental status. Screening of 38,621 patients was done over 16 weeks; of these, 441 (1.14%) were identified as being high risk for having an mTBI and met inclusion criteria. No mTBI evaluation documentation was identified in fewer than half of high-risk patients. mTBI discharge instructions were not provided to nearly half of patients diagnosed with an mTBI. Having an isolated head injury raised the odds of diagnosis by 2 times.
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