Management of Minor Traumatic Brain Injury in an ED Observation Unit

Matthew A. Wheatley, MD; Shikha Kapil, MD; Amanda Lewis, MSSc, PA-C; Jessica Walsh O'Sullivan, MD; Joshua Armentrout, MD; Tim P. Moran, PhD; Anwar Osborne, MD, MPM; Brooks L. Moore, MD; Bryan Morse, MD; Peter Rhee, MD; Faiz Ahmad, MD; Hany Atallah, MD


Western J Emerg Med. 2021;22(4):943-950. 

In This Article

Abstract and Introduction


Introduction: Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress.

Methods: This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention.

Results: There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention.

Conclusion: Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.


Traumatic brain injury (TBI) is a frequent cause for emergency department (ED) visits. The US Centers for Disease Control and Prevention (CDC) estimated there were 2.5 million ED visits related to TBI in 2013, which represents an increase from 2007.[1] Traumatic brain injury is grossly classified as mild, moderate, and severe based on the presenting Glasgow Coma Scale (GCS) score with mild TBI (mTBI) defined as a GCS of 13–15.[2]

Clinical policies and decision tools exist to aid the emergency physician (EP) in deciding which patients with mTBI need brain imaging.[3,4] Once traumatic intracranial hemorrhages (TIH) are identified with head computed tomography (HCT), patients are typically admitted or transferred to a trauma center with neurosurgical capabilities. This can happen regardless of the size and location of the hemorrhage, or clinical condition of the patient. Inpatient care is typically in an intensive care unit (ICU) setting so that they can be monitored closely for clinical deterioration. In addition, patients routinely receive repeat HCT and neurosurgical consultation.[5]

Recent studies show routine follow-up HCT in many patients are not predictive of the need for neurosurgical intervention and this practice should be reserved for patients who demonstrate deterioration of neurologic exam.[6–9] Retrospective studies by Joseph et al have concluded that minor TIH patients have low risk of requiring neurosurgical intervention and, therefore, can be managed without neurosurgical consultation.[10,11] Multiple studies have examined the necessity of ICU admission for minor TIH. Patients with isolated traumatic subarachnoid hemorrhage have low rates of clinical and radiographic deterioration.[12–14] Other studies have suggested that patients with minor TIH largely do not receive critical care interventions and, therefore, do not benefit from ICU admission.[15,16] These are retrospective analyses with no universal definition of minor TIH. Hence, the question has come up about using ED observation units (EDOU) to monitor patients with minor TIH.[14,17]

In their 2015 validation of the Brian Injury Guideline (BIG) protocol, Joseph et al recommended up to 24-hour observation for patients with minor TIH without repeat HCT or neurosurgical consultation.[18] Minor TIH fits with other conditions commonly managed in the EDOU setting, as it is a single condition and patients can be managed in under 24 hours.[19] This allows the visits to be more focused, which leads to decreased length of stay (LOS) and decreased healthcare costs.[20–27] Randomized controlled trials (RCT) that have compared EDOU and inpatient care for conditions such as chest pain, asthma, atrial fibrillation, and transient ischemic attack have found EDOU care to be more efficient and cost effective.[28–36] Yun and colleagues have looked at managing patients with TIH in an EDOU setting where they performed a retrospective analysis of TIH patients before and after an EDOU protocol was implemented.[37] They reported that use of the protocol was associated with decreased need for admission and lower likelihood of worsening TIH on repeat CT. There was no difference in LOS in EDOU patients pre-protocol and during the protocol.

This study evaluates the outcomes of patients managed in the EDOU using an mTBI protocol based on BIG criteria.