What is the recommended observation period in the Emergency Department (ED) for a patient with no apparent injury after an accident?

Observation Period for Patients with No Injury After an Accident

Patients with no apparent injury after an accident can be safely discharged from the Emergency Department after a 6-hour observation period if they have a normal clinical examination. 1

General Observation Guidelines

• For patients with mild traumatic brain injury (TBI) who present within 24 hours of injury with a Glasgow Coma Scale (GCS) score of 14-15, a 6-hour observation period is recommended if they have a normal clinical examination and a head CT scan that does not demonstrate acute injury 1
• Patients can be discharged after a shorter period of observation if they are under the care of a responsible third party who can monitor them 1
• For patients with severe abdominal injuries (AIS ≥3) treated non-operatively, observation for at least 24 hours in a unit with continuous monitoring is recommended, followed by clinical and biological observation for a minimum of 3-5 days 1

Observation Period Based on Injury Type

Head Trauma

• Patients with mild TBI (GCS 14-15) who have a normal neurologic examination and a normal head CT scan can be safely discharged after 6 hours of observation 1
• Patients with risk factors for deterioration (headache, vomiting, age >60 years, drug/alcohol intoxication, short-term memory deficits, physical trauma above the clavicle, or seizure) require closer monitoring 1
• The Canadian CT Head Rule allows for a period of 2 hours for normalization of the GCS score before deciding on imaging 1

Abdominal Trauma

• For severe abdominal injuries treated non-operatively, admission to a facility with 24/7 capacity to perform emergency laparotomy is recommended for at least the first 24 hours 1
• Most hemorrhagic complications occur within the first 5 days following trauma, with the risk being highest in the first 24 hours 1
• For splenic trauma specifically, 95% of delayed splenic bleeding occurs within the first 72 hours 1

Special Considerations

• Patients at risk of intra-abdominal pressure elevation should have their intra-abdominal pressure monitored to detect abdominal compartment syndrome early 1
• Patients with mild TBI are at risk for developing cognitive, psychosocial, and neurobehavioral abnormalities even with a normal head CT scan and GCS score of 15 1
• The average time for measuring and recording vital signs is approximately 5 minutes per set, which should be factored into staffing and workflow planning for observation periods 2

Common Pitfalls

• Discharge instructions are often poorly remembered by patients with mild TBI, with 23% unable to recall any instructions 1
• Patients admitted for observation of TBI often do not receive the intended monitoring, with studies showing only 50% of admitted patients had documented serial neurologic examinations 1
• Assuming that all patients with normal initial assessments are at low risk - up to 1.5% of patients with GCS 15 may deteriorate, with 57% of these deteriorations occurring within the first 24 hours 1

Return Precautions

• Patients should return immediately if they experience difficulty breathing, swallowing, lightheadedness, dizziness, syncope, or palpitations 3
• For head injury patients, return precautions should include worsening headache, vomiting, confusion, or unusual drowsiness 1

The 6-hour observation period represents a balance between patient safety and resource utilization, allowing sufficient time to detect most serious complications while avoiding unnecessary extended stays in the ED.