Emergency Department Disposition for 13-Year-Old with Head Impact and Negative CT
A 13-year-old patient with a head impact and negative CT scan can be safely discharged home from the emergency department with appropriate discharge instructions and return precautions. 1
Primary Recommendation
Patients with isolated mild traumatic brain injury who have a negative head CT scan are at minimal risk for developing delayed intracranial lesions and may be safely discharged from the ED. 1 This is a Level B recommendation from the American College of Emergency Physicians (ACEP) guidelines, representing strong evidence that none of the patients with negative CT scans in multiple large prospective studies required subsequent neurosurgical intervention. 1
Evidence Supporting Safe Discharge
In a prospective study of 1,170 patients with mild TBI and negative CT who were admitted for 24-hour observation, none experienced neurologic deterioration. 1
A Class I randomized trial involving 39 hospitals and 1,292 mild TBI patients with negative CT scans found that none developed complications requiring hospital admission or surgery at 3-month follow-up. 1
A comprehensive literature review of over 62,000 mild TBI patients with Glasgow Coma Scale score of 15 identified only 3 definite cases of early adverse outcomes within 2 days. 1
Among pediatric patients specifically, 94.4% of concussion patients with negative CT were discharged within 24 hours, with only two hospitalizations beyond 24 hours actually related to the concussion itself. 2
Critical Discharge Requirements
Home Observation is NOT Recommended
Frequent waking or pupil assessment at home is not supported by the literature and is not recommended. 1 The evidence demonstrates that patients with negative CT scans are at extremely low risk for delayed deterioration, making intensive home monitoring unnecessary.
Mandatory Return Precautions
Patients and caregivers must receive both written and verbal instructions to return immediately for: 1
- Repeated vomiting
- Worsening headache
- Memory problems
- Confusion
- Focal neurologic deficits
- Abnormal behavior
- Increased sleepiness or loss of consciousness
- Seizures
Discharge Instructions Format
Instructions must be: 1
- Written at sixth- to seventh-grade reading level
- Provided in both print and verbal form
- Using type font no smaller than 12 points with wide margins and left justification
Postconcussive Symptom Education
All discharged patients must receive education about postconcussive symptoms, as this is a Level C recommendation from ACEP guidelines. 1 Provide written and verbal information about: 1
- Chronic headaches
- Dizziness and balance problems
- Nausea
- Vision problems
- Sensitivity to noise and light
- Depression, mood swings, anxiety, irritability
- Memory and concentration difficulties
- Sleep disturbances
- Persistent fatigue
Activity Restrictions
Patients experiencing postconcussive symptoms should: 1
- Refrain from strenuous mental or physical activity until symptom-free
- Take 2-3 days off work or school as needed
- Receive referral to a traumatic brain injury specialist if symptoms persist beyond 3 weeks or sooner if planning to return to sports
Important Caveats and Exceptions
High-Risk Populations Requiring Individualized Assessment
The evidence for safe discharge does NOT include patients with: 1
- Bleeding disorders
- Anticoagulation therapy (warfarin, DOACs)
- Antiplatelet therapy
- Previous neurosurgical procedures (e.g., ventriculoperitoneal shunt)
For these populations, admission or extended observation may be warranted despite negative CT, as there is inadequate data to support routine discharge. 1
Clinical Observation as Alternative Strategy
For pediatric patients with mild TBI (GCS 14-15), clinical observation in the ED before deciding on CT imaging is an effective strategy that reduces unnecessary radiation exposure without increasing missed injuries. 1 Every additional hour of ED observation was associated with decreased CT utilization rates without delay in diagnosing significant TBI. 1