What is the recommended management for patients with mild traumatic brain injury (TBI)?

Management of Mild Traumatic Brain Injury

Patients with mild TBI (GCS 14-15) require selective CT imaging based on specific high-risk criteria, followed by observation protocols and structured discharge planning with clear return precautions. 1

Initial Assessment and Risk Stratification

Clinical Evaluation

• Assess severity using the Glasgow Coma Scale (GCS), documenting all three components (eye, verbal, motor) separately, along with pupillary size and reactivity. 1, 2
• Document history of loss of consciousness and duration of post-traumatic amnesia using validated tools when GCS is at ceiling (14-15). 3
• Record acute symptoms in patients with GCS verbal score of 4/5 using standardized rating scales. 3

CT Imaging Indications

Perform brain CT scan in mild TBI patients (GCS 14-15) if ANY of the following high-risk features are present: 1

• Signs of basilar skull fracture (rhinorrhea, otorrhea, hemotympanum, retroauricular hematoma [Battle's sign], periorbital hematoma [raccoon eyes])
• Displaced skull fracture
• Post-traumatic seizure
• Focal neurological deficit
• Coagulation disorders
• Current anticoagulant therapy

The French Society of Anaesthesia guidelines provide strong (Grade 1+) recommendations for these specific CT criteria, which effectively identify patients at risk for clinically significant intracranial injury. 1

Observation and Monitoring

Serial Neurological Assessment

• Monitor patients with frequent neurological checks: every 15 minutes for the first 2 hours, then hourly for 4-12 hours depending on risk level. 1
• Any decrease of ≥2 points in GCS or development of new neurological deficits mandates immediate repeat CT scanning. 1

Transcranial Doppler Monitoring

Consider TCD assessment in moderate-to-mild TBI patients, as elevated pulsatility index (PI) on admission predicts secondary neurological deterioration within the first week. 1

• Concerning thresholds: diastolic velocity (Vd) <25 cm/s or PI >1.25 indicate increased risk of deterioration. 1

Prevention of Secondary Brain Injury

Critical Physiological Parameters

Aggressively correct systemic factors that worsen outcomes: 1

• Maintain systolic blood pressure >110 mmHg - even brief episodes of hypotension (SBP <90 mmHg for ≥5 minutes) dramatically increase morbidity and mortality. 1
• Maintain oxygen saturation >90% - hypoxemia is associated with increased mortality and worse neurological outcomes. 1
• The combination of hypotension and hypoxemia carries a 75% mortality rate, making their prevention paramount. 1

Discharge Planning and Follow-up

Patient Education

Provide structured written and verbal instructions covering:

• Warning signs requiring immediate return (severe headache, repeated vomiting, seizures, weakness, numbness, confusion, drowsiness that cannot be awakened from)
• Expected symptom trajectory and recovery timeline
• Activity restrictions and gradual return-to-work/sport protocols

Follow-up Care

Arrange outpatient follow-up for persistent symptoms beyond 2 weeks, as cognitive rehabilitation may benefit patients with ongoing attention, memory, or executive function deficits. 4

Common Pitfalls to Avoid

• Do not use biomarkers (S100b, NSE, UCH-L1, GFAP) for routine clinical decision-making - while they correlate with outcomes, uncertainties in normal ranges and clinical thresholds preclude their routine use (Grade 2- recommendation). 1
• Do not perform routine repeat CT in mild TBI patients with negative initial CT and stable neurological examination - this exposes patients to unnecessary radiation without clinical benefit. 2
• Do not discharge patients on anticoagulation without extended observation or admission, as delayed hemorrhage risk is substantially elevated. 1
• Avoid missing subtle signs of basilar skull fracture, which mandate CT imaging even with normal GCS. 1

Special Considerations

Document injury mechanism, pre-existing comorbidities, age, frailty status, and social factors, as these biopsychosocial-environmental variables influence prognosis and recovery trajectory. 3

For patients requiring hospitalization despite "mild" classification, monitor disease progression over 14 days to fully characterize injury severity and guide rehabilitation planning. 3