The levels of evidence (Class I-IV) supporting the recommendations and levels of recommendation (Level 1-3) are defined at the end of the "Major Recommendations" field.
Scope of the Problem
Definition of Mild Traumatic Brain Injury (MTBI)
Currently there is no definition for MTBI that is agreed upon internationally and across disciplines. For the most part, MTBI and concussion are used synonymously (Level 3), including in this guideline. Nurses should take an active part in the consensus work needed to continue to work toward a common definition of MTBI.
Epidemiology
The true incidence of MTBI is not known due to the lack of an agreed upon definition that is accepted internationally and across disciplines for the purposes of case finding. Well-designed multidisciplinary research is needed for a more complete understanding of the epidemiology of MTBI (Level 3).
Prevention
Health promotion efforts have been shown to successfully reduce the incidence of TBI (Level 2). Well-designed nursing research is needed to compare and test efficacy of translating these health promotion efforts to prevent MTBI (Level 3). For example, a comparison of face-to-face and online teaching methodologies has not been done.
Repetitive Injury
Nurses should include the effects of repeat concussions in discharge teaching following concussion (Level 2). Better designed nursing research is needed to compare and test methods of preventing repetitive injury (Level 3).
Review of Diagnostic Studies
Noncontrast Computed Tomography (CT) — Indications for Imaging
A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, Glasgow Coma Scale (GCS) score less than 15, focal neurologic deficit, or coagulopathy (Level 1; Jagoda et al., 2008).
A noncontrast head CT should be considered in a head trauma patient without loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury, including ejection from a motor vehicle, a struck pedestrian, and a fall from a height of more than 3 feet or 5 stairs (Level 2; Jagoda et al., 2008).
Children
CT scans should be protocolized to minimize the exposure of children to radiation (Level 2). Follow CHALICE criteria for pediatric patients 2 years of age or older (see Table 1 in the original guideline document); further work is needed to develop evidence-based criteria for CT scans for children under 2 years old (Level 2).
Magnetic Resonance Imaging (MRI)
With the development of new MRI techniques, earlier diagnosis of patients with clinically significant lesions could lead to earlier implementation of new medical and neuropsychological interventions for the prevention and treatment of post-concussive symptoms (PCS), learning disorders, and psychiatric conditions (Level 3).
Assessment and Monitoring
Timing
The guideline panel recommends an initial assessment, repeated hourly until the patient returns to baseline. Any decrease in neurologic status should prompt more frequent neurologic assessment and notification of the physician. Symptoms may not be resolved at the time of discharge from the emergency department (ED) or hospital; however, neurologic status should have returned to baseline prior to discharge. For most, this will be GCS 15, full motor strength, and being alert and oriented with no focal deficits. Further research is required to establish a clear timing frequency of assessments for concussion (Level 3).
Components of Assessment
Nurses should be alert for "red flags": altered consciousness, declining neurologic examinations, abnormal pupil response, seizures, vomiting, vision changes, worsening headache, disorientation, confusion, irritability, slurred speech, balance disturbance, and numbness or weakness in arms or legs (Level 3; Department of Veterans Affairs & Department of Defense, 2009).
- Assessment of balance to identify postural stability deficits is recommended (Level 3; McCrory et al., 2009). This testing is an advanced practice assessment; however, registered nurses should be aware of balance disturbances, observe patients getting up and walking, and ensure safety. Formal assessment of balance by advanced practice nurses, physicians, or rehabilitation specialists can be performed at the bedside and monitored with serial examinations when difficulties with balance are identified.
Fatigue and sleep difficulties as well as pain level and severity should be assessed on an ongoing basis (Level 2). Establishing baseline symptom experience and monitoring for symptom resolution is helpful for monitoring treatment response (Level 3).
Assessment Tools
Nurses caring for persons with concussion should be proficient at performing neurologic examinations, with reevaluations as indicated to detect improvement of decline in neurologic status following a concussion. Nurses should assess for post-concussive symptoms and educate patients and family about their presence and expected trajectory. Use of a single assessment measure for MTBI is not currently supported, but these assessment tools may be helpful for monitoring progress or decline in status. No specific symptom assessment tool is supported in the literature at this time; however, incorporating a standardized measure into practice may be helpful to not miss subtle symptoms during assessment. Nurses should be aware of neuropsychological and neurocognitive testing that is available in order to educate patients about resources that are available should the patient need further testing and treatment (Level 3).
Patient Problems
Acute Problems
Posttraumatic Headaches
Nursing assessment or patient headache log should include (Level 3; Lew et al., 2006):
- Site of head injury and location of headache pain
- Pain radiation
- Type of pain (e.g., pulsating, dull, aching, sharp, etc.).
- Severity
- Duration
- Pain levels (e.g., Visual Analog Scale)
- Precipitating factors
Fatigue, Exhaustion, or Lack of Energy
Nurses should monitor drowsiness and fatigue in the acute period following injury as possible signs of central nervous system (CNS) deterioration (Level 3; Formisano, 2009). Nurses should also be aware of and assess for secondary causes of fatigue, including sleep disorders, pain, depression, anxiety, lifestyle, and medication side effects, all of which have been associated with a reduced tolerance for physical and mental activity (Level 2; Bushnik, Englander, & Wright, 2008).
Sleep Disturbance
Nurses should assess for sleep disturbance following MTBI (Level 2). Nurses can play a critical role in providing sleep hygiene education and, when appropriately trained, may be providers of cognitive behavior therapy for insomnia (CBT-I) as indicated.
Posture and Balance
Nurses should assess and document postural stability in the ED and on an ongoing basis post-injury (Level 2).
Chronic Problems and Rehabilitation Issues
PCS
Evidence-based treatment interventions for long-lasting PCS are not available, leading providers to focus on alleviating symptoms. Future research needs to consider validated risk-communication approaches, education strategies, and evaluation procedures in reference to MTBI and PCS treatment (Level 2).
Memory
When completing the assessment, the nurse should screen for potential risk factors that can cause ongoing memory impairments (Level 3; Evans, 1992), such as:
- Previous head injury
- Multiple trauma
- Age 40 years and older
- Alcohol and drug abuse
- Lower socioeconomic level
- Lower intellect level
Vestibular Symptoms (Shepard, Clendaniel & Ruchenstein, 2007)
Nurses should monitor and assess for the presence of vestibular symptoms following MTBI and provide appropriate referrals for additional treatment (Level 3). Nurses should also monitor patients on vestibular suppression therapy for therapeutic and potential adverse effects (Level 3).
Expected Outcomes
Initial Recovery
Any decline in neurologic status should prompt more frequent assessments as well as a medical evaluation (Level 2).
Functional Outcomes
Nurses should provide support and advocate for patients following MTBI as they return to usual activities (Level 2). Nurses should provide education regarding the trajectory of recovery and expectations in order to promote optimal recovery (Level 2).
Risk Factors for Poor Outcome
Nurses should be aware of and assess for risk factors for poor outcome following MTBI (Level 2). In cases where there is a modifiable risk factor (e.g., pain, lack of support), nurses should provide appropriate intervention in order to mediate their effect on outcome (Level 3).
Definitions:
Levels of Evidence
Class I: Randomized controlled trial without significant limitations or meta-analysis
Class II: Randomized controlled trial with important limitations (e.g., methodological flaws, inconsistent results); observational study (e.g., cohort, case control)
Class III: Qualitative study, case study, or series
Class IV: Evidence from reports of expert committees and/or expert opinion of the guideline panel, standards of care, and clinical protocols that have been identified
Levels of Recommendations
Level 1: Recommendations are supported by class I evidence.
Level 2: Recommendations are supported by class II evidence.
Level 3: Recommendations are supported by class III and class IV evidence.
