Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine and an Associate Editor for the NEJM Journal Watch Emergency Medicine.
Reference: Varner et al. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. AEM May 2021
Case: A 32-year-old female presents with headache after a low-speed motor vehicle collision as a restrained driver. She was ambulatory on scene. The patient is not anticoagulated, has no midline neck pain, and no evidence of other injuries. She is generally well appearing without any deficients on neurological examination, given her minor mechanism, and normal examination no imaging or further testing is required. You tell her you believe she has a concussion.
Background: Concussions or mild traumatic brain injury (mTBI) are commonly diagnosed in the Emergency Department (ED). Most patients recover within the first week; however, 15-30% of patients develop persistent post-concussive symptoms.
Historically, cognitive and physical rest have been recommended following the diagnosis of mTBI and patients have been advised to resume exercise only once symptoms have abated. Recent studies have challenged this dogma of “rest is best” with one multicenter study finding that early return to physical activity within a week of injury was associated with an improvement in time to symptom reduction.
One of the issues that comes up with minor head injuries is do we need to get advanced imaging. We looked at the Canadian CT Head Rule (CCHR) published by Dr. Ian Stiell in the Lancet 2001 on SGEM#106. You can find this clinical decision instrument on MDCalc.
The SGEM has also covered the issue of getting CT scans in pediatric patients with minor head injuries. That used the PECARN data which has a protocol for children less than two years of age and those older than two years of age.