CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF MILD HEAD INJURY (MHI) IN ADULTS

(1)  In adults with mild head trauma, normal neurological exam, and not on anticoagulant or antiplatelet therapy, does applying the Canadian CT Head Rule compared to routine CT reduce unnecessary imaging without missing significant injuries?

We recommend the Canadian CT Head Rule (CCHR) to guide CT use in adults with mild head injury not on anticoagulants or antiplatelets, to minimize unnecessary imaging. If CT imaging is not available, refer to an appropriate facility.

CT is indicated if any of the following are present:

· Failure to reach a GCS score of 15 within 2 hours of injury.

· Suspected open skull fracture.

· Signs of basal skull fracture.

· Vomiting more than once.

· Age > 64 years.

The Canadian CT Head Rule (CCHR) is not applicable to patients younger than 16 years, those receiving blood thinners, or patients who experience a post-traumatic seizure.

(Strong recommendation, High certainty of evidence) ^4,18,20–22

(2)   In adults over 60 years old with head trauma who present with loss of consciousness or post-traumatic amnesia, do immediate CT brain imaging, compared to no CT or delayed imaging, improve the detection of clinically significant intracranial injury and guide appropriate management?

We recommend performing a non-contrast head CT in patients over 60 years old who are present with loss of consciousness or post traumatic amnesia. If CT imaging is not available, refer to an appropriate facility.

(Strong recommendation, High certainty of evidence) ^19,23

(3) In intoxicated patients with mild head trauma , does CT scanning compared to observation improve detection of clinically significant brain injury?

We recommend performing a non-contrast head CT in intoxicated patients with mild head trauma who present with loss of consciousness or posttraumatic amnesia.  If CT imaging is not available, refer to an appropriate facility.

(Strong recommendation, Moderate certainty of evidence) ^19,23

(4)  In adults with mild head injury (MHI) who are neurologically intact and are receiving anticoagulant or antiplatelet therapy , do routine head computed tomography (CT) imaging compared to no CT imaging improve the detection of intracranial hemorrhage?

We recommend performing a non-contrast head CT in anticoagulated patients with mild head injury, rather than relying solely on clinical decision tools to exclude imaging. If CT imaging is not available, refer to an appropriate facility.

(Strong recommendation, Low certainty of evidence) ^18,24–29

(5)  In the same group of patients , does repeating a CT scan after an initial negative CT compared to no repeat CT improve detection of delayed intracranial hemorrhage?

We advise against routine repeating a non-contrast head CT in adults with mild head injury on anticoagulants or antiplatelets who remain at baseline neurologic assessment, if the initial CT is negative for hemorrhage.

(Conditional recommendation, Moderate certainty of evidence) ^18,25–29

(6)  In patients with mild head injury , does hospital admission compared with discharge with observation at home improve early detection and management of complications?

We recommend admitting patients with mild head injury to hospital if clinical assessment identifies any risk factors or concerning features that warrant close observation or further management.

Admission is advised when one or more of the established admission criteria for mild head injury are present:

·  New, clinically important abnormalities on imaging (An isolated simple linear non-displaced skull fracture is unlikely to be clinically important unless the patient is taking anticoagulant or antiplatelet medication.)

·  GCS score did not return to 15 (or pre-injury baseline) after imaging, regardless of the imaging results.

·  Indications for CT scanning are present, but scanning cannot be performed within the appropriate time period, either because CT is unavailable or because the person is not sufficiently cooperative to allow scanning.

·  Continuing worrying symptoms of concern to the clinician, such as persistent vomiting, severe headaches, or seizures.

·  Other sources of clinician concern, including but not limited to drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak, or suspicion of ongoing post-traumatic amnesia.

(Good practice statement)

(7)  In patients presenting with mild head injury , does discharging them from hospital based on normal clinical assessment and imaging results compared to continued observation or hospital admission lead to safe outcomes without missed clinically significant brain or cervical spine injuries?

We recommend discharging patients with mild head injury when clinical assessment and investigations identify no evidence of clinically important brain or cervical spine injury, provided that:

·  CT scan of the head and/or cervical spine is not indicated or has shown normal findings, and the Glasgow Coma Scale (GCS) has returned to 15 or the pre-injury baseline.

·  There are no other factors that would warrant hospital admission. (refer to recommendation number 6)

·  There is appropriate supervision at home or a suitable environment for continued observation in the community.

(Good practice statement)

(8)  In adults with mild head trauma, normal neurological exam, and on anticoagulants/antiplatelets , is inpatient admission, or prolonged ED observation compared to safe discharge from the ED equally safe without missed complications?

We advise against routine hospital admission in anticoagulated or antiplatelet-treated patients with mild head injury who have a normal neurological exam, a normal initial CT, and lack criteria warranting extended monitoring.

The criteria warranting extended monitoring and hospital admission are the same as those for patients who are not taking anticoagulant or antiplatelet therapy.

(Conditional recommendation, Low certainty of evidence) ^18,25–30

(9) In adults with mild head trauma , does providing discharge advice including red-flag symptoms and when to seek re-evaluation compared to no structured advice improve early recognition of complications and timely return for care?

We recommend providing written discharge instructions outlining red-flag symptoms and follow-up guidance to adults with mild head injury to improve early recognition of complications.

A. Discharge instructions should include advice to:

· Avoid activities that may increase the risk of recurrent head injury.

· Maintain social contact and communicate with family or friends about recovery symptoms.

· Use only medications approved by the treating physician for symptom control.

· Limit screen time and exposure to loud noise before sleep, keep a consistent sleep schedule, and rest in a quiet, dark environment.

B. Inform a trusted person about the injury and the warning signs to monitor for, as they may recognize symptoms before the patient does.

C. Arrange a follow-up visit within 48 hours of discharge.

On discharge you should inform the patient and his/her companion about red-flag symptoms:

·  A headache that gets worse and does not go away.

·  Significant nausea or repeated vomiting.

·  Unusual behavior, increased confusion, restlessness, or agitation.

·  Drowsiness or inability to wake up

·  Slurred speech, weakness, numbness, or decreased coordination.

·  Convulsions or seizures (shaking or twitching).

·  Loss of consciousness (passing out)

(Good practice statement)