Identifying patients with mild traumatic intracranial hemorrhage at low risk of decompensation who are safe for ED observation

Am J Emerg Med. 2017 Feb;35(2):255-259. doi: 10.1016/j.ajem.2016.10.064. Epub 2016 Oct 29.


Background: Patients with traumatic intracranial hemorrhage and mild traumatic brain injury (mTIH) receive broadly variable care which often includes transfer to a trauma center, neurosurgery consultation and ICU admission. However, there may be a low risk cohort of patients who can be managed without utilizing such significant resources.

Objective: Describe mTIH patients who are at low risk of clinical or radiographic decompensation and can be safely managed in an ED observation unit (EDOU).

Methods: Retrospective evaluation of patients age≥16, GCS≥13 with ICH on CT. Primary outcomes included clinical/neurologic deterioration, CT worsening or need for neurosurgery.

Results: 1185 consecutive patients were studied. 814 were admitted and 371 observed patients (OP) were monitored in the EDOU or discharged from the ED after a period of observation. None of the OP deteriorated clinically. 299 OP (81%) had a single lesion on CT; 72 had mixed lesions. 120 patients had isolated subarachnoid hemorrhage (iSAH) and they did uniformly well. Of the 119 OP who had subdural hematoma (SDH), 6 had worsening CT scans and 3 underwent burr hole drainage procedures as inpatients due to persistent SDH without new deficit. Of the 39 OP who had cerebral contusions, 3 had worsening CT scans and one required NSG admission. No patient returned to the ED with a complication. Follow-up was obtained on 81% of OP. 2 patients with SDH required burr hole procedure >2weeks after discharge.

Conclusions: Patients with mTIH, particularly those with iSAH, have very low rates of clinical or radiographic deterioration and may be safe for monitoring in an emergency department observation unit.

Keywords: Intraparenchymal hemorrhage; Observation medicine; Subarachnoid hemorrhage; Subdural hematoma; Traumatic intracranial hemorrhage.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Brain Injuries, Traumatic / diagnostic imaging
  • Brain Injuries, Traumatic / therapy*
  • Emergency Service, Hospital / organization & administration
  • Emergency Service, Hospital / standards*
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Glasgow Coma Scale
  • Humans
  • Intracranial Hemorrhage, Traumatic / diagnostic imaging
  • Intracranial Hemorrhage, Traumatic / therapy*
  • Male
  • Middle Aged
  • Monitoring, Physiologic
  • Observation
  • Outcome Assessment, Health Care / statistics & numerical data
  • Patient Discharge / standards*
  • Patient Discharge / statistics & numerical data
  • Patient Safety
  • Retrospective Studies
  • Tomography, X-Ray Computed
  • Trauma Centers / organization & administration
  • Trauma Centers / standards*
  • Trauma Centers / statistics & numerical data
  • Young Adult