Prevalence and Persistence of Mild Traumatic Brain Injury Diagnosis among Hospitalized Blunt Trauma Patients

BACKGROUND

Symptoms and complications from mild traumatic brain injury (mTBI) can persist after physical recovery from other injuries; however, little is known about the frequency of mTBI among patients with mild-to-moderate injuries and the prevalence of missed mTBI diagnoses in the presence of extracranial injuries.

METHODS

We conducted a retrospective medical record review of adult patients with mild-to-moderate injuries (ISS ≤ 15) who required hospital admission, identified through the trauma registry of a level I trauma center. Subjects were classified as having mTBI if they met the American Congress of Rehabilitation Medicine clinical definition of mTBI. Among those meeting mTBI diagnostic criteria, we then determined the proportion of subjects who were 1) given an mTBI diagnosis during their hospital stay; 2) discharged with an mTBI diagnosis; and 3) provided mTBI discharge instructions.

RESULTS

Of the 297 cases reviewed, 60 cases (20%) met mTBI diagnostic criteria.  Of these patients, 27 (45%) had had documented diagnosis of mTBI in their medical records. Nine of the 27 were diagnosed by in the emergency department and 18 were diagnosed as inpatients. Of the 60 mTBI patients in our sample, only 6 (10%) had mTBI listed on their discharge notes, and only 4 (7%) received discharge instructions specific to head injury.

CONCLUSION

In our sample of hospitalized mild-to-moderately injured patients, mTBI is often under-diagnosed.  Of patients who met diagnostic criteria, the majority do not receive specific discharge instructions for head injury, which could have long-lasting impact on recovery from and proper management of the injury.