Management of Mild Traumatic Brain Injury

Initial Assessment and Risk Stratification

The American Society of Anaesthesia recommends assessing severity using the Glasgow Coma Scale (GCS), documenting all three components (eye, verbal, motor) separately, along with pupillary size and reactivity, for patients with mild TBI (GCS 14-15) 1, 2, 3
Patients with mild TBI (GCS 14-15) require selective CT imaging based on specific high-risk criteria, followed by observation protocols and structured discharge planning with clear return precautions, as recommended by the French Society of Anaesthesia 1, 2

The French Society of Anaesthesia guidelines provide strong (Grade 1+) recommendations for performing brain CT scan in mild TBI patients (GCS 14-15) if ANY of the following high-risk features are present: signs of basilar skull fracture, displaced skull fracture, post-traumatic seizure, focal neurological deficit, coagulation disorders, or current anticoagulant therapy 1, 2, 4, 5

Monitor patients with frequent neurological checks: every 15 minutes for the first 2 hours, then hourly for 4-12 hours depending on risk level, as recommended by the American Society of Anaesthesia 4
Any decrease of ≥2 points in GCS or development of new neurological deficits mandates immediate repeat CT scanning, according to the American Society of Anaesthesia 1, 4

Aggressively correct systemic factors that worsen outcomes, including maintaining systolic blood pressure >110 mmHg and oxygen saturation >90%, as recommended by the American Society of Anaesthesia 1, 2
The combination of hypotension and hypoxemia carries a 75% mortality rate, making their prevention paramount, according to the American Society of Anaesthesia 1, 2

Provide structured written and verbal instructions covering warning signs requiring immediate return, expected symptom trajectory and recovery timeline, and activity restrictions and gradual return-to-work/sport protocols, as recommended by the American Society of Anaesthesia 3, 4, 6

Do not use biomarkers (S100b, NSE, UCH-L1, GFAP) for routine clinical decision-making, as recommended by the American Society of Anaesthesia (Grade 2- recommendation) 5, 6
Do not perform routine repeat CT in mild TBI patients with negative initial CT and stable neurological examination, as recommended by the American Society of Anaesthesia 1, 2
Do not discharge patients on anticoagulation without extended observation or admission, as recommended by the American Society of Anaesthesia 1, 2

The American College of Emergency Physicians recommends that patients with isolated mild TBI (GCS 15) and negative CT can be considered safe for discharge if they meet specific criteria, including no anticoagulation or antiplatelet therapy, no bleeding disorder or previous neurosurgical procedure, and reliable follow-up and competent caregiver 7, 8, 9, 10, 11