Management of Behavioral Issues in Traumatic Brain Injury

Risk Stratification and Early Identification

The American College of Emergency Physicians recommends identifying high-risk patients at initial ED presentation using predictors such as female gender, pre-existing psychiatric history, elevated anxiety scores, loss of consciousness, assault as mechanism of injury, alcohol intoxication, and no recall of receiving ED discharge information 1, 2
High-risk patients have significantly higher rates of persistent postconcussive symptoms at 3-6 months 1, 2

The American Academy of Emergency Medicine suggests screening for specific behavioral symptoms at the time of ED assessment, including chronic headaches, anxiety, memory problems, difficulty concentrating, sleep difficulties, and abnormal behavior 3, 1
Provide written and verbal education about these symptoms to both patient and immediate caregiver using sixth- to seventh-grade reading level materials with type font ≥12 points 3

Instruct patients to return immediately for repeated vomiting, worsening headache, confusion, abnormal behavior, increased sleepiness, or seizures 3
Mandate 2-3 days off work or school for patients experiencing postconcussive symptoms, with strict avoidance of strenuous mental or physical activity until symptom-free 3

Refer to a traumatic brain injury specialist when symptoms persist beyond 3 weeks, or earlier if planning return to sports, or if patient has identified risk factors 3, 1
18.7% of mild TBI patients report 3 or more postconcussive symptoms, with fatigue and forgetfulness being most common 1

Assess and arrange for social assistance, including driving support, employment accommodations, and financial assistance during recovery 1, 2

Do not rely on home observation protocols for patients with negative CT or low-risk features, as this is not supported by evidence 3
Do not dismiss anxiety symptoms, as they are the strongest predictor of persistent postconcussive syndrome at 3 months 1, 2
Do not delay specialist referral beyond 3 weeks of persistent symptoms, as early intervention improves outcomes 3