Management of Adult Patients Presenting to the Emergency Department with Mild Traumatic Brain Injury

Publication Date: February 28, 2023
Last Updated: March 1, 2023

Summary of Recommendations

Use the Canadian CT Head Rule (CCHR) to provide decision support and improve head CT utilization in adults with a minor head injury (Table 1). (A)

Use the National Emergency X-Radiography Utilization Study (NEXUS) Head CT decision tool (NEXUS Head CT) or the New Orleans Criteria (NOC) to provide decision support in adults with minor head injury; however, the lower specificity of the NEXUS Head CT and NOC compared with CCHR may lead to more unnecessary testing (Table 1) (B)

Do not use clinical decision tools to reliably exclude the need for head CT in adult patients with a minor head injury on anticoagulation therapy or antiplatelet therapy exclusive of aspirin. (C)

Do not routinely perform repeat imaging in patients after a minor head injury who are taking anticoagulants or antiplatelet medication and are at their baseline neurologic examination, provided the initial head CT showed no hemorrhage. (B)

Do not routinely admit or observe patients after a minor head injury who are taking anticoagulants or antiplatelet medications, who have an initial head CT without hemorrhage, and who do not meet any other criteria for extended monitoring. (B)

Provide instructions at discharge that include the symptoms of rare, delayed hemorrhage after a head injury (Consensus recommendation). (C)

Consider outpatient referral for assessment of both fall risk and risk/benefit of anticoagulation therapy (Consensus recommendation). (C)

Consider referral for patients with PCS and the following potential risk factors: female sex; previous preconcussive psychiatric history; GCS score <15; etiology of assault, acute intoxication; LOC; and preinjury psychological history such as anxiety/depression. (C)

Do not use current diagnostic tools (including biomarkers) to reliably predict which patients are at risk for PCS. (C)

Provide concussion-specific discharge instructions and selected outpatient referrals of patients at high risk for prolonged PCS (Consensus recommendation). (C)

Table 1. Overview of Clinical Decision Support Tools

Having trouble viewing table?
Clinical Decision Tool Criteria Exclusion Criteria
Canadian CT Head Rule Any one of:
Failure to reach GCS score of 15 within 2 hours of injury
Suspected open skull fracture
Signs of basal skull fracture
Vomiting more than once
Age greater than 64 y
Age <16 y
Blood thinners
Seizure after injury
New Orleans Criteria Any one of:
Age over 60 y
Drug or alcohol intoxication
Deficits in short-term memory
Physical evidence of trauma above the clavicles
Posttraumatic seizure
GCS score of <15
Age ≤3 y
Nexus Head CT Any one of:
Evidence of skull fracture
Scalp hematoma
Neurologic deficit
Abnormal level of alertness
Abnormal behavior
Persistent vomiting
Age 65 y or greater
GCS score of <15

Recommendation Grading


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.



Management of Adult Patients Presenting to the Emergency Department with Mild Traumatic Brain Injury

Authoring Organization

Publication Month/Year

February 28, 2023

Last Updated Month/Year

September 11, 2023

Document Type


Country of Publication


Target Patient Population

Adult patients with suspected brain injury

Target Provider Population

Emergency physicians, internal medicine and other allied care providers

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Diseases/Conditions (MeSH)

D001930 - Brain Injuries, D000070642 - Brain Injuries, Traumatic


traumatic brain injury, TBI, mild traumatic brain injury