Research assistants identified participants who were confirmed by the attending emergency physician. Research assistants collected clinically relevant information from the participants and/or a parent or guardian on a standardized data collection form before ED discharge. Data included demographic factors (race, ethnicity, age, insurance information, and sex), history of TBI requiring an ED visit or associated with LOC, mechanism of injury, clinical signs and symptoms of TBI (LOC, amnesia, alteration of mental status, nausea/vomiting, and headache), physical examination factors (Glasgow Coma Scale score), results of neuroimaging (if performed), ED medication administration, receipt of injury-specific discharge instructions, referrals, and disposition. Age was further dichotomized into school-aged children (5–10 years) and adolescents (11–18 years). Severe mechanism of injury was extrapolated from the definition used in the neuroimaging prediction rule by Kuppermann et al.10 (link),17 (link) We defined this to include any of the following: a motor vehicle collision, a pedestrian struck by a motor vehicle, a bicyclist without a helmet, or a fall of more than 3 feet. Other diagnoses were determined by a post hoc review of billing records for non-TBI codes from the International Classification of Disease, Ninth Revision. An abnormal finding on cranial CT was defined by the presence of any intracranial injury and the presence of skull fractures.
Three months after the initial visit, participants or parents or guardians were interviewed by telephone. The following information was collected: number of days of school missed owing to the TBI, PCS symptom score using the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and whether they were in the process of a lawsuit regarding the injury. Interviewers were blinded to the details of the initial ED presentation. The RPQ is used to assess common PCS symptoms in patients of all ages.18 (link)–20 (link) Symptoms assessed include headaches, dizziness, nausea, noise sensitivity, sleep disturbance, fatigue, irritability, depression, frustration, poor memory, poor concentration, taking longer to think, blurred vision, light sensitivity, double vision, and restlessness. Participants or their parents or guardians rated the severity of each of the 16 symptoms during the past 24 hours compared with before the injury on a scale from 0 to 4, where 0 indicates absent; 1, the same; 2, mild; 3, moderate; and 4, severe. We defined PCS as the presence of 3 or more symptoms on the RPQ that were rated as worse (score of ≥2) than before the injury. This information was extrapolated from the diagnostic criteria for PCS set out by the DSM-IV, which requires the presence of at least 3 symptoms at 3 months after the injury.
Three months after the initial visit, participants or parents or guardians were interviewed by telephone. The following information was collected: number of days of school missed owing to the TBI, PCS symptom score using the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and whether they were in the process of a lawsuit regarding the injury. Interviewers were blinded to the details of the initial ED presentation. The RPQ is used to assess common PCS symptoms in patients of all ages.18 (link)–20 (link) Symptoms assessed include headaches, dizziness, nausea, noise sensitivity, sleep disturbance, fatigue, irritability, depression, frustration, poor memory, poor concentration, taking longer to think, blurred vision, light sensitivity, double vision, and restlessness. Participants or their parents or guardians rated the severity of each of the 16 symptoms during the past 24 hours compared with before the injury on a scale from 0 to 4, where 0 indicates absent; 1, the same; 2, mild; 3, moderate; and 4, severe. We defined PCS as the presence of 3 or more symptoms on the RPQ that were rated as worse (score of ≥2) than before the injury. This information was extrapolated from the diagnostic criteria for PCS set out by the DSM-IV, which requires the presence of at least 3 symptoms at 3 months after the injury.
