Table 5

TBI-related signs and symptoms and imaging findings among a random sample of medical records assigned skull fracture ICD-10-CM codes*, by study site

Study sitesOne shock trauma, one ED in referral centres
Two EDs in university system
EDs in level I, II, III trauma hospitals
EDs in all acute care hospitals
Known or suspected signs and/or symptomsCount%Count%Count%Count%
In group 1
 Memory problems409.35915.34913.3153.9
 Loss of consciousness15435.910527.310328.05012.9
 Any group 1 sign/symptom 173 40.4 140 36.4 128 34.8 72 18.6
 No group one signs/symptoms 222 51.8 245 63.6 240 65.2 316 80.9
In group 2§
 Nausea or vomiting327.54210.95113.94110.6
 Headache/pressure in head10223.811830.611531.321154.4
 Dizziness/poor balance235.4184.7318.4328.2
 Change in vision5613.1389.94512.26617.0
 Irritable/Change in mood174.0112.9205.4
 Drowsiness/change in sleep153.5297.5133.5143.6
Imaging of the head
 Imaging performed40694.934589.635395.932583.8
 Positive imaging findings9923.113334.522864.823572.5
  • The bold values indicate that those two characteristics were exclusive (meaning a patient could not have both) and their total counts or percentages were shown in the "total" row below them.

  • *Skull fracture ICD-10-CM diagnosis codes beginning with ‘S02.0’, ‘S02.1’, ‘S02.8’ or ‘S02.91’ in any diagnosis field and seventh character of ‘A’ ‘B’ or missing. The billing record could not also have an intracranial injury code beginning with ‘S06’.

  • †Suppressed because the count was less than 11.

  • ‡Sensitivity to noise/light, speech problems, hearing problems and weakness/numbness were documented in 0.5% to 3.0% of the skull fracture sample in the study sites, except the Maryland site had 17 records (4.2%) with speech problems and Massachusetts had 31 records (8.0%) with weakness.

  • §Seventeen of the 385 sampled medical records in Colorado indicated that the patient was not a state resident, was not discharged home, did not have an injury event or was admitted as an inpatient.

  • ED, emergency department; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification; TBI, traumatic brain injury.