Peer Review Report For: Missed Diagnoses in Rural Mild TBI: The Role of EMS Delays [version 1; peer review: 1 approved]

Background Mild traumatic brain injury (mTBI) diagnosis relies on observing acute neurological signs including loss of consciousness, post-traumatic amnesia, confusion and transient motor signs. Current guidelines assume real-time observation, creating systematic underdiagnosis when emergency medical services (EMS) arrival exceeds transient qualifying sign duration—particularly problematic in rural systems with transport delays. Objective To model the missed-diagnosis window — the probability that qualifying signs resolve before first medical contact. Methods We synthesized published EMS response distributions, acute neurological sign durations, and consensus guideline criteria to model the missed-diagnosis window—the probability that qualifying signs resolve before first medical contact. Analysis incorporated systematic review evidence from 37 studies (n=239,464,121 patients). Results Critical neurological signs resolve rapidly: median loss of consciousness