Mastering Minor Care: Concussion
/Traumatic brain injury (TBI) accounts for millions of Emergency Department visits annually. While moderate and severe TBI is often managed on an inpatient basis, patients presenting with mild TBI, or concussion, are often managed solely by Emergency physicians. Despite the “mild” classification, this diagnosis carries significant implications on patient functioning and quality of life. Therefore, proper evaluation and management in the Emergency Department is critical.
Defining concussion
The term “concussion” refers to a traumatically-induced disturbance in brain function. Classic mechanisms for this type of injury include direct blunt-force trauma to the head and acceleration-deceleration events. On a cellular level, neurons are subjected to disruptive stretching forces, resulting in a cascade of damaging metabolic consequences [1].
Several definitions have been set forth for this common injury, with perhaps the most well accepted definition being introduced by the Centers for Disease Control and World Health Organization. By these criteria, a concussion is defined as a Glasgow Coma Scale (GCS) of 13-15 either 30 minutes following a head injury or at the time of presentation in the presence of loss of consciousness or altered consciousness following the injury, retrograde and/or anterograde amnesia to the event, ongoing alterations in mental status, or presence of a neurologic deficit. Concussions are often further characterized as sports-related or non-sports related [2].
There is much discussion on whether the term concussion is synonymous or distinct from mild traumatic brain injury (mTBI) [1]. For our purposes, we will be referring to this pathology as “concussion,” though it is important to note that the verbiage may vary among sources.
table 1: definition of concussion
Emergency Department Assessment
Clinching the diagnosis relies on history-taking and the physical examination. Patients who present with a GCS of 13-15 following an episode of head trauma with either loss of consciousness, amnesia, altered mental status, or a neurological deficit meet the diagnostic criteria.
The history should focus on both the events surrounding the traumatic event, as well as current symptomatology. While historical features are important in making the formal diagnosis of concussion, the burden of symptoms correlates with the length of the recovery period, with more symptomatic individuals requiring longer periods of time to return to their previous level of functioning. Symptoms of concussion are grouped into four categories: somatic, cognitive, emotional, and sleep-related (Table 2). Providers should evaluate for symptoms in each of these domains in patients who present with a history concerning for concussion, though a complete evaluation of all of these domains may be limited in the acute setting.
TABLE 2: Symptoms of concussion
A thorough physical exam should be performed, focusing on evidence of traumatic injuries and sequela of concussion. Pay close attention to the head and cervical spine for evidence of injuries that necessitate imaging, such as midline spinal tenderness and/or signs of basilar skull fracture (Table 3).
Assessment of mental status is also critical in the concussed patient. Basic cognitive function may be assessed by asking the patient to perform serial 7’s (several serial subtractions of 7 from 100) or another similar task. Repetitiveness and difficulty sustaining attention are considered typical findings. A basic visual exam may reveal deficits in accommodation and/or convergence, with patients reporting difficulty focusing on nearby objects and double vision, respectively. Additionally, impairments in vestibular function may manifest as a failed Romberg test or gait instability [2].
TABLE 3: FOCUSED PHYSICAL EXAM FOR SUSPECTED CONCUSSION
After your thorough history and physical exam, you suspect that your patient is suffering from a concussion. Do you need to send them to the CT scanner? What about an MRI? It turns out that 5-10% of patients presenting with concussion have a traumatic intracranial injury that is identified on imaging [2]. However, that does not mean that all patients should have imaging performed as part of their work-up in the Emergency Department.
Like all patients presenting to the Emergency Department with blunt head trauma, providers should determine the risk for a significant intracranial injury by considering patient risk factors (advanced age, anticoagulant use, intoxication), mechanism of injury, symptomatology (both current and prior to ED presentation), and physical exam findings. For adult patients, the Canadian CT Head Injury Rule and New Orleans Head Trauma Rule are evidence-based decision rules that are useful in risk-stratification [1]. For pediatric patients, we recommend using the PECARN Pediatric Head Injury Algorithm. For high-risk patients, a non-contrast CT Head is the test of choice. MRI is not recommended for patients presenting with an acute concussion [1].
Management and Disposition
You’ve made the clinical diagnosis of concussion and reviewed the relevant diagnostics; so what’s next for your patient? Let’s start with figuring out their disposition. In patients with an abnormal CT Head, decisions regarding management and disposition should be made in conjunction with a Neurosurgeon. These patients are often admitted to the hospital. Admission should also be strongly considered in patients with a depressed GCS, post-traumatic seizure(s), or intractable symptoms [2].
Patients that do not meet any of these criteria are appropriate for discharge from the Emergency Department. Patients should be observed by a caretaker for 24 hours following the injury. Patients and their caretakers should be instructed to return to the Emergency Department if the patient develops somnolence, confusion, worsening headaches, seizures, vision changes, or incontinence during this period of observation. A short course of medications can be provided at discharge to help manage symptoms at home. Acetaminophen, NSAIDs, and antiemetics are all reasonable choices. However, prolonged medication use should be discouraged, as these patients are at risk of developing medication-overuse headaches [2].
Thankfully, most patients will make a full recovery. In fact, 80-90% of adults and older adolescents will return to their baseline level of functioning in only 2 weeks [3]! The best thing that we can do for these patients is provide relevant education and instructions. This is a huge area for improvement nationally, as was demonstrated by a 2018 study that revealed that only 42% of patients seen at 11 US Level 1 trauma centers received educational materials on discharge [4]. Patients should be educated on physical and cognitive rest. Specifically, they should be instructed to abstain from physically and/or cognitively strenuous exercises for 24-48 hours following their injury. There is also evidence that patients should avoid screen time during this time period, as this has been associated with longer recovery periods [5]. After this initial period of rest, patients should return to their typical activities in a gradual, stepwise fashion. Instruct patients to modify their activity to stay under their symptomatic threshold, while also avoiding complete rest, as this is actually associated with a longer recovery period [6]. Close follow up with an outpatient provider should be arranged, and patients should be referred to a TBI clinic or other Neurotrauma specialist if available.
Post by colleen ARNOLD, MD
Dr. Arnold is a PGY-2 in Emergency Medicine at the University of Cincinnati and Mastering Minor Care Section Editor
Editing by alexa sabedra, MD and anita goel, md
Dr. Sabedra is an Assistant Professor at the University of Cincinnati and a graduate of the UC EM Class of 2019
Dr. Goel is an Assistant Professor at the University of Cincinnati and a graduate of the UC EM Class of 2018
ReferenceS:
Valente, Jonathan H., et al. “Clinical policy: Critical issues in the management of adult patients presenting to the emergency department with Mild Traumatic Brain Injury (executive summary).” Annals of Emergency Medicine, vol. 81, no. 5, 2023, pp. 621–623, https://doi.org/10.1016/s0196-0644(23)00252-4.
Bazarian, Jeffrey J., et al. “Recommendations for the Emergency Department Prevention of Sport-related concussion.” Annals of Emergency Medicine, vol. 75, no. 4, 2020, pp. 471–482, https://doi.org/10.1016/j.annemergmed.2019.05.032.
Harmon, Kimberly G, et al. “American Medical Society for Sports Medicine Position Statement on Concussion in sport: Erratum.” Clinical Journal of Sport Medicine, vol. 29, no. 3, 2019, pp. 256–256, https://doi.org/10.1097/jsm.0000000000000764.
Seabury SA, Gaudette É, Goldman DP, et al. Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK-TBI Study. JAMA Netw Open. 2018;1(1):e180210. doi:10.1001/jamanetworkopen.2018.0210
Macnow T, Curran T, Tolliday C, et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2021;175(11):1124–1131. doi:10.1001/jamapediatrics.2021.2782
Scorza KA, Raleigh MF, O'Connor FG. Current concepts in concussion: evaluation and management. Am Fam Physician. 2012 Jan 15;85(2):123-32. PMID: 22335212.
