The following is a point-of-care summary of the September, 2019 Emergency Medicine Practice journal issue titled Concussion in the Emergency Department: A Review of Current Guidelines. Click here for access to additional featured content from this issue, as well as subscription information. Subscribe or purchase a single issue and complete the activity to earn4 AMA PRA Category 1 Credits™. This summary is provided with the permission of our content partner EB Medicine.

Questions:


Is it necessary to image everyone with a head injury and symptoms?  No

  • The CDC recommends utilizing a decision rule to help guide the need for imaging. (CT or MRI).
    • Consider using the PECARN criteria for pediatric head injury, found here. 
    • Consider using the Canadian CT head rule for patients > 16 years old, found here.
    • Consider the need for cervical spine imaging.

What symptoms constitute a concussion?

  • The CDC prefers the term mild traumatic brain injury (mTBI), utilizing the published definition by the World Health Organization Collaborating Centre Task Force on Mild Traumatic Brain Injury. It defines mTBI as “an acute brain injury resulting from mechanical energy to the head from external physical forces” with a GCS score of 13-15 (Adult, Peds) at least 30 minutes post injury, along with at least 1 of the following additional clinical criteria:
    • Confusion or disorientation
    • Loss of consciousness (LOC) lasting ≤ 30 minutes
    • Post trau­matic amnesia lasting < 24 hours
    • Other transient neurological abnormali­ties (eg, focal signs or seizure).
    • The CDC Acute Concussion Evaluation Form also includes the following:  

What does ED treatment of concussion include? Primarily symptom management.

  • Antiemetics
  • Non-narcotic pain meds for headache
  • Allow sleep, even in the ED
  • Severe symptoms may require observation to confirm that altered mental status is improving.

What is normal expected recovery for concussion?

  • In children and adolescents, symptoms are considered persistent after 4 weeks. 
  • In adults, symptoms are considered persistent after 10-14 days. 
  • The CDC notes that symptoms resolve within 3 months of injury for most children with mTBI (70%-80%)
  • Risk factors for prolonged recovery include:
    • Previous concussions
    • Severe symptoms in the first few days after the in­jury
    • History of pre-existing mental health concerns, such as depres­sion, anxiety, learning disability, or attention deficit hyperactivity disorder (ADHD)
    • History of migraine headaches
    • Significant family or social stressors
  • Post-concussive vestibular and oculomotor deficits are very common in concussion, present in up to 60% of patients with sport related concussion (SRC).6 These patients are more likely to experience prolonged  recovery.

Is strict rest still recommended post concussion?

  • The CDC and the Concussion in Sport Group (CISG) recommend strict rest for 24-48 hours only. 
    • Several studies have found no benefit in the prescription of strict rest when compared to the resumption of moderate cognitive or physical activity. 
    • Patients who resumed moderate levels of cognitive or physical activity recovered better than those with strict rest or resumption of high levels of activity.
  • Sleep hygiene is important. Napping is therapeutic for the first few days, however it can result in sleep cycle disturbances if allowed to continue longer. 

Should patients be cleared to return to school or sports from the emergency department? No.

  • Patients should only be cleared from the concussion if:
    • All medications used to treat concussive symptoms are no longer being taken
    • All concussive symptoms have resolved
    • The physical  examination is normal, including vestibular and oculomotor function
    • There is evi­dence of  neurocognitive recovery, including the ability to fully function in school.
  • Clearance requires appropriate  documentation of successful completion of the physical return-to-sport stages published in the CISG guidelines. Due to the amount of data needed to confirm that the patient is fully recovered, it is recommended that emergency clinicians not perform concussion clearance, but instead provide referral to a primary care clinician or a specialty clinic for clearance of the concussion.
  • In the United States, all 50 states have enacted concussion-focused legislation aimed at protecting youth athletes. The specific requirements vary from state to state, but the laws typically include 3 components:  
    1. Education for coaches and other stakeholders
    2. Required removal from play with suspected  concussion
    3. Formal clearance from the concussion before return to sport.

What recommendations should be given to patients regarding activity?

  • Pa­tients should be counseled on the risks of re-injury and should not return to sport or high-risk physical activities, such as bike riding, until cleared from the concussion during a follow-up medical visit.
  • Patients may return to sport participation when all of the following criteria are met:
    • The patient is free of symptoms of concussion and is not taking medications used to treat concussive symptoms (to ensure that symptoms are not masked),
    • There are no symptoms on exertion
    • The pa­tient demonstrates normal or baseline cognitive performance.
  • In patients with prolonged recovery (> 10-15 days in an adult; > 4 weeks in a child), a symptom-limited exercise prescription may be ben­eficial. 
  • A graduated return to sports is described in the CISG guidelines, page 3, here.
  • The CDC has developed concussion discharge instruction available here

What recommendations should be given to patients regarding return to school?

  • Return to school is appropriate once severe symptoms have improved.
  • This typically occurs within 48 to 72 hours after the injury.
  • A graduated return to school is described in the CISG guidelines, page 4, here.
  • The CDC has developed concussion discharge instruction available here.

How is patient recovery assessed after emergency department discharge?

  • Consider using one of these free tools to gauge extent of symptoms and monitor progress. 
    • Age >13, Sport Concussion Assessment Tool – 5th Edition (SCAT5
    • Age 5-12, Child SCAT5 ages 5-12

When should patients be referred to specialty concussion clinics?

Early referral to a specialized concussion clinic should be considered for patients with dizziness or visual complaints. These patients will benefit from vestibular and/or physical therapy on the cervical spine. These patients may also be considered for direct referral for vestibular re­habilitation therapy, which is a specialized and effective form of physi­cal therapy provided by trained vestibular therapists.


References:

  1. Kirelik S. Concussion in the Emergency Department: A Review of Current Guidelines. Emerg Med Pract. Sept. 15, 2019. EBMedicine
  2. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-378. PubMed
  3. Bryan MA, Rowhani-Rahbar A, Comstock RD, et al. Sports- and recreation-related concussions in US youth. Pediatrics. 2016;138(1):e20154635. PubMed
  4. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838- 847. (CISG Consensus statement)   Full Text   PubMed
  5. Carroll LJ, Cassidy JD, Holm L, et al. Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004;(43 Suppl):113-125. PubMed
  6. Makdissi M, Schneider KJ, Feddermann-Demont N, et al. Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):958-968. PubMed

This summary is provided with the permission of our content partner EB Medicine; www.ebmedicine.net

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