Evaluating, Managing, Or Referring A Patient With A Suspected Concussion
The information below addresses how to evaluate a patient for a suspected concussion, how to return patients to functionality, how to manage symptoms of concussion, when to refer to a multidisciplinary care team with concussion expertise, and other relevant information for your practice.
Concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilised in clinically defining the nature of a concussive head injury include:
- May be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
- Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
- May result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
- Results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.
The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc.) or other comorbidities (e.g., psychological factors or coexisting medical conditions).
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When evaluating a patient with a suspected concussion, what should my initial exam include?
The key features of an evaluation for a concussion should include:
- A medical assessment encompassing:
- A comprehensive history, including mechanism of injury and eyewitness accounts
- Symptom assessment
- Focused neurological examination including mental status, cognitive functioning, coordination, vision
- A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates, and eyewitnesses to the injury if applicable.
- Assessing the need for emergent neuroimaging to exclude a neurosurgically remediable structural brain injury.
Most of the elements of an assessment are included in the SCAT5 (Sport Concussion Assessment Tool) and Child SCAT5.
What neuroimaging should I order for my patients who have been diagnosed with a concussion?
Neuroimaging for patients with concussion is usually not required. The PECARN (Pediatric Emergency Care Applied Research Network) Head Injury Algorithm should be reviewed.
A non-contrast head CT of the head, and possibly neck, should be considered if there is:
- Glasgow Coma Scale <= 14
- Focal neurological deficit
- Altered mental status (particularly agitation and somnolence)
- Palpable skull fracture
- Loss of consciousness
- Severe mechanism of injury
- Severe headache
- Worsening symptoms
- Multiple symptoms
Should I still use a grading system to help manage my patients who have or are suspected of having a concussion?
Extensive research on concussions has provided medical professionals with a much better understanding of the symptomatic course and risk of potential long-term complications. This led to the realization that diagnosing those who did not lose consciousness with a lower grade of concussion was inaccurate. As a result of this understanding, and other realizations, grading systems have been replaced by individualized concussion management.
For more information, learn more about the signs and symptoms of a concussion.
I’m not sure when I should refer my patient to a multidisciplinary team with concussion expertise.
- If there is neurologic deterioration including
- Worsening or persistent headache
- Dizziness, poor balance
- Visual changes
- Poor attention and problems with memory
- Profound fatigue and change in sleeping patterns
- Mood dysregulation
- For infants/toddlers exhibiting the following symptoms for an extended period of time:
- Excessive crying
- Change in nursing or eating habits
- Becoming upset easily or increased temper tantrums
- Sad or lethargic mood
- Lack of interest in favourite toys
- For assistance in determining return to school, work, or sports
- Consider referral to a neuropsychologist for children and adolescents who have ongoing challenges with learning. Patients who have diagnosed learning difficulties, pre-existing behavioural dysregulation and ADHD are at particular risk for poor outcome following concussion.
- Mental health-related issues including anxiety, anger, sadness and depression.
For more information, please review the Ontario Neurotrauma Foundation’s Guideline for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms (3rd Edition).
What is the best approach to investigation and management of persistent concussive symptoms (greater than 4 weeks post-injury)?
Persistent symptoms are reported in up to 33% of patients who have concussions. Symptoms may not be specific to concussion and it is important to consider and manage co-existent pathologies.
Investigations may include a formal neuropsychological assessment and neuroimaging to exclude structural pathology. Currently, there is insufficient evidence to recommend routine clinical use of advanced neuroimaging techniques or other investigative strategies. If neuroimaging is considered as part of a diagnostic workup, this should be discussed with a neuroradiologist.
Patients who have prolonged concussion symptoms are ideally managed by a multi-disciplinary team of health care providers with expertise in concussion. They may include physiotherapy, cognitive therapy, vision therapy, psychology, neuropsychology, psychiatry, and school support.
What management strategies can I suggest for my patients?
- Nutrition (3 meals and 2 snacks daily, proteins with each meal)
- Increased fluid intake (1 litre for children: 1.5 litres for adolescents)
- Sleep strategies to improve sleep. Melatonin might be considered (aiming for 10.5 hours for children ages 5-7 years, 10 hours for 7-10 years, 9 hours for 10-13 years, 8 hours for 14+ years)
- Address headaches and provide clear information regarding headache management:
- Identify and avoid triggers
- Advise about judicious use of OTC analgesia and potential complications resulting from medication overuse
- Consider use of nutraceuticals (riboflavin, coenzyme Q10, magnesium citrate)
- Consider biofeedback, mindfulness, meditation
- Provide information regarding appropriate rest, gradually increasing physical and cognitive activity within 2-3 days
- Avoidance of contact sports and activities which puts the patient at higher risk for injury until recovery is complete
- Limit screen and device time; can gradually increase as patient improves
- Graded Return to School strategies
- Graded Return to Sports strategies
- Advice regarding driving
- Advice regarding maintaining social network, connecting with friends and family
1. McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA. Consensus statement on concussion in sport—The 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Apr 26:bjsports-2017.