Concussion Management

Adapted from Andy Simmon's Grand Rounds lecture, January 11th, 2017. 

How to identify serious injury that requires admisison for neurosurgery or observation, and how to instruct discharged patients for recovery expectations, followup, and return precautions. 

Classically, traumatic brain injury (TBI) is classified into mild, moderate, and severe.  Mild TBI is considered concussion, while severe TBI has a mortality of 30% and less than 10% of severe TBIs experience full recovery. 

• Mild: GCS 14-15 (80% of TBI)
• Moderate: GCS 9-13 (10% of TBI)
• Severe: GCS 3-8 (10% TBI)

Alternative definitions include a discussion of impaired awareness or temporary change in brain status or neurologic function. ACEP states that concussions typically occur from nonpenetrating trauma to the head, presentation within 24 hours, and a GCS score of 14-15. 

Pathophysiology​
Disruption of the polarized neurons, leading to poor function. Efflux of potassium from the cell and influx of calcium into the cells leads to damage to mitochondria, disruption of neurotransmission, and damage of cells. 

Evaluation for Concussion

• Vacant stare
• Delayed verbal expression
• inability to focus attention
• slurred speech
• disorientation or memory defects
• Loss of conciousness 
• Amnesia

• Headache (94%)
• Dizziness (75%)
• Poor concentration (57%)
• Vision changes (38%)
• Nausea (29%)

Management

Goal is to identify those patients at risk for intracranial lesions, those who need observation, and those who may be discharged. Every patient should have a complete neurologic exam including gait and vestibulo-occular testing. 

VOMS testing (Vestibular/ocular motor screening) includes smooth pursuit, horizontal and vertical saccades, near point convergance, visual motion sensitivity, and horizontal vestibular ocular reflex. (Youtube howto). 

To help assess recovery expectations, these are some exams that can be used to assess injury. The R-WPTAS exam is the most commonly used. 

Neuroimaging should be determined by either the Canadian CT Head Rule or the New Orleans Criteria. 

Pediatric patients should be evaluated with the PECARN decision guidelines for imaging and observation. . 

Admission should be considered for patients with

• Intracranial abnormality
• Continued altered mental status
• Seizures
• Anticoagulated
• Patients at higher risk (elderly, comorbidities)

Discharged patients should be counciled on instructions for recovery and treatment. Most guidelines instruct patients to rest for 3 days before attempting to return to daily activities. Patients should follow up with concussion clinic after 1 week, and not drive prior to re-evaluation. Every patient should be given a guideline for return to play or work. 

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