Guideline For Concussion/Mild Traumatic Brain Injury & Prolonged Symptoms
3rd Edition, for Adults over 18 years of age
Diagnosis of mTBI/concussion (Table B) is the first critical step in successful management leading to improved outcomes and prevention of further injury. Patients commonly present to the Emergency Department (ED) or their Primary Care Provider’s (PCP’s) office following trauma and may be unaware that they have sustained concussion/mTBI. A high level of suspicion is required particularly when there is evidence of direct trauma to the head or mechanism of injury1 that is frequently associated with mTBI, such as motor vehicle collision, falls, assaults and nonintentional strike by/against an object, including sport and recreational injury.2 Patients may present in a post-traumatic amnestic (PTA) state, where they may have a Glasgow Coma Scale (GCS) score of 15/15; however, they may be variably oriented and not able to form continuous memories.
The purpose of the initial medical assessment is to establish the diagnosis of concussion/mTBI by ruling out more severe forms of TBI, cervical spine injuries and medical and neurological conditions that can present with concussion-like symptoms.3 The need for neuroimaging should also be determined using the Canadian CT Head Rule (Figure 1.1).4,5 Despite the current research on advanced neuroimaging studies (such as DTI and fMRI),6 CT scans represent the most appropriate and widely available diagnostic imaging test to rule out acute intracranial hemorrhage. Patients who did present symptoms compatible with a concussion/mTBI following a head injury may also be completely asymptomatic by the time they are medically assessed. Once the medical assessment has excluded more severe forms of TBI, these patients should be presumed to have sustained a concussion/mTBI and be managed accordingly.
The severity of a person’s symptoms in the initial few days after a TBI is the strongest and most consistent predictor of slower recovery, and demonstrates clinical utility in tracking recovery.7 Therefore, symptoms should be formally documented at the time of the initial assessment for the purpose of subsequent comparative analysis in the event of persistent symptoms. Blood-based biomarkers8 are still considered investigational and therefore are not recommended for use in diagnosing/assessing patients in the ED or PCP’s office.
When establishing the diagnosis of concussion/mTBI, PCPs should also prepare patients and their support person for possible delayed complications by providing both verbal and written information. Namely, given that the majority of patients will be symptomatic acutely post-concussion/mTBI, education about anticipated symptoms and duration may assist patients in anticipating and understanding their recovery.9 For instance, patients are likely to initially experience reduced cognitive functioning post-injury, which typically resolves in a few days but in some instances may persist for weeks to months.10 Provision of information regarding concussion/mTBI symptoms and expectations for recovery, as well as instructions for follow up, have been shown to be one of the more effective strategies in preventing the development of persistent symptoms post-concussion/mTBI. Follow-up by a PCP should be arranged for all patients with a diagnosed concussion/mTBI especially for those with risk factors outlined in Table 1.1. The PCP, or ED physician, if necessary, can monitor progress and ensure that patient symptoms are resolving along expected timelines and make timely arrangements for specialty referral when indicated. In both the initial assessment and the follow up period, the ED physician or PCP should also attempt to explore and document risk factors (Table 1.1) that may potentially delay recovery following concussion/mTBI, and consider closer monitoring of recovery or an acceleration of intervention strategies if needed. See Algorithm 1.1, which outlines the key steps for diagnosis/ assessment and initial management.
1.1
Concussion/mTBI should be recognized and diagnosed as soon as possible to improve positive health outcomes for patients. Concussion can be recognized in the community by a non-medical professional, whereas diagnosis should be made by a physician/ nurse practitioner.
Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).
1.2
On presentation, the primary care provider should conduct a comprehensive review of every patient who has sustained concussion/mTBI (see Appendix 1.1). The assessment should include taking a history, examination and cognitive screen for post-concussive symptoms, and review of mental health (see Table 1.2).
Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).
1.3
The need for early neuroimaging should be determined according to the Canadian CT Head Rule (see Figure 1.1). For patients who fulfill these criteria, CT scanning is the most appropriate investigation for the exclusion of neurosurgically significant lesions, such as hemorrhage. Plain skull x-rays are not recommended.
Adapted from the NSW Ministry of Health. Closed Head Injury in Adults - Initial Management (PD2012_013)
1.4
The presence of post-traumatic amnesia should be specifically assessed for during the acute assessment and its impact on the patient’s capacity should be considered when planning management (see Appendix 1.2).
Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).
1.5
Patients presenting to hospital/ clinic acutely with concussion/mTBI can be safely discharged for home observation after an initial period of in-hospital observation if they meet the following clinical criteria:
Adapted from the NSW Ministry of Health. Closed Head Injury in Adults - Initial Management (PD2012_013)
1.6
Patients with concussion/mTBI can be safely discharged for home observation after an initial period of observation if they meet the following discharge advice criteria provided in written and oral form:
Adapted from the NSW Ministry of Health. Closed Head Injury in Adults - Initial Management (PD2012_013)
1.7
If the patient re-attends an emergency department/urgent care service with symptoms related to the initial injury, the following should be conducted:
Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).
1.8
Somatic, cognitive/communication and emotional/behaviour symptoms following concussion/mTBI should be documented using a standardized assessment scale (Appendix 1.5 and 1.6) at the initial appointment as well as follow-up appointments until symptoms resolve.
Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).
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Country: USA
Design: Cross Sectional
Quality Rating: Downs & Black: 18/32 *7 sections not applicable
Carney N, Ghajar J, Jagoda A, et al. Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery. 2014;75 Suppl 1:S3-15
Country: USA
Design: Systematic Review
Quality Rating: PRISMA: 21/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable
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Country: USA
Design: Case-Control
Quality Rating: DOWNS & BLACK: 13/32 *6 of the sections were not applicable
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Country: USA
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 14/32 *6 of the sections were not applicable
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Country: USA
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 14/32 *5 of the sections were not applicable
Ayaz SI, Thomas C, Kulek A, et al. Comparison of quantitative EEG to current clinical decision rules for head CT use in acute mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(4):493-496.
Country: USA
Design: Prospective Observational
Quality Rating: DOWNS & BLACK: 15/32 *6 of the sections were not applicable
Sharp AL, Nagaraj G, Rippberger EJ, et al. Computed Tomography Use for Adults With Head Injury: Describing Likely Avoidable Emergency Department Imaging Based on the Canadian CT Head Rule. Acad Emerg Med. 2017;24(1):22-30.
Country: USA
Design: Observational Study
Quality Rating: DOWNS & BLACK: 15/32 *7 of the sections were not applicable
Meares S, Shores EA, Smyth T, Batchelor J, Murphy M, Vukasovic M. Identifying posttraumatic amnesia in individuals with a Glasgow Coma Scale of 15 after mild traumatic brain injury. Arch Phys Med Rehabil. 2015;96(5):956-959.
Country: Australia
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 14/32 *7 of the sections were not applicable
Hartwell JL, Spalding MC, Fletcher B, O'mara MS, Karas C. You cannot go home: routine concussion evaluation is not enough. Am Surg. 2015;81(4):395-403.
Country: USA
Design: Cross-Sectional
Quality Rating: DOWNS & BLACK: 14/32 *7 of the sections were not applicable
Dagher JH, Richard-Denis A, Lamoureux J, de Guise E, Feyz M. Acute global outcome in patients with mild uncomplicated and complicated traumatic brain injury. Brain Inj. 2013;27(2):189-199.
Country: Canada
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 16/32 *8 of the sections were not applicable
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Country: USA
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 15/32 *7 of the sections were not applicable
Almenawer SA, Bogza I, Yarascavitch B, et al. The value of scheduled repeat cranial computed tomography after mild head injury: single-center series and meta-analysis. Neurosurgery. 2013;72(1):56-62; discussion 63-54.
Country: Canada
Design: Systematic Review
Quality Rating: PRISMA: 15/27 *Additional analyses were not undertaken, so 3 of the items were not applicable
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Country: Italy
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 18/32 *5 of the sections were not applicable
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Country: Australia
Design: Case-Control
Quality Rating: DOWNS & BLACK: 18/32 *4 of the sections were not applicable
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