Domain 2: Initial Medical Assessment and Management

Recommendations

2.1

Physicians or nurse practitioners should perform a comprehensive medical assessment on all children/adolescents with a suspected concussion or with acute head or spine trauma.  

Tool 1.3: Manage Acute and Prolonged Symptoms Algorithm

Include a clinical history, physical examination, and the evidence-based use of diagnostic tests or imaging as needed.

2.1a

Take a comprehensive clinical history.

Level of Evidence:

Details that should be collected in the clinical history include:

  • Patient demographics (e.g., age, sex, gender).
  • Assess injury mechanism and symptoms at the time of injury.
  • Assess symptom burden at the time of initial presentation.
    • Number of symptoms.
    • Severity of symptoms.
    • Type of symptoms.
  • Presence of loss of consciousness, post-traumatic amnesia, and red flags (seizures, neck pain, focal neurological deficits).
  • Current post-concussion symptoms (using age-appropriate standardized symptom inventory).
  • Review mental health (Domain 8: Mental Health).
  • Past medical history (e.g., previous concussions, migraine or non-specific headaches, mental health disorders, coagulopathy). Note the duration until recovery from previous concussions (i.e., within 7-10 days or prolonged).
  • Allergies/immunizations.
  • Ask whether the child/adolescent is taking any substances or medications: Prescribed or over-the-counter medications or supplements, alcohol, or recreational drugs including cannabis. These substances may mask or modify concussion symptoms.

Ask about school, activities, work, and sports participation.

2.1b

Note common modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

Level of Evidence:

Link: Predicting Persistent Post-Concussive Problems in Pediatrics (5P): Score Calculator.

Modifiers that may delay recovery:

  • Age (increased risk with increased age).
  • Sex (female).
  • Duration of recovery from a previous concussion.
  • High pre-injury symptom burden.
  • High symptom burden at initial presentation.
  • Clinical evidence of vestibular or oculomotor dysfunction.
  • Personal and family history of migraines.
  • History of learning or behavioural difficulties.
  • Personal and family history of mental health.
  • Family socioeconomic status/education.

2.1c

Perform a comprehensive physical examination.

Level of Evidence:  

  • Vital signs (resting heart rate and blood pressure).
  • Level of consciousness (GCS).
  • Mental status.
  • A complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait and balance testing) (Tool 2.1: Physical examination).
  • A cervical spine examination (palpation, range of motion, provocative cervical spine tests) (Tool 2.1: Physical examination).
  • An examination of the visual and vestibular systems.

Online tools to consider:

2.1d

Consider CT of the brain or cervical spine only in patients whom, after a medical assessment, a structural intracranial or cervical spine injury is suspected; do not conduct routine neuroimaging for the purpose of diagnosing concussion. 

Level of Evidence: CT. MRI.

Most children/adolescents who sustain an acute head injury or suspected concussion do not need diagnostic imaging. 

Use the following tools, as appropriate, to determine the need for CT imaging in patients with acute head trauma:

Although validated clinical decision-making rules are highly sensitive, these tools are meant to assist but not replace clinical judgment. CT scans should be used judiciously as the exposure of children/adolescents to the effects of ionizing radiation carries a small increased lifetime risk of cancer. If a structural brain injury is suspected in a patient with acute head trauma undergoing initial medical assessment in the office setting, urgent referral to an Emergency Department should be arranged.

Diagnostic imaging of the spine should be considered when symptoms are suggestive of structural cervical spine injury. Imaging should be considered in patients with severe neck pain, tenderness or clinical evidence of radiculopathy or myelopathy. The choice of imaging modality (plain radiographs, CT or MRI of the cervical spine) should be guided by the suspected pathology.

Patients with positive traumatic findings observed on diagnostic imaging of the brain or spine should be urgently referred to a neurosurgeon for consultation.

2.2

Provide verbal information and written (electronic) handouts regarding the course of recovery and when the child/adolescent can return to school/activity/sport/work.

Level of Evidence:  

Consider the following anticipatory guidance (verbal reassurance) in order to reduce anxiety, set realistic expectations, promote recovery, and prevent re-injury: 

  • Most patients recover fully from concussion even though the recovery rate is variable and unpredictable.
  • Current symptoms are expected and common.
  • The burden and distress parents/caregivers of children/adolescents who have sustained a concussion may experience is common.
  • Children typically recover in 1-4 weeks but some children/adolescents will have symptoms at one month and beyond and need to be monitored/seek additional care. Females aged 13-18 years have an increased risk of prolonged recovery.
  • Recommendation 2.3 Recommend graduated return to physical and cognitive activity
  • Domain 12: Return-to-School and Work.

Summary of online tools to consider related to lifestyle strategies and expectations:

2.3

Recommend graduated return to cognitive and physical activity to promote recovery.

While most children/adolescents fully recover, the recovery rate can be variable. Return to physical and cognitive activity should be individualized based on activity tolerance and symptom presentation.

2.3a

Recommend an initial 24-48 hour period of rest with limited physical and cognitive activity.

Level of Evidence:  Gradual return to physical activity. Gradual return to cognitive activity.

2.3b

Recommend that low to moderate level physical and cognitive activity be gradually started 24-48 hours after a concussion at a level that does not result in recurrence or exacerbation of symptoms. Activities that pose no/low risk of sustaining a concussion should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence:  Gradual return to physical activity. Gradual return to cognitive activity.

Low to moderate level physical and cognitive activity:

2.3c

Recommend that patients avoid activities associated with a risk of contact, fall, or collisions such as high speed and/or contact activities and full-contact sport that may increase the risk of sustaining another concussion during the recovery period.

Level of Evidence:  

  • Advise/emphasize that returning to full-contact sport or high-risk activities before the child/adolescent has recovered increases the risk of delayed recovery and for sustaining another more severe concussion or more serious injury.

2.4

Provide education and guidance regarding strategies to promote recovery.

2.4a

Advise on the importance of sleep and discuss sleep hygiene.

Level of Evidence:

Advise that consistent sleep schedules and duration of sleep may contribute to general recovery from a concussion and alleviate symptoms such as mood, anxiety, pain, fatigue, and cognitive difficulties if these are present. 

Summary of tools to consider:

2.4b

Advise on maintaining social networks and interactions as tolerated beyond a brief initial period of cognitive and physical rest (24-48 hours after injury).

Level of Evidence:  

Beyond a brief initial period of cognitive and physical rest, 24-48 hours after injury, children/adolescents should participate in rewarding social activities, modified as needed, while staying below their symptom-exacerbation thresholds and avoiding risk for re-injury. There is evidence that reducing the risk of social isolation and mental health issues may promote recovery.

  • Identify these activities and suggest modifications as appropriate.
  • Educate on the principle that participation in rewarding social activities in the presence of residual or prolonged symptoms may have to be limited so that they do not result in a recurrence or exacerbation of symptoms.

2.4c

Advise on the use of computers, phones, and other devices with screens. Beyond an initial period of cognitive and physical rest (24-48 hours after injury), use of devices with screens may be gradually resumed at a level that does not result in recurrence or exacerbation of symptoms.

Level of Evidence:

Advise that computers, phone, and other devices with screens may exacerbate symptoms, especially in the first days after injury. The use of these devices can be increased according to symptom tolerance as the child/adolescent recovers. For sleep hygiene purposes, these devices should not be used in the hour prior to bedtime.

2.4d

Advise on avoiding alcohol and other recreational drugs after a concussion.

Level of Evidence:

Alcohol and recreational drugs may have a negative effect on concussion recovery. Avoiding alcohol or drugs prevents a child/adolescent from self-medicating and resorting to drugs to relieve symptoms. Impaired judgment after a concussion could lead to risky behaviour that causes further harm or may delay the identification of complications.

2.4e

Advise to avoid driving during the first 24-48 hours after a concussion. Advise patients to begin driving when they are feeling improved, can concentrate sufficiently to feel safe behind the wheel, and when the act of driving does not provoke significant concussion symptoms.

Level of Evidence:

Provide verbal information related to when an adolescent should return to driving during recovery from a concussion. Driving is a complex coordinated process that requires vision, balance, reaction time, judgment, cognition, and attention. Concussion may have affected some or all of these skills. Driving impairments have been shown to exist even in asymptomatic patients 48 hours after a concussion. Avoiding driving for at least 24-48 hours after a concussion may potentially prevent motor vehicle accidents and, therefore, injury to the adolescent or to others.

2.5

Over-the-counter medications such as acetaminophen and ibuprofen may be recommended to treat acute headache. Advise on limiting the use of these medications to less than 15 days a month and avoiding “around-the-clock” dosing to prevent overuse or rebound headaches (i.e., advise that children/adolescents avoid using over the counter medications at regular scheduled times throughout the day).

Level of Evidence:  

2.6

At present, there is limited evidence to support the administration of intravenous medication to treat acute headaches in pediatric concussion patients in the Emergency Department setting.

Level of Evidence:

2.7

After assessment, nearly all children/adolescents with concussion may be safely discharged from clinics and Emergency Departments for observation at home.

Level of Evidence:  

The decision to observe in the hospital will depend on clinical judgment. Indicators for longer in-hospital observation (or to return to emergency for re-assessment) may include:

  • Worsening symptoms (headache, confusion, irritability).
  • Decreased level of consciousness.
  • Prolonged clinical symptoms (persistent/prolonged vomiting, severe headache, etc.).
  • Bleeding disorders.
  • Multi-system injuries. 
  • Co-morbid symptoms. 

Other discharge considerations:

  • Observe the child/adolescent for a period of time to verify that they do not develop “red flag” symptoms prior to discharge. Use clinical judgment.
  • Verify that the child/adolescent has a normal mental status (alertness/behaviour/cognition) and their symptoms are improving prior to discharge. 
  • Verify that an assessment of clinical risk factors indicating the need for a CT scan was performed or a normal result was obtained if a CT scan was performed prior to discharge.
  • See Recommendation 2.1d for more information on when to consider diagnostic brain or cervical spine imaging.

2.8

Recommend a medical follow-up visit in 1-2 weeks to re-assess and monitor clinical status. Recommend an immediate medical follow-up in the presence of any deterioration.

Level of Evidence:

Those with a confirmed diagnosis of concussion may be managed by a healthcare professional who within their formally designated scope of practice has the capacity to manage ongoing concussion-related symptoms.

2.9

Consider referral to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence:

See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

2.10

Provide post-concussion information and a written medical assessment to the child/adolescent and the parent/caregiver prior to sending the child/adolescent home. 

Level of Evidence:  

Write the discharge note/written medical assessment with the following information:

Verbal and written (or electronic) guidance should include:

Examples of patient information handouts to consider: