Rich Greene, PA-C
Head injury and concussion are common outpatient complaints. This case-based approach will help you differentiate the types of concussion and their common management.
A 3 year-old male, presenting to the Emergency Department (ED) after falling off the bed while jumping on it. Patient hit their head on a tile floor and the bed is approximately 30” high. No loss of consciousness (LOC) or lacerations. No neck or back pain. Mom states that there was an immediate cry, no vomiting, and that the child is acting at baseline.
A 17-yo male is brought to the ED. He is wearing a football uniform and says that he “got his bell rung” while making a tackle. The patient also thinks there may have been helmet to helmet contact. He feels a little “woozy” but no vomiting. He is complaining of a headache but no neck or back pain. Otherwise, it is a benign neurological exam and physical exam. He is unsure of LOC but doesn’t think so. His parents say he was immediately removed from the game by his coach and trainer.
A 37-yo female brought in by EMS following a vehicle accident. She is in full backboard and cervical collar precautions. MVC was a t-bone accident on the passenger side. Patient was a restrained driver with airbag deployment. EMS denied any spider web cracks of the windshield. Patient is alert and oriented x4 with a GCS 15. She denies neck or back pain or any other injuries. The patient states that she might have hit her head but there is only a small abrasion from the airbag. She states that she just tensed up and everything “went black” for a couple seconds. While strapped to the backboard, she states that she started to develop a minor headache.
A 72-yo female sent in by the primary care physician. Patient had a slip and fall in the bathroom on a wet floor. She states that she hit her head on the wall on the way down to the floor. She has no other injuries. Denies headache, back, or neck pain. Patient is on blood thinners for Afib. She has no complaints and is alert and oriented. She does not know why she was sent to the emergency room.
All of these patients finished their initial provider interviews with the same question: I just want to know if I have a concussion?
How to Approach a Head Injury
Each of these different patients probably present to the primary care, urgent care, or the ED countless times a day. By taking a thorough history, review of systems, and physical exam, you can completely address their concerns quickly with a minimal use of time and resources keeping both the patient and practice managers happy.
There are 1.6 to 3.8 million cases of minor traumatic brain injury every year. This is according to a 1991 study from the CDC. Likewise, A 2016 study in Pediatrics, estimated 1.1-1.9 million sports-related concussions each year in youth athletics. Since the rise in attention due to NFL and military related injuries, a 2014 study demonstrated an 8-fold increase for concussive injuries between 2006-2010. There are no known specific reasons for the increase in cases. While reasons for the increase are likely multi-factorial, we suspect that increased public awareness is a significant factor. Concussion and TBI literature has been in hot topic in recent years and for a while was constantly changing. The two most recent guidelines come from the Concussion in Sport Group (CISG) in October 2016 and the CDC in 2018. These guidelines were reviewed In 2019 and various medical organizations support these findings.
What is a Concussion?
The first question to answer for ourselves and for our patient is: “What is a concussion?”
According to the CDC Heads-up website, a concussion is a type of traumatic brain injury. It is “caused by a bump, blow, or jolt to the head, or by a hit to the body that causes the head and brain to move rapidly back and forth”. In my opinion this is an excellent website for both patients and providers. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.” When counseling patients, I tend not to use such dramatic language and usually say that there is no imaging test that tells us you have a concussion. A concussion means you hit your head causing an injury and now you have these types of symptoms (see the list below).
So following a head injury, what are the signs and symptoms that point us towards a diagnosis of concussion?
|Concussion Signs |
|Concussion Symptoms REPORTED|
|Can’t recall events prior to or after a hit or fall |
Appears dazed or stunned
Forgets an instruction, is confused about an assignment, or unsure or the game, score, or opponent
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
|Headache or “pressure” in head|
Nausea or vomiting
Balance problems or dizziness, or double, or blurry vision
Bothered by light or noise Feeling sluggish, hazy, foggy, or groggy
Confusion or concentration or memory problems
Just not “feeling right” or “feeling down”
After we have evaluated the head injury patient for potentially life threatening injuries, severe TBI, and stabilized the patient (all beyond the scope of this blog), the next critical question is whether to image or not. In our in-person and online courses, we have specific lectures geared towards head injuries and imaging. There are also a couple of key clinical guidelines of this subject. Both the PECARN Pediatric Head Injury Prediction Rule as well as the Canadian CT Head Injury Rule can be used. Below is a quick synopsis of both.
The PECARN tool has also been well validated to identify pediatric patients who are low risk for TBI. Using this decision tool may help you to avoid unnecessary imaging, radiation risks, and costs. The Canadian CT Head Injury tool has also been used for patients over age 16. This clinical tool can be used to rule out head injuries requiring neurosurgical intervention without CT imaging.
Concussion should be considered once TBI has been ruled out either with imaging or clinical assessment. It is important to note though, that normal imagining does NOT rule out a concussion. The diagnosis of concussion requires both a traumatic mechanism and signs and symptoms of concussion.
Following the initial stabilization and imaging decision, ED management is symptomatic. This will typically entail anti-emetics and NSAIDS. Headaches should not be managed with narcotic pain medications. In fact, there are several published guidelines that suggest narcotics are contraindicated. In theory, in the immediate post-injury phase there is a theoretical risk of NSAIDS to increase intracranial bleeding. However, studies have not shown any harm with the use of NSAIDS. But, because of the potential risk, acetaminophen may be preferred over NSAIDS. “Patients who have severe symptoms or persistent neurological deficits, such as altered mental status, may require a period of observation (possibly inpatient) to confirm that symptoms are improving, with frequent neurological checks for those whose symptoms fail to resolve within a few hours.”
Counseling and Guidance
A key discussion for the provider and patient are the discharge instructions. In addition to the medico-legal implications, it can provide your patient with a road map of what to expect. The first step is to discuss signs and symptoms that would indicate to the patient that the condition is deteriorating and a need to return to the ED. My typical discharge instructions include: “Watch for changes in personality, persistent vomiting, worsening headache, and confusion. Return immediately for re-evaluation if these symptoms develop. Avoid narcotic pain medications after a head injury.”
The other part of the discharge discussion is to discuss what to expect regarding their recovery. Initially, recommendations were to follow strict rest. Updated recommendations now recommend a gradual return to full activity. Multiple studies have shown that strict rest inhibits recovery and that moderate cognitive and physical activity had better recoveries. Additionally, I typically print up handouts from the CDC regarding recovery from concussion and returning to school.
Parents frequently ask when to “Return to school” and “return to play”. Children can return to school (and adults to work) typically within 48-72 hours after the injury. The ability to return to school/work is appropriate once severe symptoms have improved. In some situations, some academic/work allowance may be necessary to accommodate for persistent concussive symptoms. Patients with prolonged or severe symptoms may need neurologic consult (typically for vestibular or oculomotor deficits) but a vast majority of concussive patients can be managed by their primary care physician.
For “return to play” questions, it is not appropriate for the ED or Urgent Care provider to provide return to play clearances. All 50 states have concussion-focused legislation to protect youth athletes and the specific requirements vary from state-to-state. “A patient should only be cleared from the concussion once all medications used to treat the concussive symptoms are no longer being taken; all concussive symptoms have resolved; the physical exam is normal, including vestibular and oculomotor function; and there is evidence of neurocognitive recovery, including the ability to fully function in school. Clearance also requires appropriate documentation of successful completion of the physical return-to-sport stages.” The CDC Heads-Up website has a great section on the 6-Step Return to Play Progression. This provides a general overview for parents. Team coaches and training staff manage and document the actual workouts.
Not all head injuries require imaging. In fact, imaging is not necessary to diagnose a concussion. Likewise, the use of validated clinical decision tools can help reduce unnecessary imaging. Concussions do not require strict rest for management. Gradually increasing cognitive and physical activity is also encouraged. This should also be based on symptom tolerance and improvement. Lastly, giving appropriate discharge instructions and care instructions can improve both the patient recovery experience and patient satisfaction.