Clinical scenario:
A 16-year-old boy presents after hitting his head in a collision with another player during a soccer game. He denies loss of consciousness but complains of a moderate headache, nausea, and difficulty concentrating.
Which of the following represents appropriate next steps in management?
A. Admit the patient to the hospital for overnight observation
B. Clear the patient to play after 48 hours if his symptoms resolve
C. Discharge with instructions to get follow-up care and not return to play
D. Order a head CT to rule out the presence of an intracranial bleed or swelling
The correct answer is C.
Concussions
What is a concussion?
The term "concussion" is often used in the medical literature as a synonym for mild TBI but more specifically describes a pathophysiological state that results in the characteristic symptoms and signs that individuals may experience after a mild TBI.
Symptoms
Rapid-onset short-lived neurologic function impairment that resolves on its own. These symptoms reflect functional disturbance rather than structural injury.
Diagnosis
If one or more of the following:
Symptoms, including somatic (headache, nausea, off balance), cognitive (“ in a fog,” slow), or emotional (rapidly changing)
Physical signs, such as loss of consciousness, amnesia, although LOC is not required
Behavior changes, such as irritability
Cognitive impairment, such as slowed reaction times
Sleep disturbance, such as insomnia
Evaluation
Concussion is a clinical diagnosis, and there are a variety of sideline assessment tools (that are outside the scope of the ED) that include measurements of orientation, symptoms, gross cognition, and physical examination findings (e.g. Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), computerized neurocognitive testing, and the Sport Concussion Assessment Tool version 5 (SCAT5 or Child-SCAT5)).
Physical exam should include:
assessment of the cervical spine (+/- immobilization with c-collar if cervical spine injury suspected)
detailed neurologic assessment (including mental status, cognitive functioning, and gait/balance)
structural brain imaging (i.e. CT scan or MRI) if concern for structural injury (e.g. acute brain bleed)
Discharge Precautions
This is arguably the most important part of your role in the concussed patient. Thankfully, the CDC has a ton of great literature on the subject.
Pediatric Care Packets:
Adult Care Packets:
References:
PEER IX
