Sport-Related Concussion and mTBI: Current Guidelines and ED Management

Concussion in the Emergency Department: A Review of Current Guidelines - Trauma EXTRA Supplement

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Table of Contents
About This Issue

An increasing number of patients with concussive injuries are presenting to the ED, due to a combination of factors, including media attention to sport-related concussion, early dedication to competitive sport, and improved screening and diagnostic tools for concussion. Emergency clinicians play an important role in diagnosing concussion, initiating treatment, and providing concussion education to patients and their caregivers to optimize recovery.

How do the recent consensus-based guidelines define concussion and mTBI?

What is the role of sideline assessment in evaluation for sport-related concussion and what types of sideline testing are recommended?

Can validated clinical decision rules, such as the PECARN pediatric head CT rule and the Canadian CT head rule, be used to reduce the use of neuroimaging in the evaluation of head injury?

What are the signs and symptoms of concussion? Which specific evaluations should be conducted as part of the physical examination when there is suspicion for concussion?

What is the typical recovery time for concussion in children and in adults and what are the risk factors for persistent symptoms and prolonged recovery? What types of therapies are recommended when prolonged recovery occurs?

What are the current recommendations for cognitive and physical rest following concussion and when should patients return to school, work, and/or sport?

When discharging a concussed patient from the ED, what aftercare and follow-up instructions should be provided? In what circumstances should a referral be made for specialty care?

Table of Contents
  1. Key Points
  2. Abstract
  3. Introduction
  4. Concussion in Sport Group Consensus Statement
    1. Definition of Concussion
    2. Sideline Assessment
    3. Concussion Management and Recovery Timeframe
    4. Return to Sport
    5. Complications of Concussion
    6. Concussion Prevention
  5. United States Centers for Disease Control and Prevention Pediatric Mild Traumatic Brain Injury Guideline
  6. Beyond the Guidelines: Practical Concussion Management Recommendations for the Emergency Clinician
    1. Initial Evaluation and Diagnosis
    2. Emergency Department Management
    3. Aftercare
    4. Follow-Up Care
    5. Clearance From Concussion in the Emergency Department
  7. Summary
  8. Additional Resources
    1. Tools
    2. Video demonstrating the administration of the VOMS
    3. Video demonstrating the Balance Error Scoring System
    4. Podcast
  9. Tables and Figures
    1. Table 1. Concussion in Sport Group Consensus Statement Definition of Sport-Related Concussion
    2. Table 2. Graduated Return-to-School Strategy
    3. Table 3. Graduated Return-to-Sport Strategy
    4. Table 4. Canadian CT Head Injury Rule
    5. Table 5. Differential Diagnosis of Concussion
    6. Table 6. Signs and Symptoms of Concussion
    7. Table 7. Proper Sleep Hygiene Techniques
    8. Figure 1. PECARN Decision Rule for Patients Aged < 2 Years
    9. Figure 2. PECARN Decision Rule for Patients Aged ≥ 2 Years
  10. References

Key Points

  • The application of validated clinical decision rules can reduce the use of imaging for evaluation of head injury.
  • Strict rest is no longer recommended for concussion recovery; instead, limited cognitive and physical activity should be allowed as tolerated and as symptoms improve.
  • Providing appropriate aftercare instructions to the concussed patient and the caregivers at the time of discharge can have a positive impact on recovery.


The annual number of emergency department (ED) visits for traumatic brain injury (TBI) is rising in the United States, with the majority of these visits resulting in a diagnosis of mild traumatic brain injury (mTBI), or concussion. There are limited data to support objective clinical measures to guide the management of concussion, but several guidelines have been published that provide recommendations for evaluation and management of concussion and mTBI. This supplement provides a summary of 2 recently published, consensus-based guidelines and discusses practical aspects of ED management of patients with concussive injuries, including the initial evaluation, diagnostic criteria, assessment tools, and aftercare recommendations.


The United States Centers for Disease Control and Prevention (CDC) estimates the incidence of sports-related mTBI in the United States to be 1.6 to 3.8 million per year, based on extrapolation of data from a 1991 study.1 A more recent study estimates that 1.1 to 1.9 million sports-related concussions occur each year in youth athletes in the United States.2 Concussive injuries account for an increasing number of presentations to the ED in the United States. A 2014 study demonstrated an 8-fold increase in ED visits for TBI when compared to total ED visits between 2006 and 2010. This increase may be due to a combination of factors, including improved screening and diagnostic tools, increased exposure to TBI due to early dedication to competitive sport, and more public awareness of TBI.3

The concussion literature is evolving rapidly, but rigorous, standardized research protocols remain limited. This is largely due to heterogeneity in the patient population, clinical trial design, concussion management technologies, and the data analysis techniques used to study an inherently complex disease process. Even with limited quality evidence, several consensus-based concussion guidelines have been published. This article reviews updated guidelines by the Concussion in Sport Group (CISG)4 and new guidelines by the CDC.5 The American Medical Society for Sports Medicine and the American Academy of Pediatrics Council on Sports Medicine and Fitness have also recently published clinical reports on sport-related concussion; these reports are generally reflective of the recommendations presented in the CISG and CDC guidelines.6,7

The CISG and CDC guidelines provide a general review of concussion management and do not address the management of concussion in the ED specifically. The emergency clinician is often first line when diagnosing concussion and initiating treatment. Once a concussion is diagnosed, an important role of the emergency clinician is to provide concussion education (including anticipated signs, symptoms, and recovery course), outpatient referral, and information on preventing re-injury. The CISG consensus statement specifically addresses sport-related concussion (SRC), but much of the information it presents is applicable to concussion management regardless of the mechanism of injury.


Additional Resources


Video demonstrating the administration of the VOMS

Video demonstrating the Balance Error Scoring System

Note: This video demonstrates the full protocol, which includes each of the 3 stances tested on a firm surface and on foam. In the ED setting, the modified protocol (mBESS) can be used, testing each stance only on a firm surface.


Tables and Figures

Table 1. Concussion in Sport Group Consensus Statement Definition of Sport-Related Concussion

Sport-related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilised in clinically defining the nature of a concussive head injury include:

  • SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
  • SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
  • SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  • SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.

The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc) or other comorbidities (eg, psychological factors or coexisting medical conditions).

Reproduced from British Journal of Sports Medicine, McCrory P, Meeuwisse W, Dvorak J, et al, Volume 51, pages 838-847, with permission from BMJ Publishing Group Ltd.

Table 5. Differential Diagnosis of Concussion


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent in-formation about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available.

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Publication Information

Susan B. Kirelik, MD, FAAP

Peer Reviewed By

Jeffrey J. Bazarian, MD, MPH; Tamara R. Espinoza, MD, MPH, FACEP

Publication Date

September 15, 2019

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