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?
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.
Abstract
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.
Introduction
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.
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.
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.
References
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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EXTRA Supplement Podcast
Concussion in the Emergency Department: A Review of Current Guidelines - Trauma EXTRA Supplement (Trauma CME)
Dr. Susan Kirelik, a concussion specialist and emergency medicine physician, discusses the key points of concussion diagnosis and management from the perspective of the emergency medicine clinician. The topics covered include:
The signs and symptoms of concussion and how it is diagnosed in the ED
The initial evaluation of a patient presenting with a head injury, including tools for determining when neuroimaging is indicated
Screening tools for the evaluation of patients with suspected concussion, such as the VOMS examination and the SCAT5 and Child SCAT5 tools
Management of patients in the ED after making a concussion diagnosis and the role of rest, antiemetics, and acute pain management for these patients
The importance of aftercare instructions when discharging concussed patients, in the context of new guidelines for concussion recovery
The risk factors for prolonged recovery from concussion and resources for concussion recovery
Patients seeking concussion clearance in the ED
Addressing patient or parent questions about the long-term complications of concussion, such as second impact syndrome, the potential for cumulative effects of multiple concussions, and risk for CTE (chronic traumatic encephalopathy)
Susan B. Kirelik is the Medical Director of the Rocky Mountain Pediatric OrthoONE Center for Concussion and is an attending pediatric emergency medicine physician at the Rocky Mountain Hospital for Children in Denver, Colorado.
Get quick-hit summaries of hot topics in emergency medicine. EMplify summarizes evidence-based reviews in a monthly podcast. Highlights of the latest research published in EB Medicine's peer-reviewed journals educate and arm you for life in the ED.
The Glasgow Coma Scale (GCS) estimates coma severity based on eye, verbal, and motor criteria. The PECARN Pediatric Head Injury Prediction Rule is a well-validated clinical decision aid that allows physicians to safely rule out the presence of clinically important traumatic brain injuries. The Canadian CT Head Rule (CCHR) was developed to help physicians determine which patients with minor head injury need head CT imaging.
The Glasgow Coma Scale (GCS) allows providers in multiple settings and with varying levels of training to communicate succinctly about a patient’s mental status.
The GCS has been shown to have a statistical correlation with a broad array of adverse neurologic outcomes, including brain injury, need for neurosurgery, and mortality.
The GCS has been incorporated into numerous guidelines and assessment scores (eg, ACLS, ATLS, APACHE I-III, TRISS and the WNS SAH grading scale).
In some patients, it may be impossible to assess 1 or more of the 3 components of the GCS. The reasons for this include, but are not limited to:
Eye: local injury and/or edema
Verbal: intubation
All (eye, verbal, motor): sedation, paralysis, and ventilation that eliminates all responses
If a component is untestable, a score of 1 should not be assigned (Teasdale 2014). In this circumstance, summation of the findings into a total GCS score is invalid.
The 3 parts of the GCS are charted independently, and a component can be recorded as NT (not testable), with an option of indicating the reason (eg, C for eye closure and T for intubation).
Points to keep in mind:
Correlation with outcome and severity is most accurate when applied to an individual patient over time; the patient’s trend is important.
A GCS score of 8 should not be used in isolation to determine whether or not to intubate a patient but does suggest a level of obtundation that should be evaluated carefully.
Reproducibility is usually good (Reith 2016). If individual institutions have concerns about agreement among providers, training and education are available from the GCS creators.
Simpler scores that have been shown to perform as well as the GCS in the prehospital and emergency department setting (for initial evaluation); these are often contracted versions of the GCS itself. For example, the Simplified Motor Score (SMS) uses the motor portion of the GCS only. The SMS and other contracted scores are less well studied than the GCS for outcomes like long-term mortality, and the GCS has been studied as trended over time, while the SMS has not.
Why and When to Use, and Next Steps
Why to Use
The Glasgow Coma Scale (GCS) is an adopted standard for mental status assessment in the acutely ill trauma and nontrauma patient and assists with predictions of neurological outcomes (complications, impaired recovery) and mortality.
When to Use
The GCS is designed for use in serial assessments of patients with coma from either medical or surgical causes and is widely applicable.
The GCS is commonly used in the prehospital and acute care setting as well as over a patient’s hospital course to evaluate for mental status assessment in both traumatic and nontraumatic presentations.
In the care of an individual patient, the scoring for each of the 3 components of the GCS (eye, verbal, motor) should be assessed, monitored, reported, and communicated separately.
The combined GCS score is an index of the net severity of impairment and is useful as a summary of a patient’s condition, in classifying groups of different severity, for triage, and in research. A GCS score should not be calculated if 1 or more of the components cannot be assessed.
Next Steps
The GCS can indicate the level of critical illness.
Trauma patients presenting with a GCS score < 15 warrant close attention and reassessment.
A declining GCS score is concerning in any setting and should prompt airway assessment and possible intervention.
Conversely, a GCS score of 15 should not be taken as an indication that a patient (trauma or medical) is not critically ill. Decisions about the aggressiveness of management and treatment plans should be made based on clinical presentation and context, and should not be overridden in any way by the GCS score.
Clinical management decisions should not be based solely on the GCS score in the acute setting.
If a trauma patient has a GCS score < 8 and there is clinical concern that the patient is unable to protect his/her airway or there is an expected worsening clinical course based on exam or imaging findings, then intubation can be considered.
In any patient, a rapidly declining or waxing and waning GCS score is concerning and intubation should be considered in the context of the patient's overall clinical picture.
Calculator Review Authors
Daniel Runde, MD
Department of Emergency Medicine
University of Iowa Hospitals and Clinics, Iowa City, IA
Critical Action
Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use. Clinical management decisions should not be based solely on the GCS score in the acute setting.
Evidence Appraisal
The modified GCS (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14-point original GCS) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale 1974).
The evidence presented in 53 published reports on the reproducibility of the GCS was synthesized in a systematic review by Reith et al in 2016. Eighty-five percent of the findings in the studies identified as high quality showed substantial reliability of the GCS as judged by the standard criterion of a kappa statistic > 0.6. Reproducibility of the total GCS score was also high, with kappa > 0.6 in 77% of the observations. Education and training on usage of the GCS resulted in a clear beneficial effect on reliability (Reith 2016).
In its most common usage, the 3 sections of the scale are often combined to provide a summary of severity. The authors themselves have explicitly objected to the score being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality. A GCS score of 4 predicts a mortality rate of 48% if calculated 1 + 1 + 2 for eye, verbal, and motor components, respectively, and a mortality rate of 27% if calculated 1 + 2 + 1, but a mortality rate of only 19% if calculated 2 + 1 + 1 (Healey 2014).
In summary, the modified GCS provides a nearly universally accepted method of assessing patients with acute brain damage. Summation of its components into a single overall score loses information and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the motor component of the scale (as in the SMS) can perform as well as the GCS and is less complicated. However, the scores like the SMS may be less informative in patients with lesser injuries.
The PECARN Pediatric Head Injury Prediction Rule is a well-validated clinical decision aid that allows physicians to safely rule out the presence of clinically important traumatic brain injuries.
The Pediatric Emergency Care Applied Research Network (PECARN) consortium produced the largest study, to date, aiming to derive and validate clinical prediction rules to identify children with very low risk of clinically important traumatic brain injury (ciTBI) following blunt head trauma, who would not require imaging. ciTBI was chosen as the primary outcome because it is clinically driven and accounts for the imperfect test characteristics of computed tomography (CT).
In the group of patients aged < 2 years, the rule was 100% sensitive.
In the group of patients aged > 2 years, the rule had 96.8% sensitivity.
In those aged < 2 years with a Glasglow Coma Scale (GCS) score of 14, altered mental status, or palpable skull fracture, risk was 4.4%, and CT imaging is recommended.
Risk with any of the remaining predictors was 0.9%, and < 0.02% with no predictors.
In those aged > 2 years with GCS score of 14, altered mental status, or signs of basilar skull fracture, risk was 4.3%, and CT imaging is recommended.
Risk with any of the remaining 4 predictors was 0.9%, and < 0.05% with no predictors. The PECARN Rule outperformed both the CHALICE (Children's Head injury ALgorithm for the prediction of Important Clinical Events) and CATCH (Canadian Assessment of Tomography for Childhood Head injury) clinical decision aids in external validation studies.
Although it was the largest trial of its kind, the PECARN study had low rates of traumatic brain injury (TBI) on head CT (5.2%) and even lower rates of ciTBI (0.9%), suggesting that overall TBI in children is rare. Head CTs were obtained in approximately 35% of patients, lower than the average estimate of 50%.
Why and When to Use, and Next Steps
Why to Use
Unlike in the adult population, CT imaging of the head in pediatric patients is believed to be associated with an increased risk of lethal malignancy over the life of the patient, with the risk decreasing with age. The estimated lifetime risk of lethal malignancy from a head CT for a 1-year-old patient is 1 in 1000 to 1500, with risk decreasing to 1 in 5000 for a 10-year-old patient.
There are over 600,000 emergency department visits annually in the United States for head trauma among patients aged ≤ 18 years. Applying the PECARN Pediatric Head Injury Prediction Rule allows providers to determine which pediatric patients they can safely discharge without obtaining a head CT.
When to Use
The PECARN is a well-validated clinical decision aid that allows physicians to safely rule out the presence of clinically important traumatic brain injuries among pediatric head injury patients without the need for CT imaging, including those that would require neurosurgical intervention.
The PECARN Rule only applies to children with GCS scores ≥ 14.
Next Steps
In patients with suspected or radiologically confirmed TBI, first assess ABCs (airway, breathing, circulation) and consider neurosurgical and/or intensive care unit consultation or local policies for fluid management, seizure prophylaxis, hypertonic saline/mannitol, disposition, etc.
Consider observation for 4to 6 hours for patients who are not imaged, in order to assess for changes in clinical status.
Reassurance, education, and strict return precautions are warranted for patients discharged without imaging, including direction to follow up with a primary care provider or neurologist, and anticipatory guidance on return to play/school if concussion is suspected.
Calculator Review Authors
Daniel Runde, MD
Department of Emergency Medicine
Carver College of Medicine
University of Iowa Health Care, Iowa City, IA
Joshua Beiner, MD
Department of Emergency Medicine
New York University School of Medicine, New York, NY
Critical Actions
ciTBI was a rare event (0.9%) and neurosurgical intervention was even more rare (0.1%). Over 50% of each age cohort did not meet any predictors, and CT imaging is not indicated for the vast majority of these patients, as risk of ciTBI was exceedingly low. Risk of ciTBI was > 4% with either of the 2 higher-risk predictors in each age cohort, and imaging is recommended.
For the remaining 4 lower-risk predictors in each cohort, the risk of ciTBI is approximately 0.9% per predictor, and CT imaging is indicated rather than observation. Judgment may be based on clinical experience, single versus multiple findings, signs of clinical deterioration during the observation period, patient age, and/or parental preference.
Evidence Appraisal
The original PECARN trial included 42,412 children aged < 18 years presenting to one of the 25 North American PECARN-affiliated emergency departments. There were 33,785 patients in the derivation cohort (8502 of whom were aged < 2 years) and 8627 in the validation cohort (2216 of whom were aged < 2 years).
CT scans were performed at the physician’s dis-cretion in 35.3%, while medical records, telephone surveys, and county morgue records were used to assess for cases of missed ciTBI in those discharged without imaging. The potential for CT reduction quoted above is likely underestimated, given that CT utilization in this study (35.3%) was significantly lower than the estimated average in North American emergency departments (50%).
TBI occurred in 5.2% of patients. Nine percent of patients were admitted to the hospital. ciTBI occurred in 0.9% of the cohort, neurosurgery was performed in 0.1% of the overall cohort, and 0 patients died. In patients aged < 2 years who were negative for any PECARN risk factor, the aid was 100% sensitive (95% confidence interval [CI], 86.3-100) with a negative predictive value (NPV) of 100% (95% CI, 99.7-1000) for ruling out ciTBI in the validation cohort. In patients aged > 2 years who were negative for any PECARN risk factor, the aid was 96.8% sensitive (95% CI, 89.0-99.6) with 99.95% NPV (95% CI, 99.8-99.99) for ruling out ciTBI in the validation cohort.
External validation studies have demonstrated sensitivity of 100% for ciTBI and any injury requiring neurosurgery. The algorithm has reasonable specificity (53%-60%), considering its extremely high sensitivity.
Sixty of 376 patients (15.9%) with ciTBI underwent neurosurgery, 8 patients (2.1%) with ciTBI were intubated > 24 hours, and 0 patients died.
As a result of the infrequency of ciTBI, the lower bounds of the CIs of sensitivity started at 86% and 89%, respectively, for the cohorts aged < 2 years and > 2 years. The NPV CIs very closely approximated 100%.
The PECARN Rule has now been externally validated in 2 separate studies. One trial of 2439 children in 2 North American and Italian centers found the PECARN Rule to be 100% sensitive for ruling out ciTBI in both age cohorts. The rates of 0.8% (19/2439) of patients with ciTBI and 0.08% (2/2439) of patients requiring neurosurgery were similar to the rates in the PECARN trial.
A second trial at a single United States emergency department of 1009 patients aged < 18 years prospectively compared the PECARN Rule to 2 other pediatric head CT decision aids, CHALICE and CATCH, as well as to physician estimates and physician practice. In this sample, 2% (21/1009) of patients had ciTBI and 0.4% (4/1009) of patients needed neurosurgery. Again, the PECARN Rule was found to be 100% sensitive for identifying ciTBI.
The PECARN Rule outperformed both the CHALICE and CATCH decision aids, which were 91% and 84% sensitive for ciTBI, respectively). Although the goal was to rule out those with very low risk of ciTBI, the PECARN Rule also performed well to rule out TBI on head CT. In patients aged < 2 years, sensitivity and NPV were 100% for TBI on CT, with narrow CIs. In patients aged > 2 years, sensitivity was 98.4% and NPV was 94% for TBI on CT, with relatively narrow confidence intervals.
Two PECARN Rule subgroup analyses attempted to further risk-stratify patients with single predictors (eg, isolated scalp hematoma in patients aged < 2 years). ciTBI was too uncommon to apply age, hematoma size, or hematoma location predictors. There were several non–statistically significant trends for higher rates of TBI on head CT that may affect imaging tendencies (eg, age < 3 months, nonfrontal hematoma, and large size).
Another subanalysis of those with isolated vom-iting (eg, no other PECARN predictors) reiterated the parent study results. In the cohort of patients aged > 2 years, there was a low rate of TBI on head CT (3.2%, 26 of 806 patients) and an even lower rate of ciTBI (0.7%, 10 of 1501 patients), so observation rather than emergent imaging is indicated in the majority of these patients. Number of vomiting episodes and timing of episodes was not helpful in predicting ciTBI or TBI on head CT, as there was a non–statistically significant counterintuitive trend towards less ciTBI/TBI on CT with more episodes.
The original validation trial and multiple subsequent studies (Stiell 2001, Stiell 2005, Stiell 2010) each found the high-risk criteria of the Canadian CT (computed tomography) Head Rule (CCHR) to be 100% sensitive for injuries requiring neurosurgical intervention. The CCHR has an 87% to 100% sensitivity for detecting “clinically important” brain injuries that do not require neurosurgery.
The rule excluded patients who were taking oral anticoagulants and antiplatelet agents, so no data are available for these patients.
Patients with minimal head injury (ie, no history of loss of consciousness, amnesia, and confusion) generally do not need a CT scan. For example, patients aged > 65 years may not need a CT scan just based on age if they do not have the history mentioned above.
When a patient fails the CCHR, use clinical judgment on whether a CT scan is necessary.
One study (Harnan 2011) found the CCHR to be the most consistent, validated, and effective clinical decision rule for minor head injury patients.
While there is only 1 United States validation study for the CCHR, it was 100% sensitive for clinically important injuries and injuries requiring neurosurgery. A retrospective study in the United Kingdom found that applying the CCHR would have actually resulted in an increase in the number of patients undergoing CT scans in that particular practice setting. There is debate about whether the goal should be to find all intracranial injuries or to find patient-important ones that would require neurosurgical intervention.
Why and When to Use, and Next Steps
Why to Use
There are more than 8 million patients who present annually to emergency departments in the United States for evaluation of head trauma. The vast majority of these patients have minor head trauma that will not require specialized or neurosurgical treatment. At the same time, rates of CT imaging of the head more than doubled from 1995 to 2007.
When to Use
Apply the CCHR only to patients with GCS scores of 13-15 with loss of consciousness, amnesia to the head injury event, and confusion.
Do not use in patients aged < 16 years, patients on blood thinners, or patients with seizure after injury.
The CCHR is a well-validated clinical decision aid that allows physicians to safely rule out the presence of intracranial injuries that would require neurosurgical intervention, without the need for CT imaging.
The CCHR has been found to be 70% sensitive for “clinically important” brain injury in alcohol-intoxicated patients (Easter 2013).
Next Steps
Remember to always discuss postconcussive symptoms and management with the patient, especially if he or she is being discharged without a head CT. Otherwise, a patient who feels postconcussive symptoms may worry that a CT was needed.
Educating patients on the symptoms of injuries that require neurosurgical intervention versus postconcussion symptoms can help them feel empowered and reassured.
Calculator Review Authors
Daniel Runde, MD
Department of Emergency Medicine
Carver College of Medicine
University of Iowa Health Care, Iowa City, IA
Critical Action
The CCHR has been validated in multiple settings and has been consistently demonstrated to be 100% sensitive for detecting injuries that will require neurosurgery. Depending on practice environment, it may not be considered acceptable to miss any intracranial injuries, regardless of whether they would have required intervention.
Providers may want to consider applying the New Orleans Criteria for head trauma, as there has been at least 1 trial finding it to be more sensitive than the CCHR for detecting clinically significant intracranial injuries (99.4% vs 87.3%), though this comes at the price of markedly decreased specificity (5.6% vs 39.7%). Furthermore, there are other trials in which the CCHR was found to be more sensitive than the New Orleans Criteria for detecting clinically important brain injuries.
Evidence Appraisal
The validation study (Stiell 2005) included a convenience sample of 2702 patients aged ≥ 16 years, who presented to 9 Canadian emergency departments with blunt head trauma resulting in witnessed loss of consciousness, disorientation, or definite amnesia and a Glasglow Coma Scale score of 13 to 15. Within the sample, 8.5% (231/2707) of the patients had a clinically important brain injury, and 1.5% (41/2707) of the patients had an injury that required neurosurgical intervention. In the validation trial, the CCHR was 100% sensitive for both clinically important brain injuries and injuries that required neurosurgical intervention, and was 76.3% and 50.6% specific, respectively, for these injuries.
Subsequent studies have all found the CCHR to be 100% sensitive for identifying injuries that require neurosurgical intervention. Applying the CCHR would allow physicians to safely reduce head CT imaging by around 30% (range of 6%-40%, with most studies showing an estimated 30% reduction). In most studies, 7% to 10% of patients had positive CTs, considered “clinically important” brain injuries, but typically, < 2% of patients required neurosurgical intervention. The high-risk criteria have consis-tently shown 100% sensitivity at ruling out the latter group..
Jeffrey J. Bazarian, MD, MPH; Tamara R. Espinoza, MD, MPH, FACEP
Publication Date
September 15, 2019
CME Expiration Date
October 14, 2022
CME Credits
4 AMA PRA Category 1 Credits.™ Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Date of Original Release: September 15, 2019. Date of most recent review: August 31, 2019. Termination date: September 15, 2022.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma credits, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
CME Objectives: Upon completion of this activity, you should be able to: (1) describe the current recommendations for assessment and management of sport-related concussion and mild traumatic brain injury; (2) utilize clinical decision tools to guide the diagnosis of concussive injuries; (3) identify risk factors for prolonged recovery from concussion; and (4) describe the aftercare instructions that should be given to patients with concussion, including guidance for returning to work, school, and sport participation.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Kirelik, Dr. Bazarian, Dr. Espinoza, and their related parties report no relevant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
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