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

Table of Contents

 

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?

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.

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.

Additional Resources

Tools

Video demonstrating the administration of the VOMS

Video demonstrating the Balance Error Scoring System

Podcast

Tables and Figures

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.

1. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-378. (Review article)
2. Bryan MA, Rowhani-Rahbar A, Comstock RD, et al. Sports- and recreation-related concussions in US youth. Pediatrics. 2016;138(1):e20154635. (Cross-sectional study; 3 national databases)
3. Marin JR, Weaver MD, Yealy DM, et al. Trends in visits for traumatic brain injury to emergency departments in the United States. JAMA. 2014;311(18):1917-1919. (Descriptive epidemiological study)
4. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838- 847. (Consensus statement)
5. Lumba-Brown A, Yeates KO, Sarmiento K, et al. Diagnosis and management of mild traumatic brain injury in children: a systematic review. JAMA Pediatr. 2018;172(11):e182847. (Guideline)
6. Harmon KG, Clugston JR, Dec K, et al. American Medical Society for Sports Medicine position statement on concussion in sport. Clin J Sport Med. 2019;29(2):87-100. (Position statement)
7. Halstead ME, Walter KD, Moffatt K. Sport-related concussion in children and adolescents. Pediatrics. 2018;142(6):e20183074. (Clinical report)
8. Meeuwisse WH, Schneider KJ, Dvorak J, et al. The Berlin 2016 process: a summary of methodology for the 5th International Consensus Con-ference on Concussion in Sport. Br J Sports Med. 2017;51(11):873-876. (Conference summary)
9. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale. Br J Sports Med. 2017;51(11):848-850. (Assessment tool)
10. Davis GA, Purcell L, Schneider KJ, et al. The Child Sport Concussion Assessment Tool 5th edition (Child SCAT5): Background and rationale. Br J Sports Med. 2017;51(11):859-861. (Assessment tool)
11. Makdissi M, Schneider KJ, Feddermann-Demont N, et al. Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):958-968. (Systematic review; 25 articles)
12. Carroll LJ, Cassidy JD, Holm L, et al. Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004;(43 Suppl):113-125. (Systematic review; 313 articles)
13. Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol. 2002;32(4):228-231. (Discussion)
14. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort study; 42,412 patients)
15. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396. (Prospective cohort study; 3121 patients)
16. Plog BA, Nedergaard M. Why have we not yet developed a simple blood test for TBI? Expert Rev Neurother. 2015;15(5):465-468. (Editorial)
17. Shin SS, Bales JW, Edward Dixon C, et al. Structural imaging of mild traumatic brain injury may not be enough: overview of functional and metabolic imaging of mild traumatic brain injury. Brain Imaging Behav. 2017;11(2):591-610. (Review article)
18. Welch RD, Ellis M, Lewis LM, et al. Modeling the kinetics of serum glial fibrillary acidic protein, ubiquitin carboxyl-terminal hydrolase-L1, and S100B concentrations in patients with traumatic brain injury. J Neurotrauma. 2017;34(11):1957-1971. (Prospective multicenter study; 167 patients)
19. O’Connor KL, Baker MM, Dalton SL, et al. Epidemiology of sport-related concussions in high school athletes: National Athletic Treatment, Injury and Outcomes Network (NATION), 2011-2012 through 2013-2014. J Athl Train. 2017;52(3):175-185. (Descriptive epidemiological study)
20. Matuszak JM, McVige J, McPherson J, et al. A practical concussion physical examination toolbox. Sports Health. 2016;8(3):260-269. (Review article)
21. Edlow JA. A new approach to the diagnosis of acute dizziness in adult patients. Emerg Med Clin North Am. 2016;34(4):717-742. (Review article)
22. Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014;42(10):2479-2486. (Cross-sectional study; 64 patients)
23. Bell DR, Guskiewicz KM, Clark MA, et al. Systematic review of the balance error scoring system. Sports Health. 2011;3(3):287-295. (Systematic review)
24. Khanna NK, Baumgartner K, LaBella CR. Balance error scoring system performance in children and adolescents with no history of concussion. Sports Health. 2015;7(4):341-345. (Descriptive laboratory study; 100 patients)
25. Quatman-Yates C, Hugentobler J, Ammon R, et al. The utility of the balance error scoring system for mild brain injury assessments in children and adolescents. Phys Sportsmed. 2014;42(3):32-38. (Retrospective review and prospective study)
26. McCrea M, Hammeke T, Olsen G, et al. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004;14(1):13-17. (Retrospective survey; 1532 participants)
27. Meehan WP, 3rd, Mannix RC, O’Brien MJ, et al. The prevalence of undiagnosed concussions in athletes. Clin J Sport Med. 2013;23(5):339- 342. (Multicenter cross-sectional study; 486 patients)
28. Anderson BL, Gittelman MA, Mann JK, et al. High school football players’ knowledge and attitudes about concussions. Clin J Sport Med. 2016;26(3):206-209. (Survey; 120 participants)
29. Petrelli T, Farrokhyar F, McGrath P, et al. The use of ibuprofen and acetaminophen for acute headache in the postconcussive youth: A pilot study. Paediatr Child Health. 2017;22(1):2-6. (Randomized controlled trial; 80 patients)
30. Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?”: recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259. (Review article)
31. Grool AM, Aglipay M, Momoli F, et al. Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA. 2016;316(23):2504-2514. (Prospective multicenter cohort study; 3063 patients)
32. Varner CE, McLeod S, Nahiddi N, et al. Cognitive rest and graduated return to usual activities versus usual care for mild traumatic brain injury: a randomized controlled trial of emergency department discharge instructions. Acad Emerg Med. 2017;24(1):75-82. (Randomized controlled trial; 118 patients)
33. Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):213-223. (Randomized controlled trial; 88 patients)
34. Brown NJ, Mannix RC, O’Brien MJ, et al. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133(2):e299-e304. (Prospective cohort study; 335 patients)
35. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43(3):265-274. (Retrospective cohort study; 95 patients)
36. Giza CC, Hovda DA. The new neurometabolic cascade of concussion. Neurosurgery. 2014;75 Suppl 4:S24-S33. (Review article)
37. Signoretti S, Vagnozzi R, Tavazzi B, et al. Biochemical and neurochemical sequelae following mild traumatic brain injury: summary of experimental data and clinical implications. Neurosurg Focus. 2010;29(5):E1. (Review article)
38. Vagnozzi R, Signoretti S, Tavazzi B, et al. Hypothesis of the postconcussive vulnerable brain: experimental evidence of its metabolic occurrence. Neurosurgery. 2005;57(1):164-171. (Animal study)
39. Bartnik-Olson BL, Holshouser B, Wang H, et al. Impaired neurovascular unit function contributes to persistent symptoms after concussion: a pilot study. J Neurotrauma. 2014;31(17):1497-1506. (Randomized controlled trial; 15 patients)
40. Vagnozzi R, Signoretti S, Cristofori L, et al. Assessment of metabolic brain damage and recovery following mild traumatic brain injury: a multicentre, proton magnetic resonance spectroscopic study in concussed patients. Brain. 2010;133(11):3232-3242. (Multicenter prospective study; 70 patients)
41. Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics. 2013;132(5):948-957. (Clinical report)
42. Grady MF, Master CL. Return to school and learning after concussion: tips for pediatricians. Pediatr Ann. 2017;46(3):e93-e98. (Review article)
43. Chan LG, Feinstein A. Persistent sleep disturbances independently predict poorer functional and social outcomes 1 year after mild traumatic brain injury. J Head Trauma Rehabil. 2015;30(6):E67-E75. (Retrospective cohort study; 374 patients)
44. Jaffee MS, Winter WC, Jones CC, et al. Sleep disturbances in athletic concussion. Brain Inj. 2015;29(2):221-227. (Review article)
45. Kostyun R. Sleep disturbances in concussed athletes: a review of the literature. Conn Med. 2015;79(3):161-165. (Review article)
46. Gradisar M, Wolfson AR, Harvey AG, et al. The sleep and technology use of Americans: findings from the National Sleep Foundation’s 2011 Sleep in America poll. J Clin Sleep Med. 2013;9(12):1291-1299. (Survey; 1508 participants)
47. Barlow KM, Crawford S, Stevenson A, et al. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics. 2010;126(2):e374-381. (Prospective cohort study; 670 patients)
48. Corwin DJ, Wiebe DJ, Zonfrillo MR, et al. Vestibular deficits following youth concussion. J Pediatr. 2015;166(5):1221-1225. (Retrospective cohort study; 247 patients)
49. Lau BC, Kontos AP, Collins MW, et al. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011;39(11):2311-2318. (Prospective cohort study; 107 patients)
50. Pearce KL, Sufrinko A, Lau BC, et al. Near point of convergence after a sport-related concussion: measurement reliability and relationship to neurocognitive impairment and symptoms. Am J Sports Med. 2015;43(12):3055-3061. (Cross-sectional study; 78 patients)
51. Master CL, Scheiman M, Gallaway M, et al. Vision diagnoses are common after concussion in adolescents. Clin Pediatr (Phila). 2016;55(3):260-267. (Cross-sectional study; 100 patients)
52. DuPrey KM, Webner D, Lyons A, et al. Convergence insufficiency identifies athletes at risk of prolonged recovery from sport-related concussion. Am J Sports Med. 2017;45(10):2388-2393. (Retrospective cohort study; 270 patients)
53. Ellis MJ, Cordingley DM, Vis S, et al. Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion. J Neurosurg Pediatr. 2017;19(1):38-45. (Retrospective study; 399 patients)
54. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014;48(17):1294-1298. (Randomized controlled trial; 29 patients)
55. Park K, Ksiazek T, Olson B. Effectiveness of vestibular rehabilitation therapy for treatment of concussed adolescents with persistent symptoms of dizziness and imbalance. J Sport Rehabil. 2018;27(5):485-490. (Systematic review; 4 studies)
56. Simon LM, Mitchell CN. Youth concussion laws across the nation: implications for the traveling team physician. Curr Sports Med Rep. 2016;15(3):161-167. (Systematic review)