01Approach to the Critical Patient/attcp55

Immediate Triage

›Critical features requiring immediate action

›GCS <15 at 2 hours post-injury

›CT head immediately

›Neurosurgery consult

›Focal neurological deficit

›Immediate CT head non-contrast

›Paralysis, hemiplegia, aphasia, anisocoria

›Seizure post-injury

›Airway protection priority

›CT head immediately

›Suspected open or depressed skull fracture

›Neurosurgery activation

›Avoid pressure on wound

›Signs of basilar skull fracture

›Raccoon eyes, Battle sign, hemotympanum, CSF otorrhea/rhinorrhea

›CT head with bone windows

›Deteriorating level of consciousness

›Immediate resuscitation bay

›Airway assessment

Monitoring and Stabilization

›Monitoring targets in the ED

›Continuous GCS reassessment

›Target GCS 15 within 2 hours

›Neurological deterioration triggers CT

›Vital signs monitoring

›Autonomic dysfunction may cause transient hypertension and tachycardia

›Persistent abnormalities require workup beyond concussion

02History/hx67

Mechanism and Event

›Mechanism of injury

›Direct blow to head vs. indirect force (whiplash, blast)

›Intensity: fall height, collision speed, ejection from vehicle

›Dangerous mechanism

›Pedestrian struck by vehicle

›Ejection from vehicle

›Fall >3 feet or >5 stairs

›Temporal relationship

›Symptom onset immediately or within minutes to hours

›Symptom evolution over days is common

›Loss of consciousness (LOC)

›Duration: brief vs. >30 seconds

›LOC not required for diagnosis

›Amnesia

›Retrograde: events before injury

›Anterograde: events after injury

›Duration of amnesia matters for CT decision rules

Symptoms

›Physical symptoms

›Headache: most common symptom

›Pressure in head

›Dizziness and balance problems

›Nausea and vomiting

›Photophobia and phonophobia

›Visual disturbance

›Fatigue

›Cognitive symptoms

03Physical Exam/exam40

Neurological Examination

›Level of consciousness and cognition

›GCS: eyes, verbal, motor components

›Orientation to person, place, time, event

›Immediate memory: 5-word list recall

›Concentration: digits backward, months in reverse

›Delayed recall at 5 minutes

›Cranial nerve and motor exam

›Pupillary size and reactivity

›Extraocular movements

›Facial symmetry

›Upper and lower extremity strength

›Coordination: finger-to-nose, heel-shin

Vestibular and Oculomotor Screen

›Vestibular-oculomotor testing

›Smooth pursuits: horizontal and vertical

›Saccades: accuracy and speed

›Near-point convergence

›Normal <5 cm from nose

›Abnormal convergence >10 cm suggests oculomotor dysfunction

›Vestibulo-ocular reflex (VOR): head thrust test

›Abnormalities predict delayed recovery

Balance and Gait

›Modified Balance Error Scoring System (mBESS)

›Double-leg stance eyes closed: 20 seconds

›Single-leg non-dominant stance eyes closed: 20 seconds

›Tandem stance eyes closed: 20 seconds

›Count errors: loss of balance, opening eyes, hand-hip separation

04Differential Diagnosis/ddx46

Life-Threatening Diagnoses

›Intracranial hemorrhage

›Epidural hematoma: ICD-10 S06.4

›Lucid interval followed by deterioration

›Middle meningeal artery rupture

›Subdural hematoma: ICD-10 S06.5

›Can present subacutely

›Higher risk with anticoagulation

›Subarachnoid hemorrhage: ICD-10 S06.6

›Thunderclap headache

›Sentinel bleed pattern

›Intraparenchymal hemorrhage: ICD-10 S06.3

›Focal deficit

›Depressed level of consciousness

›Less than 10% of mTBI have CT abnormalities; approximately 1% require neurosurgery

›Skull fracture

›Open or depressed fracture: ICD-10 S02

›Basilar skull fracture

›Clinical signs more sensitive than CT in some locations

Structural and Vascular Mimics

›Cervical spine injury

›Frequently coexists with concussion

›Overlapping symptoms: dizziness, headache, neck pain

›Must be excluded before clearance

›Vertebral or carotid artery dissection

›Neck pain with headache after trauma

›CTA neck for diagnosis

›Stroke risk from thromboembolism

05Laboratory Tests/lt23

Routine Studies

›Standard labs generally not indicated for uncomplicated concussion

›Clinical diagnosis based on history and exam

›Lab testing reserved for specific indications below

Coagulation and Hematology

›Coagulation studies

›Indication: anticoagulant or antiplatelet use

›INR, aPTT, anti-Xa level as appropriate to agent

›Platelet count if thrombocytopenia suspected

›Result guides CT threshold and reversal decisions

Metabolic and Toxicology

›Blood glucose

›Hypoglycemia may mimic or worsen altered mental status

›Point-of-care testing in altered patients

›Blood alcohol level

›Intoxication affects clinical assessment reliability

›High BAL may mandate observation until sober

›Urine toxicology screen

›If intoxication suspected and mechanism unclear

›Helps interpret clinical exam findings

Biomarkers

›Serum brain injury biomarkers

›GFAP (Glial Fibrillary Acidic Protein) and UCH-L1

›FDA-cleared to identify adults who do not need CT within 12 hours of injury

›Negative predictive value high; not for diagnosis of concussion

›ACEP 2023 Clinical Policy: routine use not yet recommended

›hs-CRP: limited evidence for predicting post-concussion syndrome; not recommended routinely

06Diagnostic Tests/dt71

Scoring Systems

›Canadian CT Head Rule (CCHR)

›High-risk factors mandating CT

›GCS <15 at 2 hours post-injury

›Suspected open or depressed skull fracture

›Signs of basilar skull fracture

›Vomiting ≥2 episodes

›Age ≥65 years

›Medium-risk factors suggesting CT

›Amnesia before impact ≥30 minutes

›Dangerous mechanism of injury

›Sensitivity 100% for neurosurgical intervention; 83% for brain lesion on CT

›New Orleans Criteria (NOC)

›CT indicated if any: headache, vomiting, age >60, drug or alcohol intoxication, deficits in short-term memory, visible trauma above clavicle, seizure

›Sensitivity approaching 100% but lower specificity than CCHR

›PECARN Pediatric Head Injury Rules

›Age <2: CT if GCS <15, palpable skull fracture, altered behavior, loss of consciousness >5 seconds, severe mechanism, scalp hematoma not frontal

›Age ≥2: CT if GCS <15, LOC, suspected skull fracture, severe mechanism, vomiting, severe headache

›ACEP Level B recommendation for pediatric head injury

›Sport Concussion Assessment Tool (SCAT6)

›Standardized sideline assessment tool

›Symptom checklist, cognitive screening (SAC), neurological screen, mBESS

›Not a CT decision tool; used for concussion identification and monitoring

›Standardized Assessment of Concussion (SAC)

›Orientation, immediate memory, concentration, delayed recall

›Score 0-30; decline of ≥1 point suggests concussion

›Post-Concussion Symptom Scale (PCSS)

›22-item self-report inventory rated 0-6 per symptom

›Total score 0-132; tracks symptom burden over time

MRI

›MRI head in concussion

›Not routinely indicated acutely

›Standard MRI often normal in concussion

›Does not exclude concussion diagnosis

›Indications for MRI

›Persistent symptoms >4 weeks with negative CT

›Clinical concern for structural injury not seen on CT

›Preparation for return-to-activity clearance in complex cases

›Advanced MRI sequences

›Diffusion tensor imaging (DTI): white matter tract injury

›Susceptibility-weighted imaging (SWI): microhemorrhages

›fMRI: functional connectivity changes; research use only

›ACR Appropriateness Criteria: MRI appropriate for persistent symptoms after mTBI when CT negative

CT

›CT head non-contrast

›Modality of choice in acute ED evaluation

›Rapid, widely available, no sedation required

›Identifies hemorrhage, fracture, mass effect

›Indications: use validated decision rule (CCHR, NOC, PECARN)

›<10% of mTBI patients have CT abnormalities

›Approximately 1% require neurosurgical intervention

›CT indications regardless of decision rule

›Anticoagulant use

›Coagulopathy

›Age ≥65 with any LOC or amnesia

›Focal neurological deficit

›GCS <15 at 2 hours

›CT angiography head and neck

›Indicated if vascular injury suspected

›Rapidly expanding hematoma, carotid bruit, neck pain after high-energy mechanism

›ACEP 2023 Clinical Policy Level B: CT head recommended for mTBI patients with CCHR high-risk factors

Ultrasound

›Ocular ultrasound

›Not primary modality for concussion assessment

›Cannot diagnose concussion directly

›Optic nerve sheath diameter (ONSD)

›ONSD >5 mm suggests elevated intracranial pressure

›Threshold: >5.7-6.0 mm in adults

›Operator-dependent; adjunct to clinical assessment

›Indication: bedside assessment of ICP when CT pending in deteriorating patient

›Point-of-care ultrasound (POCUS)

›Limited role in isolated concussion

›Useful to rule out other traumatic injuries

›FAST exam for abdominal trauma in polytrauma

›Hemothorax or pneumothorax in high-energy mechanism

07Disposition/dispo28

Discharge Criteria

›Criteria for safe discharge

›GCS 15 with stable or improving symptoms

›Normal neurological examination

›CT not indicated by decision rule, or CT obtained and negative

›Reliable companion available for 24-hour home observation

›Patient and companion educated on return precautions

›No contraindication to outpatient management

›Follow-up planning before discharge

›Early medical follow-up within 1 week of injury

›Weekly follow-up facilitates recovery

›Return-to-school and return-to-sport protocols provided

Admission Criteria

›Indications for hospital admission or observation

›GCS <15 at 2 hours or not improving to 15

›Abnormal CT findings

›Intracranial hemorrhage of any type

›Depressed or open skull fracture

›Persistent vomiting, worsening symptoms, or neurological deterioration

›Anticoagulant use with positive CT or high-risk features

›No reliable home observer available

›Intoxication precluding adequate assessment

›Concern for non-accidental trauma

Specialist Consultation Triggers

›Triggers for specialty referral

›Any intracranial hemorrhage: neurosurgery immediately

›Abnormal cervical spine imaging: spine surgery or neurosurgery

›Symptoms persisting >4 weeks: multidisciplinary concussion clinic

08Treatment/t79

Immediate ED Management

›Acute symptom control in ED

›Headache management

›Acetaminophen 500-1000 mg orally every 4-6 hours

›Ibuprofen 400-600 mg orally every 6-8 hours

›Limit use to <10 days per month to avoid medication-overuse headache

›Avoid opioids, barbiturates, and oral ergotamines

›Nausea and vomiting

›Ondansetron 4-8 mg orally or IV every 6-8 hours as needed

›Metoclopramide 10 mg IV as alternative

›Migraine-type headache if first-line fails

›Sumatriptan 50-100 mg orally or 6 mg subcutaneous

›Rizatriptan 10 mg orally

Cognitive Rest and Activity

›Early activity guidance

›Strict prolonged rest is counterproductive

›Evidence shows brief relative rest then gradual return is superior

›Scorza and Cole, American Family Physician 2019

›Relative rest for 24-48 hours immediately post-injury

›Avoid activities that significantly worsen symptoms

›Light daily activities that do not provoke symptoms are acceptable

›Symptom-limited aerobic exercise early after injury

›Reduces incidence of persisting symptoms

›Begin once symptoms allow mild exertion without significant worsening

Graduated Return-to-Activity Protocol

›Graduated return-to-sport protocol (minimum 24 hours per step)

›Step 1: Symptom-limited daily activity

›Walking, reading, screen time as tolerated

›No exercise or sport

›Step 2: Light aerobic exercise

›Walking, stationary cycling

›No resistance training

›Step 3: Sport-specific exercise

›Running drills, skating drills

›No contact

›Step 4: Non-contact training drills

›More complex drills, resistance training

›Step 5: Full-contact practice after medical clearance

›Step 6: Return to competition

›Advance only if symptoms do not worsen more than mildly

›Acceptable: ≤2-point increase on 0-10 scale resolving within 1 hour

›If worse: return to previous step for 24 hours

Return to Learn Protocol

›Academic reintegration

›Full return to school and learn should precede unrestricted return to sport

›Academic accommodations as needed

›Extended time for assignments and tests

›Reduced workload during recovery

›Scheduled rest breaks

›Provider letter to facilitate academic support

Pharmacological Headache Prophylaxis

›Prophylactic therapy: indicated if >10 headache days per month

›First-line agents

›Amitriptyline 10-25 mg orally at bedtime

›Titrate up to 75 mg as tolerated

›Also addresses sleep and mood symptoms

›Propranolol 40-80 mg orally twice daily

›Avoid if asthma or bradycardia

›Second-line agents

›Candesartan 8-16 mg orally daily

›Topiramate 25-100 mg orally daily

›Cognitive side effects may limit use in concussion

›Venlafaxine 37.5-150 mg orally daily

›Useful if comorbid anxiety or depression

›Triptans for migraine-like acute episodes

›Sumatriptan, rizatriptan as abortive therapy

Sleep and Mood Management

›Sleep disturbance management

›Sleep hygiene counseling: first-line

›Consistent sleep schedule

›Dark, cool, quiet sleep environment

›Melatonin 0.5-5 mg orally at bedtime

›Commonly recommended; evidence limited but safe

›Avoid sedating antihistamines long-term

Persistent Symptoms Management

›Referral for multidisciplinary care if symptoms persist >4 weeks

›Vestibular physiotherapy

›For persistent dizziness, balance problems, motion sensitivity

›Vision therapy

›For persistent oculomotor dysfunction, convergence insufficiency

›Cognitive behavioral therapy (CBT)

›Addresses fearful avoidance and psychological amplification

›Cognitive rehabilitation

›For persistent cognitive impairment

›Cervical physiotherapy

›If cervicogenic headache or neck pain identified

09Special Populations/sp66

Pregnancy

›Physiologic considerations in pregnancy

›Hypercoagulable state increases subdural risk

›CT head threshold should not differ; radiation dose acceptable

›ACR and ACOG: CT head safe in pregnancy for clear indication

›Fetal radiation exposure from CT head extremely low

›Estimated 0.001-0.01 mGy; well below threshold for harm

›Medication modifications in pregnancy

›Acetaminophen: preferred analgesic in pregnancy

›Short-term use at lowest effective dose

›NSAIDs: avoid after 20 weeks gestation

›Risk of premature closure of ductus arteriosus

›First trimester use also associated with pregnancy loss

›Triptans: limited data; sumatriptan category C

›Discuss risk-benefit with obstetrics

›Amitriptyline: relatively safer in pregnancy than other TCA

›Neonatal withdrawal possible if used near term

›Topiramate: avoid; teratogenic (oral cleft risk)

›Valproate: avoid; high teratogenicity

›Propranolol: use with caution; fetal bradycardia risk

›Return-to-activity

›Graduated protocol applies with obstetric guidance

›Contact sports avoided throughout pregnancy

Geriatric

›Higher-risk population

›Age ≥65 is an independent indication for CT head after mTBI

›CCHR high-risk criterion

›Lower threshold for imaging

›Anticoagulant and antiplatelet use prevalent

›Warfarin, DOACs, aspirin: CT mandatory after any LOC or amnesia

›Reversal agents if intracranial hemorrhage found

›Cerebral atrophy increases subdural hematoma risk

›Bridging veins more susceptible to tearing

›Delayed subdural may present days to weeks later

›Symptom assessment challenges

›Baseline cognitive impairment complicates assessment

›Pre-morbid neuropsychological testing needed for comparison

›Pre-existing balance and gait disorders

›Medication cautions in elderly

›Amitriptyline: Beers Criteria - avoid in elderly due to anticholinergic burden and fall risk

›Prefer nortriptyline or venlafaxine if TCA needed

›NSAIDs: caution with renal impairment and GI risk

›Fall prevention counseling essential during recovery

Pediatrics

›Children aged <12 years

›PECARN rules validated for pediatric CT decisions

›Age <2: different criteria from older children

›Observation period of 4-6 hours can be used when CT borderline

›Higher rates of prolonged symptoms than adults

›Approximately one-third of untreated adolescents have symptoms persisting >4 weeks

›Return-to-learn must precede return-to-sport

›Academic accommodations: extra time, reduced load, scheduled rest breaks

›Symptom reporting in young children

›Parent and teacher report often needed

›Child SCAT and Child PCSS for age-appropriate assessment

›Adolescents aged 12-18 years

›Highest risk group for sport-related concussion

›SCAT6 validated from age 13

›Graduated return-to-sport protocol mandatory before return to contact sport

›Medical clearance required from physician

›ACEP and AAP consensus

›Mental health vigilance

›Adolescents at higher risk for depression and anxiety post-concussion

›Psychiatric referral if persistent mood symptoms

›Medication considerations in children

›Acetaminophen: weight-based 10-15 mg/kg orally every 4-6 hours; max 75 mg/kg/day

›Ibuprofen: 5-10 mg/kg orally every 6-8 hours; max 40 mg/kg/day

›Ondansetron: 0.1-0.15 mg/kg IV or orally; max 4 mg per dose

›Melatonin: 0.5-3 mg at bedtime; safe and commonly used

10Background/b70

Epidemiology

›Incidence and prevalence

›Concussion is the most common form of traumatic brain injury

›Estimated 3.8 million sport-related concussions annually in the United States

›Significant underreporting; true incidence likely 2-5 times higher

›Contact sports: football, hockey, rugby, soccer highest incidence

›ICD-10 classification

›S09.90XA: unspecified injury of head, initial encounter

›S06.0X0A: concussion without LOC, initial encounter

›S06.0X1A: concussion with LOC <30 minutes, initial encounter

›Demographics

›Peak incidence in adolescents 14-19 years

›Female athletes report higher symptom burden and longer recovery

›Males more often injured; females more symptomatic when injured

›Prognosis

›Most concussions resolve within 2-4 weeks

›Median symptom-free approximately 14 days

›Median return to school approximately 8 days

›Approximately one-third of untreated adolescents have symptoms >4 weeks

›Risk of second concussion significantly elevated until full recovery

Pathophysiology

›Neurometabolic cascade

›Biomechanical force creates shear stress to brain tissue

›Diffuse axonal injury at white matter tracts

›No macroscopic structural lesion in uncomplicated concussion

›Ionic flux disturbance

›Potassium efflux from cells

›Sodium and calcium influx

›Cell membrane depolarization

›Neurometabolic crisis

›Increased glucose demand during reduced cerebral blood flow

›Energy crisis state

›Duration: days to weeks

›Autonomic dysfunction

›Concussion induces transient cardiovascular autonomic dysfunction

›Heart rate variability reduced

›Orthostatic intolerance

›Transient hypertension and tachycardia

›Mechanism: disruption of hypothalamic and brainstem autonomic centers

›Symptom generation

›Headache: trigeminovascular activation plus neuroinflammation

›Cognitive symptoms: disrupted default mode network connectivity

›Dizziness: vestibular nucleus and cerebellovestibular pathway dysfunction

›Sleep disturbance: hypothalamic and reticular activating system disruption

›Chronic traumatic encephalopathy (CTE) risk

›Repetitive subconcussive impacts associated with tau protein accumulation

›CTE diagnosed only at autopsy; causation not fully established

›Single concussion insufficient evidence to cause CTE

Therapeutic Considerations

›Evidence base for treatment

›Strict prolonged rest: evidence shows inferior outcomes to active approach

›Brief relative rest 24-48 hours then graduated activity

›ACEP 2023 Clinical Policy Level B

›Aerobic exercise early after injury

›Reduces incidence of persisting symptoms

›Improves cerebrovascular autoregulation

›Evidence: Scorza and Cole 2019, multiple RCTs

›Analgesics: no concussion-specific pharmacotherapy exists

›Acetaminophen and NSAIDs for symptom control only

›Risk of medication-overuse headache with frequent use

›Biomarker and serology evidence

›GFAP and UCH-L1: FDA-cleared blood test

›Helps predict CT findings within 12 hours

›Does not diagnose or rule out concussion

›ACEP 2023 Clinical Policy Level B: serum biomarkers may be used to predict CT findings

›Emerging and investigational therapies

›Omega-3 fatty acids (DHA and EPA)

›Strongest emerging evidence for neuroprotective benefit

›Particularly for athletes exposed to repetitive head impacts

›No definitive human clinical trial evidence yet for treatment

›Cervical and vestibular physiotherapy

›Strong evidence for benefit in vestibular-oculomotor concussion subtype

›Reduces recovery time

11Patient Discharge Instructions/pdi46

copy discharge instructions

›Discharge instructions for concussion

›You have been diagnosed with a concussion

›A concussion is a brain injury caused by a blow or jolt to the head

›Most people recover fully within 2-4 weeks

›Recovery is faster with the right care at home

›Activity in the first 24-48 hours

›Rest, but strict complete rest is not necessary or recommended

›Light activities such as walking are acceptable if symptoms allow

›Gradually increase activity as symptoms improve

›Avoid activities that significantly worsen your symptoms

›Return to school and work

›Begin with partial days and shorter tasks

›Ask your doctor for an accommodation letter if needed

›Return to school before returning to contact sport

›Return to sport and physical activity

›Do not return to contact sport until cleared by a doctor

›Follow the graduated return-to-sport program as instructed

›Do not skip steps even if you feel better

›Medications for headache at home

›Acetaminophen 500-1000 mg every 4-6 hours as needed

›Ibuprofen 400-600 mg every 6-8 hours as needed with food

›Do not use pain medications more than 10 days per month to avoid rebound headache

›Avoid opioid pain medications

›Sleep and rest

›Maintain a regular sleep schedule

›It is safe to sleep after a concussion if you are awake and alert now

›Your companion should check on you in the first night

12References/r38

Guidelines and Key Sources

›ACEP Clinical Policy 2023

›Valente JH et al. Annals of Emergency Medicine 2023

›Critical Issues in the Management of Adult Patients with Mild Traumatic Brain Injury

›ACEP Board approved February 2023

›Sport-Related Concussion

›Leddy JJ. New England Journal of Medicine. 2025

›Comprehensive review of sport-related concussion management

›American Medical Society for Sports Medicine Position Statement

›Harmon KG et al. Clinical Journal of Sport Medicine. 2019

›Evidence-based concussion management in sport

›Concussion in Sport - 6th International Conference Recommendations

›Lau K. American Family Physician. 2024

›Amsterdam consensus statement update

›Current Concepts in Concussion

›Scorza KA, Cole W. American Family Physician. 2019

›Initial evaluation and management

›Diagnosis and Management of Concussion

›Reams N. Clinics in Sports Medicine. 2026

›Action Collaborative on Traumatic Brain Injury Care

›Silverberg ND et al. Annals of Family Medicine. 2025

›Adapted Clinical Practice Guideline

›ACR Appropriateness Criteria Head Trauma 2021 Update

›Expert Panel on Neurological Imaging, Shih RY et al. JACR. 2021

›Sport-Related Concussion in Children and Adolescents

›Halstead ME, Walter KD, Moffatt K. Pediatrics. 2018

›AAP policy statement

›ACS Best Practices in Management of Traumatic Brain Injury

Evidence & Review

Evidence & Review