01Approach to the Critical Patient/attcp56

Immediate threats and escalation

›Critical status triggers

›Airway compromise

›If GCS 8 or rapidly declining mental status, secure airway

›Shock or persistent hypotension

›Alternative cause search

›Refractory hypoxia

›Thoracic injury consideration

›Ongoing seizure

›Benzodiazepine first line

›Signs of herniation

›Hyperosmolar therapy pathway

›Focal neurologic deficit

›Stroke and intracranial hemorrhage pathway

›Repeated vomiting with worsening headache

›Intracranial hemorrhage pathway

›Agitation with unsafe behavior

›De-escalation and chemical sedation pathway

›Immediate stabilization

›Cervical spine precautions when indicated

›High risk mechanism

›Midline cervical tenderness

›Neuro deficit or paresthesias

›Hemodynamic targets

›Systolic blood pressure 100 to 110 mmHg minimum depending on age

›Oxygen saturation 94 percent or higher

›Glucose check

›Hypoglycemia correction if present

02History/hx87

Core concussion history

›Presenting syndrome

›Headache

›Onset relative to injury

›Worsening pattern

›Nausea or vomiting

›Number of episodes

›Delayed vomiting

›Dizziness or imbalance

›Falls risk

›Visual disturbance

›Diplopia

›Blurred vision

›Photophobia

›Cognitive symptoms

›Confusion

›Feeling slowed down

›Concentration difficulty

›Memory impairment

›Emotional symptoms

›Irritability

›Anxiety

›Mood lability

›Sleep disturbance

›Somnolence

›Insomnia

›Injury event

›Mechanism

03Physical Exam/exam58

Focused neuro and trauma exam

›Neurologic assessment

›GCS components

›GCS total

›Trend over time

›Mental status

›Orientation

›Attention

›Short-term recall

›Cranial nerves

›Pupillary size and reactivity

›Extraocular movements

›Facial symmetry

›Speech clarity

›Motor and sensory

›Upper extremity strength symmetry

›Lower extremity strength symmetry

›Sensory asymmetry

›Coordination and gait

›Finger to nose

›Tandem gait if safe

›Vestibulo-ocular screen

›Smooth pursuit symptoms

›Saccades symptoms

›Near point convergence symptoms

›Head and face exam

›Scalp and skull

›Hematoma location

04Differential Diagnosis/ddx39

Intracranial and neurologic

›Intracranial hemorrhage

›Epidural hematoma (S06.4)

›Lucid interval pattern

›Subdural hematoma (S06.5)

›Anticoagulation association

›Traumatic subarachnoid hemorrhage (S06.6)

›Severe headache pattern

›Cerebral contusion (S06.33)

›Focal deficits possible

›Skull fracture

›Basilar skull fracture (S02.1)

›CSF leak signs

›Depressed skull fracture (S02.0)

›Palpable deformity

›Cervical spine injury

›Cervical fracture (S12)

›Midline tenderness

›Vascular

›Cervical artery dissection

›Neck pain with neuro symptoms

›Ischemic stroke

›Focal deficit

›Seizure and metabolic

›Postictal state

›Witnessed convulsion

›Hypoglycemia

›Low point-of-care glucose

05Laboratory Tests/lt24

Targeted labs only

›Metabolic screening

›Point-of-care glucose for altered mental status

›Immediate correction threshold based on local protocol

›Electrolytes for persistent vomiting or significant dehydration

›Sodium abnormality contribution to symptoms

›Bleeding risk and anticoagulation

›INR for warfarin exposure

›Elevated INR increases intracranial bleed risk

›Platelet count for thrombocytopenia concern

›Platelets low increases bleeding risk

›Creatinine for DOAC clearance context

›Reduced clearance increases exposure

›Anti-Xa level when locally available for factor Xa inhibitors

›Supports reversal decision when bleeding confirmed

›Special situations

›Pregnancy test in reproductive potential before CT when applicable

›Radiation counseling support

›Ethanol level when intoxication confounds exam

›Does not exclude intracranial injury

›PITFALLS and limitations

›Normal labs do not exclude intracranial injury

›Imaging and clinical course are primary

›Coagulopathy testing does not replace imaging when indicated

›Decision rule override for deterioration

06Diagnostic Tests/dt108

Scoring Systems

›Decision rules for head CT

›Canadian CT Head Rule for adults with minor head injury

›Applicability

›GCS 13 to 15 with witnessed loss of consciousness, amnesia, or disorientation

›Age 16 years or older

›Exclusions include anticoagulation in some implementations and obvious open skull fracture

›High risk criteria for neurosurgical intervention

›GCS less than 15 at 2 hours after injury

›Suspected open or depressed skull fracture

›Any sign of basilar skull fracture

›Vomiting two or more episodes

›Age 65 years or older

›Medium risk criteria for clinically important brain injury

›Amnesia before impact 30 minutes or more

›Dangerous mechanism

›New Orleans Criteria for adults with GCS 15

›Indications

›Headache

›Vomiting

›Age older than 60 years

›Drug or alcohol intoxication

›Persistent anterograde amnesia

›Visible trauma above clavicles

›Seizure

›NEXUS Head CT decision instrument

›High risk features

›Evidence of skull fracture

›Scalp hematoma

›Neurologic deficit

›Abnormal alertness

›Abnormal behavior

›Persistent vomiting

›Coagulopathy

›Age 65 years or older

›Pediatric decision rule

›PECARN for children with minor head trauma

›Age group split

›Younger than 2 years

›2 years or older

›Very low risk features

›Normal mental status

›No signs of skull fracture

›No severe mechanism

›No persistent vomiting in older group

›Observation pathway for intermediate risk

›Shared decision making

›Symptom and function tools

›Concussion symptom scales

›SCAT6 components for athletes

›Post-Concussion Symptom Scale options

›Return-to-learn and return-to-play staging

›Stepwise progression with symptom-limited advancement

›Evidence levels and policy anchors

›ACEP clinical policy supports validated decision tools for CT selection in adult minor head injury (ACEP Level B)

›Avoid routine imaging in low risk patients when decision rule criteria not met (ACEP Level B)

›Shared decision making for intermediate risk patients appropriate for observation (ACEP Level C)

MRI

›MRI brain indications

›Persistent or worsening symptoms beyond expected recovery

›New focal deficit

›Progressive cognitive decline

›Concern for diffuse axonal injury with normal CT and significant impairment

›Prolonged confusion

›Concern for structural complication

›Subacute subdural hematoma

›MRI timing and protocols

›Not first line for acute emergency evaluation in stable mTBI

›CT preferred for acute hemorrhage detection

›Sequences commonly used

›Susceptibility weighted imaging for microhemorrhage

›Diffusion weighted imaging for acute ischemia and axonal injury patterns

›MRI limitations

›Normal MRI does not exclude concussion

›Functional injury without visible structural lesion

›Access and time constraints in acute care

›Patient monitoring needs

CT

›Non-contrast CT head

›Primary role

›Acute intracranial hemorrhage detection

›Skull fracture detection

›Indications in mTBI

›Decision rule positive

›Anticoagulation with symptoms or concerning course

›Neurologic deterioration

›Seizure after injury

›Interpretation pearls

›Early epidural hematoma may evolve

›Small subdural hematoma in elderly may be subtle

›Repeat CT considerations

›Neurologic deterioration at any time

›Routine repeat CT in stable patients with normal exam not universally indicated

›Higher consideration in anticoagulated with initial hemorrhage

›Radiation and risk communication

›Pediatric radiation sensitivity

›CT avoidance when very low risk

›Pregnancy counseling

›Maternal stabilization priority

Ultrasound

›Point-of-care ultrasound adjuncts

›Optic nerve sheath diameter for increased intracranial pressure screening

›Not a stand-alone rule-out test

›Useful when herniation concern and CT delayed

›Pediatric skull fracture ultrasound

›Adjunct when scalp hematoma and equivocal exam

›Operator dependent

›Limitations

›Does not rule out intracranial hemorrhage

›CT required when indicated

›Threshold variability across studies

›Local training and calibration needed

07Disposition/dispo36

Observation, admission, discharge

›Discharge eligibility

›Normal neurologic exam and stable course

›No deterioration during ED observation when used

›No CT indication by validated rule or negative CT when obtained

›Imaging result reconciled with symptoms

›Reliable supervision for 24 hours

›Adult observer available

›Clear return precautions provided

›Written instructions

›Follow-up plan established

›Primary care or concussion clinic

›ED observation pathway

›Intermediate risk features

›Persistent symptoms with borderline rule criteria

›Intoxication limiting initial exam reliability

›Serial reassessments

›Mental status trend

›Headache and vomiting trend

›Admission indications

›Intracranial hemorrhage on imaging

›Neurosurgery input for level of care

›Persistent abnormal mental status

›Inability to ensure safety at home

›Uncontrolled vomiting or pain

›Dehydration risk

›Social barriers

›No reliable supervision

08Treatment/t90

Symptom control and brain protection

›General management principles

›Relative rest for 24 to 48 hours

›Symptom-limited physical activity after initial rest

›Sleep hygiene support

›Regular sleep schedule

›Avoid alcohol and sedatives

›Masking neurologic decline risk

›Avoid second impact until cleared

›Catastrophic brain swelling risk in rare cases

›Analgesia

›Acetaminophen

›Adult dosing

›650 to 1000 mg orally every 6 hours as needed

›Maximum 3000 mg per 24 hours typical conservative ceiling

›Pediatric dosing

›15 mg per kg orally every 6 hours as needed

›Maximum 60 mg per kg per 24 hours typical

›NSAID use considerations

›Avoid in first 24 hours when hemorrhage not excluded

›Preference for acetaminophen early

›If CT negative and no bleeding risk, NSAID reasonable for headache

›Ibuprofen adult dosing

›400 mg orally every 6 hours as needed

›Maximum 1200 mg per 24 hours over the counter typical

›Avoid opioids when possible

›Sedation and symptom confounding

›Antiemetics

›Ondansetron

›Adult dosing

›4 mg orally or IV every 8 hours as needed

›QT prolongation risk consideration

›Pediatric dosing

›0.15 mg per kg orally or IV

›Maximum 8 mg per dose

›Headache phenotype guided therapy

›Migraine-like headache

›Metoclopramide IV

›10 mg IV

›Dystonia prevention with diphenhydramine optional

›Prochlorperazine IV

›10 mg IV

›Akathisia risk monitoring

›Cervicogenic component

›Heat and gentle range of motion

›Early physiotherapy referral when persistent

›Dizziness and vestibular symptoms

›Vestibular rehabilitation referral for persistent symptoms

›Balance therapy improves recovery in selected patients

›Meclizine short course for severe vertigo

›Adult dosing

›25 mg orally every 8 hours as needed

›Sedation risk and avoidance of prolonged use

›Cognitive symptoms and school or work accommodations

›Return-to-learn staged plan

›Initial reduced screen time

›Short study blocks with breaks

›Work restrictions

›No driving if slowed reaction or dizziness

›Anticoagulation and antiplatelet management

›If intracranial hemorrhage present, reversal pathway

›Warfarin

›Vitamin K IV

›10 mg IV

›Slow infusion to reduce reaction risk

›Four-factor PCC

›Dose per INR and local protocol

›Class I recommendation for life-threatening bleeding reversal in many guidelines

›Dabigatran

›Idarucizumab

›5 g IV divided doses

›If life-threatening bleed confirmed

›Factor Xa inhibitors

›Andexanet alfa or PCC per availability and protocol

›Agent selection based on institutional policy

›Antiplatelet agents

›Platelet transfusion not routine without operative indication

›Neurosurgery guidance

›Seizure management

›Active seizure

›Lorazepam IV

›0.1 mg per kg IV

›Maximum 4 mg per dose

›Post-traumatic seizure prophylaxis

›Not routine for uncomplicated concussion

›Consider only with structural injury and specialist input

›Therapies not recommended routinely

›Corticosteroids for traumatic brain injury

›Not recommended due to harm signal in severe TBI trials

›Routine antibiotics for basilar skull fracture without infection

›Not recommended in most guidance without clear infection

09Special Populations/sp35

Pregnancy

›Pregnancy specific considerations

›Maternal stabilization priority

›Fetal well-being depends on maternal perfusion and oxygenation

›Imaging decision making

›CT head radiation to fetus minimal

›Decision rule use with clinical judgment

›Nausea and vomiting differential broadened

›Hyperemesis vs concussion symptoms

›Medication safety

›Acetaminophen preferred for pain

›NSAID avoidance especially later gestation

Geriatric

›Older adult considerations

›Higher intracranial hemorrhage risk

›Brain atrophy with bridging vein vulnerability

›Anticoagulant and antiplatelet prevalence

›Lower threshold for CT

›Baseline cognitive impairment

›Harder symptom attribution

›Fall risk and prevention

›Mobility aids review

›Disposition safety

›Supervision and home supports

Pediatrics

›Pediatric considerations

›PECARN preferred for imaging selection

›CT avoidance when very low risk

10Background/b31

Epidemiology

›Epidemiology overview

›Concussion definition

›Mild traumatic brain injury with transient neurologic dysfunction

›Common settings

›Falls

›Sports

›Motor vehicle collisions

›Under-recognition

›Many cases do not seek care

›Recovery expectations

›Most recover within days to weeks

›Subset develop persistent post-concussive symptoms

Pathophysiology

›Neurometabolic cascade

›Ionic flux and neurotransmitter release

›Energy crisis with increased glucose demand

›Altered cerebral blood flow

›Mismatch of supply and demand

›Axonal stretching and dysfunction

›Functional impairment without visible lesion

›Vulnerability period

›Increased risk with repeat injury before recovery

Therapeutic Considerations

›Therapeutic rationale

›Rest then graded activity

›Prolonged strict rest associated with worse symptoms in some studies

›Symptom-targeted therapy

11Patient Discharge Instructions/pdi32

copy discharge instructions

›Discharge instructions package

›Diagnosis explanation

›Concussion is a mild brain injury that can cause headache, dizziness, nausea, and trouble thinking

›Home supervision

›Adult supervision for the first 24 hours

›Activity and rest

›Light physical and mental rest for 24 to 48 hours

›Gradual return to normal activity as symptoms allow

›Driving and safety

›No driving if dizzy, slowed, very sleepy, or not thinking clearly

›Avoid alcohol and recreational drugs until fully recovered

›Pain control

›Acetaminophen as directed

›Avoid NSAIDs in first 24 hours unless clinician says safe

›Screen time

›Reduce screen time early if it worsens symptoms

›Return-to-learn and return-to-play

›Return to school with breaks and reduced workload if needed

›No sports until symptom-free and cleared by a clinician

›Return to emergency immediately for any of the following

›Worsening headache

›Repeated vomiting

›Increasing confusion or unusual behavior

›Trouble waking up or excessive sleepiness

›Weakness, numbness, trouble walking

›Slurred speech

›Seizure

12References/r23

Clinical guidelines and decision tools

›Core guideline sources

›ACEP Clinical Policy for Adult Mild Traumatic Brain Injury

›CT decision tools and disposition guidance

›CDC Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury in Children

›Imaging avoidance and return-to-activity guidance

›Amsterdam International Consensus Statement on Concussion in Sport

›Return-to-play framework

›Brain Trauma Foundation guidance for traumatic brain injury principles

›Resuscitation targets and secondary injury prevention

›Decision rules primary sources

›Canadian CT Head Rule derivation and validation studies

›Adult minor head injury CT selection

›New Orleans Criteria studies

›Adult GCS 15 CT selection

›NEXUS Head CT instrument studies

›Adult CT selection

›PECARN head trauma rule study

›Pediatric very low risk identification

›Symptom and recovery tools

›SCAT6 materials

›Athlete symptom and exam framework

›Return-to-learn recommendations from pediatric and sports medicine societies

›Academic accommodations guidance

Evidence & Review

Evidence & Review