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Concussion

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Overview

Concussion describes a mild traumatic brain injury (mTBI) that results in a transient change in mental status. This may be due to a direct blow to the head or rapid deceleration of the head. All head injuries should be managed according to the guidelines set out by NICE. These are discussed in Head Injury: NICE guidelines.

A concussion describes transient confusion, disorientation, or loss of consciousness lasting not more than 30 minutes and a GCS no worse than 13.

Assessment

Initial assessment

Use an ABCDE approach when assessing and stabilising a patient:

  • If a cervical spine injury is suspected (e.g. neck pain is present) – full cervical spine immobilisation
  • Arrange a CT head as set out in Head Injuries: NICE guidelines.
  • Perform a neurological examination and check the skull for fractures.
  • Record the patient’s Glasgow coma scale (GCS)
  • Check how the injury happened.
  • Check if the patient takes any anticoagulants.

Presentation

  • Physical symptoms:
    • Headaches
    • Dizziness
    • Disturbed gait
    • Visual changes
    • Fatigue
    • Vomiting/nausea – more common in adolescents and children
    • Neck pain – suggests a cervical spine injury
  • Cognitive disturbance:
    • Confusion 
    • Brain fog and difficulty concentrating
    • Amnesia
    • Mood changes and irritability
  • Sleep problems:
    • Drowsiness
    • Sleeping more or less than usual
    • Difficulty falling asleep

Red Flags

Features suggesting an intracranial haemorrhage include:

  • Severe or worsening headaches
  • Repeated episodes of vomiting
  • Deteriorating consciousness
  • Seizures
  • Vision abnormalities – blurring/double vision
  • Confusion

Investigations

Management

Overview

Management is supportive and involves giving analgesia such as paracetamol. Patients may be discharged if:

  • A CT scan is not indicated as per the guidelines set out in Head Injuries: NICE guidelines or
  • A CT scan is normal, the GCS has returned to 15, a neurological exam is normal, and no features warranting admission are present (discussed below).

Patients that return within 48 hours with any changes or recurring symptoms should be considered for another CT scan. These patients should be discussed with a senior colleague.

Admission

Most patients do not require admission. However, the following patients should be admitted:

  • New abnormalities on imaging
  • GCS has not returned to 15
  • CT scans are indicated but cannot be done within the recommended timeframe
  • Continued or new red flags as mentioned above
  • Other concerning features (e.g. other injuries, suspicion of non-accidental injury, suspicion of meningitis, alcohol or drug intoxication etc.)

Patient Advice

  • Patients should have a responsible adult staying with them for the first 24 hours post-injury
  • Patients should seek immediate help if neurological features such as weakness, persistent or worsening headaches, vomiting, changes in consciousness, leakage of cerebrospinal fluid (rhinorrhoea and/or otorrhoea), or agitation occur
  • Symptoms may last for up to 2 weeks
    • Patients should avoid work or going to school until they feel better
    • Patients should not drive until they have fully recovered

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