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Concussion

What's new

Updated 2023 LCG, 2022 AAP/AAO, 2021 VA/DoD, 2021 ACR, and 2018 CDC guidelines for the evaluation and management of concussion.

Background

Overview

Definition
Concussion is a mTBI induced by direct or indirect biomechanical force transmitted to the head that is characterized by reversible symptoms of dizziness, headache, nausea, imbalance, and loss of consciousness.
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Pathophysiology
Concussion is caused by biomechanical force transmitted to the head in the setting of work environment, motor vehicle crashes, sports and recreation, and falls at home among elderly.
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Disease course
Clinical manifestations include dizziness, headache, nausea, imbalance, loss of consciousness, and on occasions malignant brain swelling. Repeated concussions may cause post-traumatic epilepsy, postconcussion syndrome, and delayed post-traumatic brain degeneration leading to dementia and movement disorders.
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Prognosis and risk of recurrence
Concussion is associated with increased mortality risk in the elderly with adjusted HR 1.25 (95% CI 1.16-1.34).
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of concussion are prepared by our editorial team based on guidelines from the American College of Emergency Physicians (ACEP 2023), the Living Concussion Guidelines (LCG 2023,2022,2017), the American Academy of Ophthalmology (AAO/AAPOS/AACO/AAP 2022), the American College of Radiology (ACR 2021,2020), the United States Department of Defense (DoD/VA 2021,2016), the American Academy...
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Screening and diagnosis

Terminology: as per DoD/VA 2016 guidelines, Consider using the terms "history of mTBI" or "concussion" and refraining from using the terms "brain damage" or "patients with mTBI" in communication with patients and the public.
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Classification and risk stratification

Clinical decision tools: as per ACEP 2023 guidelines, Use the Canadian CT Head Rule to provide decision support and improve head CT utilization in adult patients with a minor head injury.
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Diagnostic investigations

History and physical examination: as per LCG 2022 guidelines, Recognize suspected concussion as soon as possible
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and refer to a physician/nurse practitioner for diagnosis confirmation.
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  • Diagnostic imaging (head CT)

  • Diagnostic imaging (other modalities)

  • Serum biomarkers

  • EEG

  • Assessment of headache

  • Assessment of vision

  • Assessment of cognitive difficulties

  • Assessment of mental health

  • Assessment of sleep-wake disturbances

  • Assessment of fatigue

Respiratory support

Hyperbaric oxygen therapy: as per LCG 2023 guidelines, Do not offer hyperbaric oxygen therapy for the management of symptoms post-concussion.
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Medical management

Setting of care, initial management: as per DoD/VA 2016 guidelines, Consider offering a primary care, symptom-driven approach for the evaluation and management of patients with a history of mTBI and persistent symptoms.
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  • Setting of care (prolonged symptoms)

  • Management of vestibular dysfunction (acute mTBI)

  • Management of vestibular dysfunction (post-acute mTBI)

  • Management of visual symptoms

  • Management of headache

  • Management of neck pain

  • Management of cognitive issues

  • Management of mental health issues

  • Management of sleep-wake disturbances

  • Management of fatigue

  • Management of exertion-induced symptoms

Nonpharmacologic interventions

Alternative and complementary therapies: as per DoD/VA 2021 guidelines, Insufficient evidence to recommend for or against any of the following interventions in the treatment of patients with symptoms attributed to mTBI:
acupuncture
tai chi
meditation
mindfulness
yoga
massage
chiropractic therapy
cranial electrotherapy stimulation
sensory deprivation tanks.
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Therapeutic procedures

Transcranial magnetic stimulation: as per DoD/VA 2021 guidelines, Avoid offering repetitive transcranial magnetic stimulation in the treatment of patients with symptoms attributed to mTBI.
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Specific circumstances

Pediatric patients, clinical assessment: as per CDC 2018 guidelines, Use an age-appropriate, validated symptom rating scale as a component of the diagnostic evaluation in pediatric patients with acute mTBI.
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  • Pediatric patients (diagnostic imaging)

  • Pediatric patients (serum biomarkers)

  • Pediatric patients (assessment of vision)

  • Pediatric patients (counseling)

  • Pediatric patients (management of headache)

  • Pediatric patients (management of cognitive issues)

  • Pediatric patients (management of sleep disturbances)

  • Pediatric patients (evaluation of persistent symptoms)

  • Pediatric patients (assessment of recovery)

  • Pediatric patients (return to activity)

  • Pediatric patients (return to school)

  • Pediatric patients (sport-related concussion, prevention)

  • Pediatric patients (sport-related concussion, cervical spine stabilization)

  • Pediatric patients (sport-related concussion, evaluation of prolonged symptoms)

  • Pediatric patients (sport-related concussion, return to sport)

Patient education

General counseling, recovery
As per LCG 2023 guidelines:
Counsel and reassure patients with symptoms persisting after 1 month that a symptom-based approach will facilitate recovery and most patients achieve symptom resolution.
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Provide this education in written, verbal, and/or pictorial formats.
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Counsel patients in a compassionate manner that involvement in litigation is associated with slower recovery.
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  • General counseling (long-term effects)

Follow-up and surveillance

Discharge from hospital: as per LCG 2022 guidelines, Consider discharging patients presenting to the hospital/clinic acutely with a concussion for home observation if meeting the following clinical criteria:
normal mental status (alertness/behavior/cognition) with clinically improving post-concussive symptoms
no clinical risk factors indicating the need for CT or normal CT result if obtained because of the presence of risk factors.
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  • Evaluation of prolonged symptoms

  • Evaluation of delayed symptoms

  • Return to activity

  • Return to work

  • Return to driving