Evaluating, Managing, Or Referring A Patient With A Suspected Concussion

The information below addresses how to evaluate a patient for a suspected concussion, how to return a patient with concussion to functionality, how to manage symptoms of concussion, when to refer to an interdisciplinary care team with concussion expertise, and other relevant information for your practice.
Definition: 1
Concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilised in clinically defining the nature of a concussive head injury include:
  • May be caused either by a direct blow to the head, face, neck or by a blow to elsewhere on the body with an impulsive force transmitted to the head.
  • Typically results in the acute onset of short-lived impairment of neurological function that generally resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes and up to 72 hours.
  • May result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a transient disturbance in brain functioning rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  • Results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases the patient may experience persisting symptoms.
The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (e.g., cervical injuries, peripheral vestibular dysfunction, etc.) or other comorbidities (e.g., psychological factors, coexisting medical conditions).

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Learn more about how to evaluate patients for a concussion with the SCAT6 Tool and review other Resources. 

When evaluating a patient with a suspected concussion, what should my initial exam include?

The key features of an evaluation for a concussion should include:
  • A medical assessment encompassing:
  • A comprehensive history, including mechanism of injury and eyewitness accounts when available
  • Symptom assessment
  • Focused neurological examination including mental status, cognitive functioning, coordination, vision
  • A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates, and eyewitnesses to the injury when available.
  • Assessing the need for emergent neuroimaging to exclude a neurosurgically remediable structural brain injury.
Most of the elements of an assessment are included in the SCAT6 (Sport Concussion Assessment Tool), Child SCAT6, SCOAT6 (Sport Concussion Office Assessment Tool), and Child SCOAT6.

What neuroimaging should I order for my patients who have been diagnosed with a concussion?

Neuroimaging for patients with concussion is usually not required. The PECARN (Pediatric Emergency Care Applied Research Network) Head Injury Algorithms (2 years or older and younger than 2 years) or the Canadian Head CT Rule should be reviewed.

A non-contrast head CT of the head, and possibly neck, should be considered if there is:
  • Glasgow Coma Scale <= 14
  • Focal neurological deficit
  • Altered mental status (particularly agitation and somnolence)
  • Palpable skull fracture
  • Loss of consciousness
  • Severe mechanism of injury
  • Severe headache
  • Worsening symptoms
  • Multiple symptoms
  • Coagulopathy

Should I still use a grading system to help manage my patients who have or are suspected of having a concussion?

Extensive research on concussions has provided medical professionals with a much better understanding of the symptomatic course and risk of potential long-term complications. This has led to the realization that diagnosing those who do not lose consciousness with a lower grade of concussion is inaccurate. As a result of this understanding, and other realizations, grading systems have been replaced by individualized concussion management.

For more information, learn more about the signs and symptoms of a concussion.

I’m not sure when I should refer my patient to an interdisciplinary team with concussion expertise.

Consider referral:
  • If there is neurologic deterioration, including:
  • Worsening or persisting headache
  • Dizziness, poor balance
  • Visual changes
  • Poor attention and problems with memory
  • Profound fatigue and change in sleeping patterns
  • Mood dysregulation
  • For infants/toddlers exhibiting the following symptoms for an extended period of time:
  • Excessive crying
  • Change in nursing or eating habits
  • Becoming upset easily or increased temper tantrums
  • Sad or lethargic mood
  • Lack of interest in favourite toys
  • For assistance in determining return to school, work, activity, or sports
  • Consider referral to a neuropsychologist for children and adolescents who have ongoing challenges with learning. Patients who have diagnosed learning difficulties, pre-existing behavioural dysregulation, and ADHD are at particular risk for poor outcome following concussion.
  • Mental health-related issues including anxiety, anger, sadness, and depression.
For more information, please review:
- Living Concussion Guidelines: Guideline for Concussion & Prolonged Symptoms for Adults 18 years of Age or Older

What is the best approach to investigation and management of persisting concussive symptoms (>4 weeks post-injury)?

Persisting symptoms are reported in up to 30% of patients who have concussions. As symptoms may not be specific to concussion, it is important to consider and manage co-existent pathologies.

Investigations may include a formal neuropsychological assessment and neuroimaging to exclude structural pathology. Currently, there is insufficient evidence to recommend routine clinical use of advanced neuroimaging techniques or other investigative strategies. If neuroimaging is considered as part of a diagnostic workup, this should be discussed with a neuroradiologist.

Patients who have persisting concussion symptoms are ideally managed by an interdisciplinary team of licensed healthcare professionals with expertise in concussion. They may include physiotherapy, cognitive therapy, vision therapy, psychology, neuropsychology, psychiatry, and school support.

What management strategies can I suggest for my patients?

Management strategies:
  • Nutrition (3 meals and 2 snacks daily, proteins with each meal)
  • Increased fluid intake (1 litre for children: 1.5 litres for adolescents)
  • Sleep strategies to improve sleep. Melatonin might be considered (aiming for 10.5 hours for children ages 5-7 years, 10 hours for 7-10 years, 9 hours for 10-13 years, 8 hours for 14+ years)
  • Address headaches and provide clear information regarding headache management:
  • Identify and avoid triggers
  • Advise about judicious use of OTC analgesia and potential complications resulting from medication overuse
  • Consider use of nutraceuticals (riboflavin, coenzyme Q10, magnesium citrate)
  • Consider biofeedback, mindfulness, meditation
  • Provide information regarding relative rest, gradually increasing physical and cognitive activity within 2 days
  • Avoidance of contact sports and any activities putting the patient at higher risk for injury until recovery is complete
  • Limit screen and device time for the first 48 hours post-injury
  • Graded Return to School strategies
  • Graded Return to Sports strategies
  • Advice regarding driving
  • Advice regarding maintaining social network, and connecting with friends and family
1. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, Davis GA, Echemendia RJ, Makdissi M, McNamee M, Broglio S. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British Journal of Sports Medicine. 2023 Jun 1;57(11):695-711.