Author: Shivon Manchanda
We recently had a wonderful guest lecture from Elizabeth Pieroth, PsyD, ABPP, the Director of the Concussion Program at Midwest Orthopedics, about how to approach concussions in the ED. This post is a summary of that lecture.
Initial Assessment:
The initial assessment of a suspected concussion patient requires the examination of three aspects of the history of events: Mechanism of injury, initial symptoms, and time of symptom onset.
Mechanism of Injury
The diagnosis of concussion requires contact to the head or a movement forceful enough to cause injury. Problematically, we do not actually have a threshold for the force required to cause a concussion. While the studies are all over the place, it does appear that rotational movement seems to be most likely to cause this type of injury. Currently we lack knowledge of other contributory factors, which is why getting a good history and physical, as well as ruling out other diagnoses, is important.
Initial Symptoms
Not only are initial symptoms helpful in determining if this is a concussion, but they can also give you insight into whether there may be a prolonged recovery. Martinez et al. suggest that vestibular or ocular changes seem to predict a longer recovery. Otherwise, some common early symptoms can include confusion, headache, dizziness, and nausea/vomiting.
Still, this is hard. How many other things can you think of that can cause those symptoms? The differential is broad, and you need to make sure something else isn’t contributing. Another issue is that the signs and symptoms of concussion are ever-present in the general public. Dr. Pieroth notes for example that over 50% of people report having recurrent headaches. Iverson et al. found that 28% of high school girls met the ICD diagnosis of post-concussion syndrome…without ever having a concussion in the first place! Moreover, college students often have fatigue, poor concentration, slowed mentation, etc. So this is a very difficult diagnosis to make!
Differential Diagnosis of Concussion
- Intracranial Injury
- Cervical strain
- primary headache disorder, including migraine
- vestibular dysfunction
- dehydration
- anxiety
- seizure
- sinus infection
Time of symptom onset
Symptoms are usually present soon after injury. However, delayed symptoms can happen, and have been seen up to about 4 hours later. If someone starts having symptoms days later, it is not a concussion!
Screening in the ED
There are several tools available to use for patients with concussion, but you just need to know one: The Sport Concussion Assessment Tool (SCAT) 5.
SCAT 5 and Child SCAT5 were made for athletes and have both an on-field and off-field component. We would just need to use the off-field component. Child SCAT is for those under 13 and is modified a bit, taking out some questions and including a parent report. There are other tools like IMPACT and computerized tests, but these are more for return to play and not diagnostic, so don’t worry about them.
Again, remember to consider your other diagnoses! This is not the only tool you should use, it’s just a good tool to use when other things on your differential are ruled out or not as likely. If you’re using the SCAT, you’ve probably already used the Canadian Head CT Rule, for example.
Recommendations for Acute Injury:
It is ok to say I don’t know if this is a concussion!
Seriously, it’s a difficult diagnosis. But if you think that is what is going on, patients need early intervention and active rehabilitation.
People talk about rest – but it has been misunderstood
First, rest should be prescribed during the acute phase. This is about 24-48 hours. After that, rest can make things worse! Rest also does not mean that you lie in bed for two days and do absolutely nothing. It does not mean you absolutely cannot use your phone or electronics and that you are stuck doing nothing in a dark room. It just means that you should not do anything that bothers you. Reduce electronic use to a point where they won’t cause symptoms. Patients only need a dark room if they are photosensitive.
After the acute phase, patients should ease back into activity. Leddy et al. found that subthreshold aerobic exercise in the first week can speed up recovery. So, on day three patients can start moving more. No running. They can’t do anything with head contact potential. They shouldn’t be exposed to aggravating stimuli. But they can start moving around.
Recommendations for kids
Along with the above, kids require some modifications with regards to their school activities. Del Rossi et al. found aerobic exercise to be good for children too! They should sit out from PE, but recess does not need to be taken away. Just given them restrictions on things like kickball, touch football, etc. Exams can be delayed for 1-2 weeks unless they are feeling better earlier than that. Remember that high school moves fast, so you don’t have to put them in the hole and straight up ban homework. Let them approach it as tolerated. And let them leave early from class so they don’t get overstimulated in the hallway. Classes like band, which are incredibly stimulating, should be avoided as well.
The concussion specialist you’re going to have your patient see will probably take care of most of this. But writing a doctor note with this information for the time before they get in to see the specialist will help.
What should you do about chronic symptoms?
Honestly, there’s not much you’re going to be able to do. These patients need reassurance, and a referral to a specialist. They do not require the initial restrictions.
What is true recovery?
Studies have been conducted using various modalities, such as blood markers, MRIs, EEGs, etc…and there are no good markers that indicate recovery. So how is recovery determined? It is based on 3 things:
- Asymptomatic at rest and with exertion
- Normal balance and ocular exam
- They should not have nystagmus for example
- Intact cognitive functioning
- How is there school/work performance?
- Cognitive testing
- Won’t be done in the ED
- Very good for athletes
- This is standardized – done on computer, scantron, etc
Usually recovery takes about 1-3 weeks.
Post-Concussion Syndrome
Dr. Pieroth states this term has become meaningless. People get this diagnosis with wildly different symptoms. It should occur only 1-month post-concussion, but people have been getting this diagnosis well outside this window as well. It also does not even meet the criteria of a syndrome. Like concussion, the definition is vague, and there are no specific signs or symptoms for this diagnosis.
So, when someone comes in with persistent symptoms after their concussion, consider other causes before jumping to PCS. The Big 6 categories to think about are:
- Cervical
- Vestibular
- Ocular – motor
- Migraine
- Autonomic dysfunction – like posttraumatic POTS (category is rare)
- Other psychological factors
- Strongest factor for persistent symptoms is anxiety and depression history
Another big one is malingering. This is the case in 30-40% of adults and 15-17% of children. Other causes include poor sleep, medication side effects, and persistent pain.
Once you have ruled out other significant causes of persistent symptoms, still, consider NOT giving the diagnosis of post-concussion syndrome. While it is not yet an ICD 10 diagnosis, in the future consider using “Persistent Post-Concussion SYMPTOMS” as the diagnosis. For now, your impression can be the actual symptoms they came in with. As stated above, the strongest factor for persistent symptoms is anxiety and depression history. It is likely that the google search results from “post-concussion syndrome” might fuel more anxiety.
Ultimately, these patients should go see the concussion specialist. As stated in the literature, the sooner they see a specialist, the sooner they recover.
What to Emphasize to your Patients:
- Recovery is 1-3 weeks, maybe 4
- Complete rest is NOT the best treatment
- Concussions are treatable!
References:
1. Martinez C, Christopherson Z, Lake A, et al. Clinical examination factors that predict delayed recovery in individuals with concussion. Arch Physiother. 2020;10:10. doi:10.1186/s40945-020-00081-z
2. Del Rossi G, Anania T, Lopez RM. Early Aerobic Exercise for the Treatment of Acute Pediatric Concussions. J Athl Train. Published online June 5, 2020. doi:10.4085/1062-6050-404-19
3. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249/JSR.0000000000000505
4. Iverson GL, Silverberg ND, Mannix R, et al. Factors Associated With Concussion-like Symptom Reporting in High School Athletes. JAMA Pediatr. 2015;169(12):1132-1140. doi:10.1001/jamapediatrics.2015.2374