Initial Medical Assessment and Management

Domain 2: Initial Medical Assessment and Management

Recommendations

2.1

Physicians or nurse practitioners should perform a comprehensive medical assessment on all children/adolescents with a suspected concussion or with acute head or spine trauma.  

Include a clinical history, physical examination, and the evidence-based use of diagnostic tests or imaging as needed.

Online resources to consider:

Tool 1.3: Manage Acute and Prolonged Symptoms Algorithm

2.1a

Take a comprehensive clinical history.

Level of Evidence:

Details that should be collected in the clinical history include:

  • Patient demographics (e.g., age, sex, gender).
  • Assess injury mechanism and symptoms at the time of injury.
  • Assess symptom burden at the time of initial presentation.
    • Number of symptoms.
    • Severity of symptoms.
    • Type of symptoms.
  • Presence of loss of consciousness, post-traumatic amnesia, and red flags (seizures, neck pain, focal neurological deficits).
  • Current post-concussion symptoms (using age-appropriate standardized symptom inventory).
  • Review mental health (Domain 8: Mental Health and Psychosocial Factors).
  • Past medical history (e.g., previous concussions, migraine or non-specific headaches, mental health disorders, coagulopathy, other risk modifiers that may delay recovery). Note the duration until recovery from previous concussions (i.e., within 7-10 days or persisting).
  • Allergies/immunizations.
  • Ask whether the child/adolescent is taking any substances or medications: Prescribed or over-the-counter medications or supplements, alcohol, or recreational drugs including cannabis. These substances may mask or modify concussion symptoms.

Ask about school, activities, work, and sports participation.

2.1b

Perform a comprehensive physical examination.

Level of Evidence:  

  • Vital signs (resting heart rate and blood pressure).
  • Level of consciousness (Glasgow Coma Scale).
  • Mental status.
  • A complete neurological examination (cranial nerve, motor, sensory, reflex, cerebellar, gait, and balance testing) (Tool 2.1: Physical examination).
  • A cervical spine examination (palpation, range of motion, provocative cervical spine tests) (Tool 2.1: Physical examination).
  • An examination of the visual and vestibular systems.

Online tools to consider:

2.1c

Consider CT of the brain or cervical spine only in patients whom, after a medical assessment, a structural intracranial or cervical spine injury is suspected; do not conduct routine neuroimaging for the purpose of diagnosing concussion. 

Level of Evidence: CT. MRI.

Most children/adolescents who sustain an acute head injury or suspected concussion do not need diagnostic imaging. 

Use the following tools, as appropriate, to determine the need for CT imaging in patients with acute head trauma:

Although validated clinical decision-making rules are highly sensitive, these tools are meant to assist, but not replace, clinical judgment. CT scans should be used judiciously as the exposure of children/adolescents to the effects of ionizing radiation carries a small increased lifetime risk of cancer. If a structural brain injury is suspected in a patient with acute head trauma undergoing initial medical assessment in the office setting, urgent referral to an Emergency Department should be arranged.

Diagnostic imaging of the spine should be considered when symptoms are suggestive of structural cervical spine injury. Imaging should be considered in patients with severe neck pain, tenderness or clinical evidence of radiculopathy or myelopathy. The choice of imaging modality (plain radiographs, CT or MRI of the cervical spine) should be guided by the suspected pathology.

Patients with positive traumatic findings observed on diagnostic imaging of the brain or spine should be urgently referred to a neurosurgeon for consultation.

2.2

Note common modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

Level of Evidence:

Link: Predicting Persistent Post-Concussive Problems in Pediatrics (5P): Score Calculator.

Modifiers that may delay recovery:

  • Age (increased risk with increased age).
  • Sex (female).
  • Duration of recovery from a previous concussion.
  • High pre-injury symptom burden.
  • High symptom burden at initial presentation.
  • Clinical evidence of vestibular or oculomotor dysfunction.
  • Vestibular-Ocular Reflex (VOR) and tandem gait parameters.
  • Orthostatic intolerance.
  • Personal and family history of migraines.
  • History of learning or behavioural difficulties.
  • Personal and family history of mental health.
  • Family socioeconomic status/education.

2.2

Provide verbal information and written (electronic) handouts regarding the course of recovery and when the child/adolescent can return to school/activity/sport/work.

Level of Evidence:  

Consider the following anticipatory guidance (verbal reassurance) in order to reduce anxiety, set realistic expectations, promote recovery, and prevent re-injury: 

  • Most patients recover fully from concussion even though the recovery rate is variable and unpredictable.
  • Current symptoms are expected and common.
  • The burden and distress parents/caregivers of children/adolescents who have sustained a concussion may experience is common.
  • Children typically recover in 1-4 weeks but some children/adolescents will have symptoms at one month and beyond and need to be monitored/seek additional care. Females aged 13-18 years have an increased risk of prolonged recovery.
  • Tool 2.0: Living Guideline Return to Activity Sports and School Protocol (Updated Sept 2023)
  • Recommendation 2.3 Recommend graduated return to physical and cognitive activity. 
  • Return to school should be step-wise as soon as the student is able and include temporary academic modifications based on the student’s symptom tolerance. See Domain 12: Return-to-School and Work for more recommendations and a list of return-to-school resources.

Summary of online tools to consider related to lifestyle strategies and expectations:

2.3

Recommend graduated return to cognitive and physical activity to promote recovery.

While most children/adolescents fully recover, the recovery rate can be variable. Return to physical and cognitive activity should be individualized based on activity tolerance and symptom presentation.

2.3a

Recommend an initial 24-48 hour period of relative rest*.

Level of Evidence: A Gradual return to physical activity. B Gradual return to cognitive activity.

*Relative rest: activities of daily living including walking and other light physical and cognitive activities are permitted as tolerated. (this definition has been harmonized with and adapted from the Amsterdam International Consensus Statement on Concussion in Sport)

See Living Guideline Return to Sport/Activity and School Protocols

Updated Sept 2023

2.3b

2.3b Recommend that physical and cognitive activity be started 24-48 hours after a concussion increasing the intensity gradually as part of the initial treatment for acute concussion. Activities that pose no/low risk of sustaining a concussion should be resumed even if mild residual symptoms are present.

Start with ‘light-intensity’ aerobic exercise, progressing to ‘moderate-intensity’ aerobic exercise, and continue to increase the intensity over time as symptoms are tolerated.* Suggest taking a break from the activity if the increase in symptoms is more than mild and brief** or the symptoms cannot be tolerated. 

Level of Evidence:  B

Updated: Sept 2023

*Light-intensity aerobic exercise: Target heart rate of up to approximately 55% of the person’s maximum heart rate (estimated according to age- 220 beats/min minus age in years)

Moderate-intensity aerobic exercise: Target heart rate of up to approximately 70% of the person’s maximum heart rate

**More than mild and brief symptom exacerbation: An increase in current concussion symptoms of no more than 2 points on a 0-10 point scale for less than an hour compared to the resting value prior to the physical activity. Example of a 0-10 point Symptom severity scale: Visual Analog Scale (VAS)

(these definitions have been harmonized with and adapted from the Amsterdam International Consensus Statement on Concussion in Sport)

2.3c

Recommend that patients avoid activities associated with a risk of contact, fall, or collisions such as high-speed and/or contact activities and full-contact sport that may increase the risk of sustaining another concussion until medically cleared (see Recommendation 4.1: Consider patients for medical clearance to return to full-contact activities and sport/gameplay if clinical criteria have been met. Note: An update to Rec 4.1 was performed Sept 2023). 

Level of Evidence:  

  • Advise/emphasize that returning to full-contact sport or high-risk activities before the child/adolescent has recovered increases the risk of delayed recovery and for sustaining another more severe concussion or more serious injury.

2.3d

Refer select patients (e.g., highly-active or competitive athletes, those who are not tolerating a graduated return to physical activity, or those who are slow to recover) following acute injury to a medically supervised interdisciplinary team with the ability to individually assess aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:

 
Patients who are active may benefit from referral to a medically supervised interdisciplinary team with the ability to individually assess aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:
Links to exertion test resources:
 
(Updated: Sept 2023)

2.4

Provide education and guidance regarding strategies to promote recovery.

2.4a

Advise on the importance of sleep and discuss sleep hygiene.

Level of Evidence:

Advise that consistent sleep schedules and duration of sleep may contribute to general recovery from a concussion and alleviate symptoms such as mood, anxiety, pain, fatigue, and cognitive difficulties if these are present. 

Summary of tools to consider:

2.4b

Advise on maintaining social networks and interactions (as tolerated). Children/adolescents should participate (modified as needed) in rewarding social activities that avoid the risk of re-injury. Social engagement may promote recovery and reduce the risk of mental health issues. 

Level of Evidence:  

Updated Sept 2023

2.4c

Screentime should be minimized in the first 48 hours after injury. After the initial period of relative rest, the use of devices with screens may be gradually resumed. The use of these devices can be increased according to symptom tolerance as the child/adolescent recovers.

Level of Evidence: B

Updated Sept 2023

2.4d

Advise on avoiding alcohol and other recreational drugs after a concussion.

Level of Evidence:

Alcohol and recreational drugs may have a negative effect on concussion recovery. Avoiding alcohol or drugs prevents a child/adolescent from self-medicating and resorting to drugs to relieve symptoms. Impaired judgment after a concussion could lead to risky behaviour that causes further harm or may delay the identification of complications.

2.4e

Advise to avoid driving during the first 24-48 hours after a concussion. Advise patients to begin driving when they are feeling improved, can concentrate sufficiently to feel safe behind the wheel, and when the act of driving does not provoke significant concussion symptoms.

Level of Evidence:

Provide verbal information related to when an adolescent should return to driving during recovery from a concussion. Driving is a complex coordinated process that requires vision, balance, reaction time, judgment, cognition, and attention. Concussion may have affected some or all of these skills. Driving impairments have been shown to exist even in asymptomatic patients 48 hours after a concussion. Avoiding driving for at least 24-48 hours after a concussion may potentially prevent motor vehicle accidents and, therefore, injury to the adolescent or to others.

2.5

Over-the-counter medications such as acetaminophen and ibuprofen may be recommended to treat acute headache. Limit the use of these short-term acting medications to the first week post-injury and avoid “around-the-clock” dosing to prevent overuse or rebound headaches.

Level of Evidence:  

Updated Sept 2023

2.6

At present, there is limited evidence to support the administration of intravenous medication to treat acute headaches in pediatric concussion patients in the Emergency Department setting.

Level of Evidence:

2.7

After assessment, nearly all children/adolescents with concussion may be safely discharged from clinics and Emergency Departments for observation at home.

Level of Evidence:  

The decision to observe in the hospital will depend on clinical judgment. Indicators for longer in-hospital observation (or to return to emergency for re-assessment) may include:

  • Worsening symptoms (headache, confusion, irritability).
  • Decreased level of consciousness.
  • Prolonged clinical symptoms (persistent/prolonged vomiting, severe headache, etc.).
  • Bleeding disorders.
  • Multi-system injuries. 
  • Co-morbid symptoms. 

Other discharge considerations:

  • Observe the child/adolescent for a period of time to verify that they do not develop “red flag” symptoms prior to discharge. Use clinical judgment.
  • Verify that the child/adolescent has a normal mental status (alertness/behaviour/cognition) and their symptoms are improving prior to discharge. 
  • Verify that an assessment of clinical risk factors indicating the need for a CT scan was performed or a normal result was obtained if a CT scan was performed prior to discharge.
  • See Recommendation 2.1c for more information on when to consider diagnostic brain or cervical spine imaging.

2.8

Recommend a medical follow-up visit in 1-2 weeks to re-assess and monitor clinical status. Recommend an immediate medical follow-up in the presence of any deterioration.

Level of Evidence:

Those with a confirmed diagnosis of concussion may be managed by a healthcare professional who within their formally designated scope of practice has the capacity to manage ongoing concussion-related symptoms.

2.9

Refer patients at elevated risk for delayed recovery to an interdisciplinary concussion team. Level of Evidence: 

See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

2.9a

Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury. Level of Evidence:  

2.10

Provide post-concussion information and a written medical assessment to the child/adolescent and the parent/caregiver prior to sending the child/adolescent home. 

Level of Evidence:  

Write the discharge note/written medical assessment with the following information:

Verbal and written (or electronic) guidance should include:

Other patient information handouts to consider:

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