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    Concussion – Management

    Neurological, Trauma

    Last Updated Aug 08, 2019
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    Context

    • The majority (80–90%) of concussions resolve in 7–10 days. However, recovery time may be longer in adolescents and children.
    • Historically, patients were advised to rest (cognitively and physically) until symptoms resolved.
    • Current guidelines indicate after 24–48 hours of physical and cognitive rest, patients should attempt light physical and cognitive activity as long as symptoms are stable or improving.

    Recommended Treatment

    Return to activity

    • Stage 1: Initial Rest
      • Physical and cognitive rest for 24–48 hours in a quiet environment with limited distractions (pending acute symptom resolution).
      • Complete physical and cognitive rest for over 48 hours is generally not recommended, as there is no evidence that this is beneficial.
    • Stage 2: Gradual Increase in Activity Level as Tolerated
      • Perform simple tasks around the home, read, or do light physical activity (ie. walking or riding a stationary bike).
      • Symptoms usually get slightly worse with increased activity level, but these symptom changes tend to go away within a day. If symptoms are persistently worse with increased activity, return to the previous level of activity.
    • Stage 3: Full Return to Activity
      • Gradually taper off extra rest breaks.
      • Do not return to risky activities where another concussion could occur, such as contact sports or dangerous job tasks, until symptoms have fully resolved.
    • 30–80% of patients with mild to moderate TBI will experience at least one symptom of postconcussion syndrome (See Concussion Diagnosis).

     

    Symptom management

    • Treatment includes management of headache, sleep disturbances, and psychologic and cognitive complaints that can occur after concussion.

     

    Headache management

    • Headache is the most common symptom following a concussion.
    • Acetaminophen and NSAIDs are reasonable adjuncts to cognitive and physical rest during the first few days after injury, but can be ineffective or cause medication-overuse headaches if used regularly after the initial stages of injury.
    • Amitriptyline has been widely used for post-traumatic tension-type headaches, and for symptoms such as irritability, dizziness, depression, fatigue, and insomnia.
    • An inpatient program of repetitive IV dihydroergotamine and metoclopramide may provide relief of refractory chronic post-traumatic headaches.

    Criteria For Hospital Admission

    • Patients at risk for immediate complications from head injury, including patients with:
      • GCS <15
      • Abnormalities on head CT (eg, intracranial hemorrhage, ischemia, mass effect, midline shift)
      • Seizures
      • Bleeding diathesis or oral anticoagulation
      • Neurologic deficit
      • Recurrent vomiting.

    Criteria For Safe Discharge Home

    • Outpatient observation may be permitted for the patient whose neurologic condition is unlikely to deteriorate.
    • There is substantial evidence that patients with a GCS = 15, normal examination and head CT, and no predisposition to bleeding are unlikely to suffer subsequent neurologic deterioration.

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