Clinical Notes : Orthopedics and Trauma

46. Concussion




  • Concussion is a brain injury (often called ‘mild traumatic brain injury’) caused by biomechanical forces, either by a direct blow to the head or by an impulsive force.

  • Typically resulting in short lived impairment of neurological function that resolves spontaneously, but symptoms and signs may evolve over a number of minutes to hours

    • It may or may not involve loss of consciousness.

    • No structural injury seen on imaging


  • At the time of injury

    • Appearance

      • Loss of consciousness or responsiveness

      • Lying motionless on ground

      • Slow to get up Unsteady on feet

      • Balance problems or falling over

      • Incoordination

      • Grabbing / Clutching of head

      • Dazed, blank or vacant look Confused

      • Not aware of plays or eventse

    • Improper responses to questioning

      • “What venue are we at today?”

      • “Which half is it now?”

      • “Who scored last in this game?”

      • “What team did you play last week / game?”

      • “Did your team win the last game?”

  • After the injury

    • Somatic

      • headache

      • loss of consciousness

    • Cognitive

      • ‘feeling in a fog’

      • amnesia

      • slowed reaction times

      • emotional lability

      • irritability

    • Sleep disturbance e.g. insomnia


Concussion Clinical Domains

concussion 1.jpg
concussion 1.jpg


  • At the time of injury

    • “If in doubt, sit them out”

    • Do not allow a child or adult with suspected concussion to return to play the same day

  • After he injury

    • An initial period of complete physical and cognitive rest of 48 hours

    • including TV and smart phones

    • Followed by 7 days of physical rest

    • Then a graded programme of return to social, school and work activities before a return to sport



  • 80% to 90% resolve over 7 to 10 days

  • may be longer in children and adolescents


Adults referral to A+E


  • Emegency referral (requires CT head within 1 hour)

    • GCS <13 on immediately after injury

    • GCS<15 at 2 hours after injury

    • More than one episode of vomiting since head injury

    • Post-traumatic seizure

    • Focal neurological deficit

    • Suspected open or depressed skull fracture

    • Any sign of basal skull fracture

  • e.g. ‘panda’ eyes, CSF leakage from ears or nose

  • Urgent referral (requires CT scan within 8 hours)

    • Patients on anticoagulants (e.g. warfarin)

    • There has been a loss of consciousness or amnesia since the head injury and any of the following risk factors are present:

  • Age >65

  • History of bleeding or clotting disorder

  • Dangerous mechanism of injury e.g. pedestrian or cyclist hit by motor vehicle, or fall from height of >1 metre or 5 stairs

  • More than 30 minutes of retrograde amnesia of events immediately before the head injury


Children referral to A+E


  • >1 yr. old (requires CT head within 1 hour)

    • GCS<14 immediately after injury

    • GCS<15 at 2 hours after injury

    • Suspicion of non-accidental injury

    • Post traumatic seizure

    • Suspected skull fracture, tense fontanelle, any sign of basal skull fracture

    • e.g. ‘panda’ eyes, CSF leakage from ears or nose

    • Focal neurological deficit


  • <1 yr. old (requires CT scan within 8 hours)

    • GCS paediatric <15

    • Bruise, swelling or laceration of >5cm on head


Concussion Clinical Domains

concussion 3.jpg

May not require CT scan, but does require minimum 4 hrs observation

  • Witnessed loss of consciousness >5minutes

  • Abnormal drowsiness

  • 3 or more episodes of vomiting

  • Dangerous mechanism of injury

  • Amnesia lasting >5 minutes in a child aged over 5

Discharge and follow up

  • Inform patients and carers about the possibility of persistent or delayed symptoms after head injury

  • A responsible adult should stay with the patient for the first 24 hours

  • Give verbal and printed discharge advice to patients with any degree of head injury

  • Minor Head Injury discharge advice factsheet

  • Graduated Return to Play Contact Sports factsheet

Delayed referral

  • Persistent symptoms for >10 days (post concussion syndrome)

    • refer to head injury team for multidisciplinary assessment to look for other causes


Early management of head injury: summary of updated NICE guidance

Sarah Hodgkinson, Vicki Pollit, Carlos Sharpin, Fiona Lecky

BMJ 2014;348:g104. January 2014



Concussion Guidelines for the Education Sector

Sport and Recreation Alliance

June 2015


Head injury: assessment and early management

NICE Clinical guideline CG176

Published date: January 2014

Last updated: June 2017


Consensus statement on concussion in sport

the 5th international conference on concussion in sport held in Berlin, October 2016

Paul McCrory et al.

BMJ Journal of Sports Medicine

Volume 51, Issue 11



Concussive head injury in children and adolescents

Gary J Browne, Stefan Dimou

Royal Australian College of General Practitioners

Australian Family Physician Volume 45, No.7, July 2016 Pages 470-476


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