From the Guidelines
The appropriate workup for a patient presenting with a concussion begins with a thorough clinical assessment, including a detailed history of the injury mechanism and symptoms, followed by a comprehensive neurological examination. Vital signs should be monitored and the Glasgow Coma Scale used to assess consciousness level. Cognitive function should be evaluated using tools like the Sport Concussion Assessment Tool (SCAT5) or the Military Acute Concussion Evaluation (MACE) 1.
Key Components of Concussion Workup
- A detailed history of the injury mechanism and symptoms
- Comprehensive neurological examination
- Monitoring of vital signs
- Assessment of consciousness level using the Glasgow Coma Scale
- Evaluation of cognitive function using tools like SCAT5 or MACE
Neuroimaging and Laboratory Tests
Neuroimaging is not routinely required for uncomplicated concussions but should be considered if there are concerning features such as prolonged loss of consciousness (>30 minutes), persistent vomiting, worsening headache, seizures, focal neurological deficits, or signs of skull fracture 1. When indicated, a non-contrast CT scan of the head is the preferred initial imaging modality, with MRI reserved for persistent symptoms or specific concerns. Laboratory tests are generally not necessary unless there are concerns about other medical conditions.
Management and Return to Activities
The patient should be monitored for deterioration, educated about expected symptoms, and advised on gradual return to normal activities. Rest for 24-48 hours followed by progressive reintroduction of cognitive and physical activities as tolerated is recommended 1. Medications should be limited to acetaminophen for headache, avoiding NSAIDs initially due to bleeding risk, and avoiding sedating medications that could mask neurological changes.
Considerations for Persistent Symptoms
For patients with persistent postconcussive symptoms, consideration should be given to offering early information and advice, graded physical exercise, vestibular rehabilitation, and manual treatment of neck and spine, as these interventions have shown promise in reducing the burden of postconcussion symptoms 1.
From the Research
Workup for Concussion
The workup for a patient presenting with a concussion involves a comprehensive evaluation to assess the severity of the injury and to monitor recovery. The following are key components of the workup:
- A thorough medical history, including any previous concussions or head injuries 2
- A physical examination, including evaluation of cranial nerves, manual muscle testing, and deep tendon reflexes 3
- A mental status examination, including orientation, immediate and delayed recall, concentration, mood, affect, insight, and judgment 3, 4
- A balance assessment, such as a static or dynamic balance test 2, 3
- A screening ocular examination 3
- A cervical spine examination, including inspection for trauma or tenderness and cervical range of motion 3
Use of Standardized Assessment Tools
Standardized assessment tools, such as the Standardized Assessment of Concussion (SAC) or the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), can be useful in evaluating concussion and monitoring recovery 5, 4. These tools can provide an objective measure of cognitive function and can help identify patients who may be at risk for prolonged recovery.
Imaging and Laboratory Tests
Imaging tests, such as CT or MRI scans, are typically reserved for patients with suspected intracerebral bleeding or other severe injuries 2. Laboratory tests, such as blood work, are not typically necessary in the evaluation of concussion.
Monitoring and Follow-up
Patients with concussion should be monitored closely for deteriorating physical or mental status and should be followed up regularly to assess recovery 2. The use of a Severity Index (SI), which is a summation of the number of standard deviations from baseline on ImPACT testing, can be a useful prognostic tool in predicting recovery time and symptom regression 5.