Diagnosing Concussion in the Emergency Department
The diagnosis of concussion in the emergency department requires a thorough history, neurological examination, balance assessment, and cognitive function evaluation, while neuroimaging should be reserved only for cases with suspected structural brain abnormalities. 1
Initial Assessment
History Taking
- Obtain detailed information about:
- Mechanism of injury
- Loss of consciousness (present in less than 10% of concussions) 1
- Previous head injuries
- Timing and progression of symptoms
Symptom Evaluation
Use a standardized symptom checklist to assess for:
Physical Symptoms
- Headache
- Dizziness
- Nausea/vomiting
- Unsteadiness/loss of balance
- Visual disturbances (seeing stars, double vision)
- Sensitivity to light or noise
- Ringing in the ears 1
Cognitive Symptoms
- Feeling "dinged," "dazed," or "stunned"
- Confusion
- Slow to answer questions
- Poor concentration
- Memory problems 1
Behavioral Signs
- Personality changes
- Inappropriate emotions (laughing, crying)
- Vacant stare/glassy-eyed appearance
- Slurred speech
- Inappropriate playing behavior (if sports-related) 1
Physical Examination
Neurological Examination
- Mental status assessment
- Cranial nerve testing
- Motor and sensory examination
- Deep tendon reflexes
- Coordination testing
Balance Assessment
- Balance Error Scoring System (BESS): performed in 3 positions (feet together, single leg stance, tandem stance) on firm surface and foam surface 1
- Romberg test
- Tandem gait assessment
Cognitive Function Assessment
- Standardized Assessment of Concussion (SAC): 95% sensitive and 76% specific for concussion when any decrease from baseline is observed 1
- Maddock's questions (more reliable than standard orientation questions) 1
- Immediate and delayed recall testing
Neuroimaging Considerations
Conventional neuroimaging is typically normal in concussion and contributes little to evaluation and management. 1 CT scans should be reserved for patients with:
- Glasgow Coma Scale score less than 15 at 2 hours after injury
- Suspected open or depressed skull fracture
- History of worsening headache
- Irritability on examination
- Signs of deterioration in neurological status 1
CT is the test of choice to evaluate for intracranial hemorrhage during the first 24-48 hours after injury and is superior for detecting skull fractures. 1
Post-Assessment Management
- If concussion is identified, the patient should be removed from any athletic activity for that day 1
- Continue monitoring for several hours to evaluate for deterioration
- Provide clear discharge instructions about:
- Warning signs requiring return to the ED
- Expected symptoms and their management
- Activity restrictions
- Follow-up care recommendations 1
Common Pitfalls to Avoid
Relying solely on loss of consciousness: LOC occurs in less than 10% of concussions and is not a reliable indicator of severity 1
Overuse of neuroimaging: Routine CT or MRI contributes little to concussion evaluation and management unless there are specific concerns for structural injury 1
Inadequate follow-up planning: Patients should receive clear guidelines on when to return to the ED or follow up with their primary care provider 1
Using standard orientation questions: Memory assessment is more sensitive than time/place/person orientation questions for concussion evaluation 1
Immediate return to activity: There should be no same-day return to play/activity for anyone diagnosed with concussion 2
By following this structured approach to concussion evaluation in the emergency department, clinicians can accurately diagnose concussions, identify patients requiring neuroimaging, and provide appropriate guidance for post-concussion management to reduce morbidity and improve outcomes.