What is the appropriate management for a 24-year-old patient with a possible head concussion after being hit on the right eyebrow region with a barbell, presenting with vision changes, nausea, headache (HA), and dizziness?

Management of Concussion Following Head Trauma

The patient should be immediately evaluated for concussion and referred for neuroimaging due to the presence of visual changes, consistent nausea, headache, and dizziness following head trauma.

Initial Assessment

This 24-year-old patient presents with classic signs and symptoms of concussion following a direct impact to the right eyebrow region from a barbell during bench pressing. Key symptoms include:

• Vision changes with streaks of lights
• Consistent nausea
• Headache
• Dizziness
• Symptoms began within 5 minutes of the injury

Concussion Diagnosis

The patient's presentation is consistent with a concussion, which is a type of mild traumatic brain injury (mTBI) caused by rapid movement of the head and brain 1. The symptoms fall into the physical category of concussion manifestations, which commonly include:

• Headache (most frequently reported symptom) 1
• Dizziness/balance problems
• Nausea/vomiting
• Visual disturbances
• Light sensitivity

Immediate Management

1. Remove from physical activity: The patient should immediately discontinue any physical activity or exercise 1.

2. Neuroimaging evaluation: Due to the presence of visual changes (streaks of light) and persistent symptoms, the patient should undergo CT imaging of the brain 1. The 2024 American Heart Association guidelines recommend that patients with signs or symptoms of severe head injury (including visual changes) should be evaluated by healthcare professionals 1.

3. Neurological assessment: Perform a detailed neurological examination including:

   • Glasgow Coma Scale assessment
   • Pupillary responses
   • Balance testing
   • Cranial nerve examination with focus on visual fields and eye movements
   • Assessment for retrograde and anterograde amnesia 1

4. Document symptoms using a standardized scale: Use a postconcussion symptom scale to document baseline symptoms and track recovery 1. This should include assessment of:

   • Physical symptoms (headache, nausea, dizziness, visual problems)
   • Cognitive symptoms (difficulty concentrating, memory issues, feeling "foggy")
   • Emotional symptoms (irritability, nervousness)
   • Sleep disturbances

Treatment Plan

1. Rest for 24-48 hours: Physical and cognitive rest is recommended in the acute phase following concussion 1.

2. Symptom monitoring: The patient should be monitored for worsening symptoms that may indicate more serious injury 1:

   • Worsening headache
   • Repeated vomiting
   • Increased drowsiness
   • Confusion
   • Seizures
   • Focal neurological deficits

3. Provide written discharge instructions: Discharge instructions should be given in both written and verbal form, at approximately a sixth to seventh-grade reading level 1. These should include:

   • Warning signs that require immediate medical attention
   • Expected symptoms and their typical duration
   • Guidance on gradual return to activities

4. Education about postconcussive symptoms: Inform the patient that symptoms may persist for weeks to months 1. Common postconcussive symptoms include:

   • Chronic headaches
   • Dizziness/balance problems
   • Vision problems
   • Sensitivity to light/noise
   • Concentration difficulties
   • Memory problems

5. Follow-up plan: Schedule follow-up within 24-72 hours to reassess symptoms and adjust management plan as needed.

Return to Activity Protocol

Implement a gradual return to activity protocol once the patient is symptom-free at rest 1:

1. Light aerobic exercise (walking, swimming)
2. Sport-specific exercise (running drills)
3. Non-contact training drills
4. Full-contact practice after medical clearance
5. Return to competition/full activity

Each step should take at least 24 hours, and if symptoms recur, the patient should return to the previous asymptomatic level.

Important Considerations and Pitfalls

• Do not dismiss symptoms: Visual changes following head trauma should be taken seriously as they may indicate more serious injury 1.
• Avoid premature return to activity: Returning to physical activity too soon increases risk of prolonged symptoms and repeat injury 1.
• Monitor for delayed symptoms: Some concussion symptoms may not appear immediately and can develop or worsen over hours to days 2.
• Consider referral to specialist: If symptoms persist beyond 2-3 weeks, consider referral to a concussion specialist or neurologist 1.
• Maintain adequate cerebral perfusion: Ensure systolic blood pressure >110 mmHg to prevent secondary brain injury 3.

By following this structured approach to concussion management, you can minimize the risk of complications and promote optimal recovery for this patient.