Is it reasonable to admit a patient with a concussion for observation and further evaluation?

Management of Concussion: Admission vs. Discharge

Patients with concussion who have normal CT scan findings and normal neurological examination can be safely discharged from the emergency department rather than admitted for observation.

Assessment of Concussion Severity

The decision to admit a patient with concussion depends on several key factors:

High-Risk Features Requiring Admission

• Abnormal CT findings showing intracranial injury 1
• Persistent altered mental status (GCS < 15) 1
• Deteriorating neurological status 1
• Prolonged loss of consciousness (>30 seconds) 2
• Persistent confusion or disorientation 2
• Focal neurological deficits 1
• Age >60 years (higher risk of delayed hemorrhage) 1
• Intoxication that prevents proper assessment 1
• Lack of responsible caregiver for home observation 1

Low-Risk Features Supporting Discharge

• Normal CT scan findings 1
• Normal neurological examination 1
• GCS score of 15 1
• Presentation >6 hours after injury 1
• Availability of responsible adult for home observation 1

Evidence-Based Decision Algorithm

1. Obtain head CT if any of these risk factors are present 1:

   • Headache
   • Vomiting (especially more than once)
   • Age >60 years
   • Drug or alcohol intoxication
   • Short-term memory deficits
   • Physical evidence of trauma above the clavicle
   • Seizure
   • GCS <15 at 2 hours post-injury
   • Suspected skull fracture
   • Signs of basal skull fracture

2. Admit patient if:

   • Positive CT findings showing intracranial injury 1
   • Persistent neurological deficits 1
   • Inability to complete proper assessment (e.g., intoxication) 1
   • No responsible adult available for home observation 1

3. Discharge patient if:

   • Normal CT scan findings AND
   • Normal neurological examination AND
   • GCS score of 15 1

Supporting Evidence

The evidence strongly supports that patients with mild traumatic brain injury (MTBI) who have normal CT findings and normal neurological examinations can be safely discharged. According to the Annals of Emergency Medicine clinical policy, "Patients with MTBI who present 6 hours after sustaining the injury, have a normal clinical examination, and who have a head CT scan that does not demonstrate acute injury can be safely discharged from the ED" 1.

A randomized trial by af Geijerstam et al. involving 2,602 patients with MTBI (GCS score 15) found no significant difference in outcomes between patients who were admitted for observation versus those who underwent CT and were discharged if findings were normal 1. Importantly, no patients with normal immediate CT had complications later during the 3-month follow-up period 1.

Important Caveats and Pitfalls

1. Observation quality concerns: Studies have shown that patients admitted for observation often don't receive adequate neurological monitoring. One study found only 50% of admitted patients had documented serial neurological examinations 1.

2. Discharge instruction retention: 23% of patients discharged from the ED with MTBI could not remember any of their discharge instructions 1. Therefore, written discharge instructions are essential.

3. Post-concussive syndrome risk: Even patients with normal CT findings and GCS of 15 remain at risk for developing cognitive, psychosocial, and neurobehavioral abnormalities related to MTBI 1. This should be discussed with patients.

4. Follow-up importance: Schedule follow-up within 24-72 hours to reassess symptoms and adjust the management plan 2.

5. Delayed deterioration: While extremely rare with normal CT findings, patients and caregivers should be educated about warning signs requiring immediate return to the ED: worsening headache, repeated vomiting, increased drowsiness, confusion, seizures, and focal neurological deficits 2.

In conclusion, while neurology's desire to admit the patient for observation is understandable, current evidence supports that patients with concussion who have normal CT findings and normal neurological examination can be safely discharged with appropriate instructions and follow-up rather than admitted for observation.