What is the management plan for a patient with a concussion without loss of consciousness?

Management of Concussion Without Loss of Consciousness

Manage concussion without loss of consciousness identically to concussion with loss of consciousness—the absence of LOC does not indicate a milder injury and should not alter your management approach. 1, 2

Key Principle: Loss of Consciousness is NOT a Reliable Severity Indicator

• Loss of consciousness is no longer considered a critical discriminator for concussion severity or management decisions. 1, 2
• Approximately 1.8% of patients with mild TBI without LOC can develop intracranial lesions, and 0.6% may require neurosurgical intervention. 2
• The need for neurosurgical intervention is essentially identical (0.4% vs 0.5%) between patients with and without LOC. 2
• One study found 4.9% of patients without LOC or post-traumatic amnesia still developed intracranial lesions. 2

Immediate On-Field/Acute Management

Remove the patient from play immediately—"When in doubt, sit them out!" 1

• Never allow same-day return to play, regardless of symptom resolution. 3, 1
• This applies even without LOC, as the risk of delayed symptom progression and second-impact syndrome remains. 3

Initial Rest Period (First 24-48 Hours)

Implement moderate physical and cognitive rest for 24-48 hours after injury. 1, 4

Physical rest includes:

• No sports or vigorous physical activity 1
• Avoid activities that increase heart rate significantly 4

Cognitive rest includes:

• Temporary reduction in school workload 1
• Avoidance of video games, computer use, television, and loud music 1
• Limit activities requiring sustained concentration 4

Critical pitfall: Do NOT prescribe strict prolonged rest exceeding 3 days, as this worsens outcomes. 1, 4

Symptom Management

• Use acetaminophen for headache management. 1
• Avoid NSAIDs and aspirin due to theoretical bleeding risk. 1
• Monitor symptom number and severity closely during the initial phase. 4

Graduated Return to Activity Protocol (After Initial 24-48 Hours)

Begin a stepwise progression once the initial rest period is complete, with each step requiring minimum 24 hours before advancement. 3, 1

The protocol follows these specific stages:

1. Light aerobic exercise (walking, stationary cycling at <70% maximum heart rate) 1
2. Sport-specific exercise (running drills, no head impact) 1
3. Non-contact training drills (more complex training activities) 1
4. Full-contact practice (normal training activities) 1
5. Return to competition (unrestricted play) 1

If ANY symptoms recur at any stage:

• Return to the previous asymptomatic level 3, 1
• Rest for 24 hours 3, 1
• Restart progression from that lower level 1

Supervised, non-contact aerobic exercise below the symptom-exacerbation threshold is particularly beneficial for adolescents. 1, 4

Return to School

• Gradually increase duration and intensity of academic activities as tolerated. 4
• Customize protocols based on symptom severity. 4
• Implement appropriate educational accommodations if symptoms interfere with academic performance. 4

Criteria for Full Return to Activity

Allow return to full activity ONLY when ALL three criteria are met: 1, 4

1. Patient has returned to premorbid performance level
2. Patient remains symptom-free at rest
3. No symptom recurrence occurs with increasing physical exertion

Management of Persistent Symptoms (>10 Days)

Implement multidisciplinary management for symptoms persisting beyond 10 days. 3, 1

Treatment options include:

• Sub-symptom threshold aerobic exercise 1
• Cervical physical therapy 1
• Vestibular rehabilitation 1
• Vision therapy 1
• Cognitive behavioral therapy 1
• Pharmacological management as needed 1

Refer to a traumatic brain injury specialist if symptoms persist beyond 3 weeks. 1

Neuroimaging Considerations

Standard structural neuroimaging (CT/MRI) will be normal by definition in concussion. 1

However, obtain immediate CT if ANY high-risk features are present, regardless of LOC absence: 2

• Glasgow Coma Scale score of 14 2
• Vomiting 2
• Severe headache 2
• Signs of basilar skull fracture 2
• Focal neurological deficit 2
• Coagulopathy or anticoagulant use 2
• Age >65 years 2
• Dangerous mechanism of injury (fall from height, pedestrian struck) 2

Critical Pitfalls to Avoid

• Never allow same-day return to play after diagnosed concussion, even without LOC. 3, 1
• Do not return to play while taking medications for concussion symptoms—this indicates incomplete recovery. 3, 1
• Avoid high-intensity physical activity during recovery. 1, 4
• Do not rely solely on patient-reported symptoms without objective assessment. 1
• Be more conservative with younger athletes (<18 years) due to potential catastrophic effects on the maturing brain. 1
• The absence of LOC should not create false reassurance—these patients can develop serious complications and require the same neurological follow-up. 2