What is the most appropriate next step in care for a patient with increased forgetfulness and difficulty sleeping after a head injury with loss of consciousness and a negative head computed tomography (CT) scan?

Recommend an Outpatient Workup with Structured Concussion Management

The most appropriate next step is recommending an outpatient workup with referral to a concussion specialist or sports medicine physician, as this patient is presenting with persistent postconcussive symptoms (increased forgetfulness and sleep disturbance) following a documented concussion with loss of consciousness and a negative head CT. 1

Why Outpatient Management is Appropriate

• Hospital admission is not indicated because the patient had a negative head CT at the time of injury and is not exhibiting any red flag symptoms requiring immediate intervention 2, 1
• The patient's symptoms (forgetfulness and sleep disturbance) are consistent with recognized concussion subtypes rather than evolving intracranial pathology 2
• Repeat neuroimaging (CT or MRI) is not warranted in the absence of new or worsening neurologic symptoms, as the initial negative CT effectively ruled out acute intracranial injury requiring intervention 2, 1

Understanding This Patient's Presentation

This patient is experiencing postconcussive symptoms that fall into two recognized subtypes:

• Cognitive symptoms (increased forgetfulness) representing the cognitive/fatigue subtype 2
• Sleep disturbance as a concussion-associated condition that commonly occurs following brain injury and can adversely affect recovery 2

These symptoms are expected in 28-44% of patients at this timeframe post-concussion 2, 3

Specific Outpatient Management Plan

Immediate Activity Modifications

• Begin sub-symptom threshold aerobic exercise immediately at 60-70% of maximum heart rate for 15-20 minutes daily, gradually increasing as tolerated 1
• Avoid strict rest beyond 48-72 hours, as complete rest may actually delay recovery 1
• Implement partial cognitive rest with screen time limited to 30-minute intervals with breaks, and consider shortened work days with reduced workload 1

Specialist Referral Criteria

• Refer to a concussion specialist or sports medicine physician because symptoms are persisting beyond the acute injury period and require specialized management 2, 1
• This referral is particularly important given the patient's cognitive symptoms and sleep disturbance, which may benefit from targeted interventions including vestibular rehabilitation, psychological treatment, or interdisciplinary coordinated care 2

Red Flags Requiring ED Return

Provide written and verbal discharge instructions (at 6th-7th grade reading level) instructing the patient to return immediately for: 2, 1

• Repeated vomiting
• Worsening or severe headache
• Increasing confusion or memory problems
• Focal neurologic deficits
• Abnormal behavior
• Increased sleepiness or loss of consciousness
• Seizures

Common Pitfalls to Avoid

• Do not admit for observation based solely on persistent postconcussive symptoms in the absence of red flags, as home observation with frequent waking is not supported by evidence 2
• Do not order repeat neuroimaging without new concerning symptoms, as this represents unnecessary testing that will not change management 2, 1
• Do not prescribe complete activity restriction, as this may prolong recovery beyond the initial 48-72 hour period 1
• Do not use medications to mask symptoms to allow premature return to activities, as any need for symptom control indicates incomplete recovery 1

Expected Prognosis

• Most patients (80-85%) recover completely within 3 months 1
• Persistent symptoms beyond 3 months occur in 15-20% and constitute post-concussion syndrome 1
• Risk factors for prolonged recovery include age >40 years, female gender, prior concussion history, and high initial symptom burden 1, 4