Management of GCS 14 Concussion
A patient with a Glasgow Coma Scale (GCS) score of 14 after blunt head trauma requires immediate head CT scanning and should not be discharged the same day, with serial neurological assessments every 15 minutes initially to detect deterioration that may require neurosurgical intervention. 1
Immediate Assessment and Imaging
A GCS score of 14 mandates non-contrast head CT scanning regardless of other clinical features. 1 This is a Level A recommendation from the American College of Emergency Physicians, as GCS 14 is an independent predictor of intracranial injury requiring neurosurgical intervention. 1
The historical distinction between GCS 15 ("mild") and GCS 14 is critical—approximately 13% of patients with initially normal GCS scores deteriorated to coma in pre-CT era studies, and GCS 14 carries substantially higher risk than GCS 15. 1
Serial GCS determinations are more valuable than a single score, as the original Teasdale and Jennett paper demonstrated a patient admitted with GCS 14 who maintained that score for 3 hours before declining to 13, then 4, requiring emergency subdural hematoma evacuation. 1
Critical Monitoring Requirements
Perform serial neurological examinations every 15 minutes initially to detect clinical deterioration, as GCS 14 places patients at moderate-to-high risk for intracranial pathology requiring intervention. 2
Any patient with GCS 14 and positive CT findings (subdural hematoma, epidural hematoma, contusion, or midline shift >5mm) requires immediate neurosurgical consultation. 1, 2
Never discharge a patient with GCS 14 on the day of injury, even if CT is negative and the patient improves to GCS 15 within 2 hours. 1 Admission for observation is required to monitor for delayed deterioration.
Physiological Management Priorities
Maintain systolic blood pressure >110 mmHg (mean arterial pressure ≥80 mmHg) to prevent secondary brain injury, as hypotension dramatically increases mortality. 2, 3
Ensure oxygen saturation >95% to prevent hypoxemia-related secondary injury, as the combination of hypotension and hypoxemia carries 75% mortality. 2, 3
Control ventilation with end-tidal CO2 monitoring to maintain PaCO2 within normal range (35-45 mmHg), as hypocapnia induces cerebral vasoconstriction and ischemia risk. 1
Cognitive and Physical Rest Protocol
Immediate cognitive and physical rest must begin at the time of injury, not delayed. 4 Patients who started rest immediately after injury recovered 4.6 days sooner than those who delayed rest by 1-7 days (10.3 vs 14.4 days, P=0.005). 4
The initial rest period should be 24-48 hours of strict cognitive and physical rest, meaning no screen time, reading, texting, video games, or physical exertion. 1, 5
No return to play should occur on the day of injury under any circumstances. 1 This is universally recommended across all major guidelines.
Return-to-Activity Protocol
Once asymptomatic at rest for 24-48 hours, begin a graded 5-step return-to-play protocol with each step taking a minimum of 24 hours. 1, 6
If any symptoms recur during the graded protocol, the patient must rest and return to the previous asymptomatic level. 1 This is non-negotiable.
Medical clearance from a licensed healthcare provider trained in concussion management is required before full return to play. 1, 6
Risk Factors for Prolonged Recovery
Previous concussion history significantly increases risk of prolonged recovery and recurrent injury. 6 Each subsequent concussion carries higher risk and longer recovery time.
Age >40 years, female gender, lower educational level, alcohol abuse, and multiple trauma are established risk factors for persistent post-concussive syndrome lasting months to years. 7
Pre-existing mood disorders, learning disorders, ADHD, and migraine headaches complicate both diagnosis and management, requiring more conservative approach. 6
Post-Concussive Syndrome Monitoring
Symptoms persisting beyond 10 days require multidisciplinary management including possible neuropsychological testing, neurology referral, and academic accommodations. 1, 6
Approximately 50-60% of patients become symptom-free with medication after first diagnosis of concussion-related symptoms, but a distinct minority have persistent deficits for months or years. 7
Students require academic accommodations including reduced workload and extended test time while recovering. 6 Cognitive rest is as important as physical rest.
Common Pitfalls to Avoid
Never assume GCS 14 is "mild" TBI—many experts consider GCS 13 to represent moderate TBI with higher surgical intervention rates, and GCS 14 falls in an intermediate risk category requiring aggressive monitoring. 1
Do not discharge based solely on negative CT scan—clinical deterioration can occur hours after initial presentation, particularly in elderly patients or those on anticoagulation. 1
Never allow premature return to cognitive or physical activity—the concussed brain shows decreased responsiveness to neural activation and premature activity causes prolonged dysfunction. 6
Do not use single GCS score for prognosis—serial determinations are essential, as 13% of patients with initial GCS 15 later became comatose in validation studies. 1