A concussion is a mild traumatic brain injury (TBI) resulting from a blow to the head or a sudden, violent jolt to the body, causing the brain to move rapidly inside the skull. This movement disrupts normal brain function, leading to chemical and metabolic changes within the nerve cells. When visiting the Emergency Room (ER) for a suspected concussion, the primary goal is not to provide a cure, as rest is the only treatment for the concussion itself. Instead, the purpose is to quickly rule out more severe, life-threatening injuries, such as a skull fracture, intracranial hemorrhage, or structural damage to the brain. Once these serious conditions are excluded, the focus shifts to managing symptoms and providing a safe discharge plan.
Initial Triage and History Taking
The assessment process begins immediately with initial triage, where medical staff check basic safety metrics to prioritize care. This rapid evaluation includes checking the patient’s vital signs, such as blood pressure, heart rate, and respiration rate, to ensure fundamental systems are stable. A standardized tool called the Glasgow Coma Scale (GCS) provides a quick, objective measure of the patient’s level of consciousness. The GCS evaluates eye opening, verbal response, and motor response; a total score of 15 indicates full consciousness, while a score below 15 suggests an altered mental status requiring urgent attention.
Gathering a detailed patient history is a simultaneous and important step in the initial assessment. The provider will ask about the exact mechanism of injury, including the direction and force of the impact, and whether the patient experienced any loss of consciousness. Questions focus on the duration and progression of symptoms since the injury, such as headache, confusion, or vomiting. Collateral information from a witness is often sought to clarify the events, especially regarding any amnesia or confusion immediately following the trauma.
The Focused Neurological Examination
Once the patient is stabilized, the ER physician performs a focused neurological examination to pinpoint functional impairments. This assessment involves checking the cranial nerves, which control functions like eye movement and facial sensation. The doctor will look for nystagmus (involuntary eye movement) or check for an abnormal “H-pattern” of eye tracking, which can indicate issues with ocular motor control. Unequal pupil size or reaction to light is a serious sign suggesting pressure on the brain and requires immediate investigation.
A comprehensive evaluation of the patient’s motor function is also performed, including checks of deep tendon reflexes and muscle strength. Postural stability and coordination are tested with exercises like the Romberg sign or an assessment of gait, as subtle balance issues are common with concussions. Cognitive function is assessed by testing memory, orientation, and concentration, often by asking the patient to recall a short list of words or answer simple questions about the time and place. While a concussion diagnosis is often subtle, any focal neurological deficit—such as weakness in a limb or slurred speech—is a red flag pointing toward a more severe underlying injury.
Determining the Need for Imaging
The decision to order a Computed Tomography (CT) scan is calculated, as imaging is not necessary for every minor head injury. CT scans do not diagnose a concussion, but they are effective at ruling out acute structural problems like intracranial bleeding (hemorrhage), brain swelling, or skull fractures. Clinical decision rules, such as the Canadian CT Head Rule, help guide this process by identifying high-risk features that necessitate immediate imaging.
Specific signs that trigger an immediate CT scan within one hour include a GCS score that has dropped below 15 two hours after the injury, evidence of a skull fracture, or a post-traumatic seizure. Other indicators are a focal neurological deficit identified during the exam or more than one episode of vomiting. The patient’s history also plays a role; factors like being over age 65, having a history of a bleeding disorder, or experiencing a dangerous mechanism of injury (e.g., being ejected from a vehicle) increase the likelihood of a scan.
Discharge Protocol and Red Flags
For patients who are stable, have a normal CT scan, and do not require hospital admission, the ER visit concludes with a detailed discharge protocol. The immediate treatment plan centers on cognitive and physical rest for the first 24 to 48 hours, which allows the brain to heal. Patients are instructed to avoid activities that require intense concentration, such as extensive screen time, studying, or driving, until symptoms improve.
A detailed list of “Red Flags” or warning signs is provided to the patient and their caregiver, emphasizing that an immediate return to the ER is required if any of these symptoms appear. These danger signs include:
- A headache that worsens significantly or does not go away.
- Repeated vomiting.
- New or worsening confusion.
- The inability to wake up from sleep.
- Seizures.
- Slurred speech, or new weakness or numbness in the arms or legs.
- The presence of one pupil being noticeably larger than the other, which warrants an immediate return for emergency re-evaluation.