Management of mTBI “Concussion” in the ED

Much like the assessment of mTBI in the ED, the subsequent management and advice given to patients following diagnosis is variable. Most ED’s have a minor head injury advice leaflet that they give to such patients. This gives out important safety advice but it often fails to usefully answer their most pressing questions:

What can I do immediately?

When is it safe for me to drive?

When should I return to work or school and how should I go about doing this?

When can I play sport again and how should I go about doing this?

Below this article I have attached the advice leaflet developed at my ED to provide patients with this information, in the hope of improving their care. It comes as a fancy booklet produced by medical illustration in hard copy, but you get the idea of the information being delivered! While this booklet is certainly not all encompassing, it gives the patient guidelines on progression through their injury and what to do if they are struggling.

I am asked frequently by my Emergency Medicine colleagues what treatments are available for concussion (aside form rest!). I have been present in the ED on many occasions when the phrase “CT is normal, they can go home” has been used. While this is probably true it fails to fully recognise the potential negative effects of not properly addressing and managing an underlying mTBI. Normal imaging does not mean no injury!

Treatments such as progressive cardiovascular exertion, vestibular and cervicogenic rehabilitation, visual processing and perhaps most importantly, education can all play a huge role depending on the cause of the concussion. It is perhaps most useful to think of concussion as an injury to the brain and much like an injury to a muscle there are treatment steps to progress through before it is safe to use fully again.

Currently concussion follow up clinics employing some of these treatments are few and far between in the UK and while most mTBI’s recover without incident there is a small percentage that require specialist opinion. If symptoms are persisting longer than 14 days in an adult (28 in a child) or the patient has experienced more than 2 concussions in a 12-month period it is wise to seek this opinion.

Hopefully as more time passes and the research into and awareness of mTBI amongst clinicians increases, we can start to standardise Emergency Department care and reduce the negative long-term complications of this injury.