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    • Diagnosis of mTBI/concussion is the critical first step in successful management, leading to improved outcomes and prevention of further injury. This requires a high index of suspicion in situations of increased risk of mTBI concussion such as playing contact sport; here, any person suspected of a possible mTBI/concussion should be removed of play to avoid the risk of re-injury.

      The initial medical assessment aims to establish a diagnosis of mTBI/concussion by ruling out other conditions with similar symptom profiles, such as more severe forms of traumatic brain injury, cervical spine injuries and some medical and neurological and mental health conditions.

      Not all people who experience mTBI/concussion will present to the emergency department, with many presenting to primary care. Regardless of setting, assessment should be carried out by an appropriately qualified health professional.

    • In light of the limited evidence on pre-hospital tools that specifically determine the need for assessment in the acute hospital setting following mTBI/concussion, the following consensus-based recommendations for adults and children were informed by the Canadian CT Head Rule and the Pediatric Emergency Care Applied Research Network study. These are identified as “red flags” in concussion recognition tools. Additional considerations apply for elderly adults due to the likely presence of comorbidities.

    • Physical examination looks for objective signs of disorientation, amnesia or other dysfunction following mTBI/concussion and examines for other potential diagnoses. Mental health status should also be reviewed as there is evidence that pre-injury psychiatric history or disorder is a predictor of persisting post-concussion symptoms and disability following mTBI/concussion.

    • A thorough assessment of a person with mTBI/concussion should be carried out by an appropriately qualified health professional to both assess the condition and to exclude potential neurosurgical or medical complications. The examination should include:

    • Computed tomography (CT) scanning is an appropriate investigation for the exclusion of neurosurgically significant lesions (e.g. haemorrhage) in the acute phase (≤48 hours after injury) but not in the post-acute phase (>48 hours after injury).

      People with bleeding disorders or who are taking direct oral anticoagulant treatment or a vitamin K antagonist require extra attention as they have an increased risk of haemorrhage. People with neurodevelopmental disabilities sustain more injuries than those without and also require special consideration as neurological deterioration can be harder to assess.

      Imaging protocols are beyond the scope of this guideline. For guidance on imaging for children, please see PREDICT recommendations 24, 25 and 26.

      Table 1: Pediatric Emergency Care Applied Research Network (PECARN) Head Injury Decision Rule

      Notes:     See also Appendix C. 

      * Struck by a motor vehicle, occupant ejected from a motor vehicle or death of another passenger, motor vehicle rollover; bicyclist without helmet struck by motorised vehicle; falls of 1 m or more for children aged less than 2 years and more than 1.5 m for children aged 2 years or older; or head struck by a high-impact object).

      ** Isolated vomiting, without any other risk factors, is an uncommon presentation of more severe forms of traumatic brain injury. Vomiting, regardless of the number of vomits or persistence of vomiting, in association with other risk factors increases concern for more severe forms of traumatic brain injury.

      Source:  Adapted from PREDICT and Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Jr., Atabaki SM, Holubkov R, et al. Identification of Children at Very Low Risk of Clinically-Important Brain Injuries after Head Trauma: A Prospective Cohort Study. Lancet. 2009;374(9696):1160–70.

      Table 2: The Canadian CT Head rule for adults with mTBI/concussion

      Source: Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6. doi: 10.1016/s0140-6736(00)04561-x.

    • Simple linear skull fractures do not require specific intervention if a head CT reveals no underlying injury.  A meta-analysis and four retrospective studies found a very low risk of adverse outcomes in children with isolated, non-displaced, linear skull fractures. Evidence on the level of risk for adverse outcomes in people aged >12 with mTBI (GCS 13–15) and injuries identified by head CT is limited, but 27.7% may require hospital admission and 13% neurosurgery, intensive care admission or intubation. Risk factors for deterioration include anticoagulation, GCS<15, abnormal neurological examination, and significant extracranial injury. Evidence of intracranial injury or intracranial haemorrhage on head CT requires urgent neurosurgical consultation.

    • People with a simple linear skull fracture on head CT should be observed for 4 to 6 hours in hospital or the emergency department. People are admitted for observation if there is any suspicion or clinical evidence of a more severe brain injury. Structured observation is appropriate in people who do not fulfil criteria for routinely available imaging and necessary in those requiring transfer to access appropriate imaging.

    • Adults taking anticoagulant or antiplatelet therapies who have a mild head injury are at an increased risk of intracranial haemorrhage and delayed neurological deterioration (up to 6 hours). People without symptoms and a GCS of 15 may not need a head CT and instead undergo structured observation. However, elderly people (>60 years) are at higher risk of intracranial haemorrhage and have a higher mortality, thus elderly patients on anticoagulant or antiplatelet therapy should be considered for a CT scan.  Evidence on the risk of important intracranial injuries in children with bleeding disorders compared to those without bleeding disorders is limited. It is likely that the risk of intracranial haemorrhage differs between types of bleeding disorders and types of anticoagulant or antiplatelet therapy.

      Urgent anticoagulant reversal should be considered for people with acute intracranial haemorrhage, as ongoing bleeding and hemorrhage enlargement can cause neurologic deterioration, elevation in intracranial pressure, and poor functional outcome or death. Urgent reversal may not be necessary for a clinically stable person with a small, chronic subdural hemorrhage and no evidence of elevated intracranial pressure. Here, the potential benefit of reversing anticoagulation must be weighed against the risk of thrombosis/stopping the anticoagulation.

    • Neurodevelopmental disorders, such as attention deficit/hyperactivity disorder (ADHD) and specific learning disorder (LD) may increase the risk of bodily injury, including mTBI/concussion, over the lifetime in both males and females.95