Guidelines Quick Access
Initial Management
There is evidence that providing information about expected symptoms, their likely time course, and suggested coping strategies minimises stress and anxiety and optimizes early management among adults and children who experience mTBI/concussion.28,118
EBR (Strong) 24,119-123
Provide patient/parent/support person with clear, age-appropriate verbal and written advice including:
EBR (Strong) 27,28,95,120,121,124-127
All people discharged from medical care after presenting with a mTBI/concussion should be given clear, age appropriate, written and verbal advice on when to return to the emergency department; this includes worsening symptoms (e.g. headache, confusion, irritability, or persistent or prolonged vomiting), a decreased level of consciousness or seizures.
EBR (Strong) 27,28,95,120,121,124-127
All people discharged from medical care after presenting with mTBI/concussion, should be given contact information for the emergency department, telephone advice line or other local providers of advice.
Alcohol and recreational drugs may have a negative effect on mTBI/concussion recovery. Avoiding alcohol or drugs prevents people from self-medicating and resorting to drugs to relieve symptoms. Impaired judgement after a mTBI/concussion could lead to risky behaviour that causes further harm and may delay the identification of complications.
CBR
Advise people who have experienced mTBI/concussion to avoid alcohol and other recreational drugs while symptoms persist.
Further guidance
Pain management in the first 2 weeks after mTBI/concussion may involve paracetamol or ibuprofen. After 2 weeks, use of these should be limited to < 3/week or 15/month due to the risk of medication-associated headache. Non-steroidal anti-inflammatory medications (e.g. ibuprofen, naproxen) are not suitable for people taking anticoagulants or who have a bleeding disorder unless under the direction of their regular physician.
EBR (Conditional) 137-139
Over-the-counter medications such as paracetamol and ibuprofen may be recommended to treat acute headache in people with mTBI/concussion. Use paracetamol in those who are also taking anticoagulants or antiplatelet medication.
Receiving adequate sleep has been shown to facilitate health128 and, when not adequate, adversely affects medical conditions, including mTBI/concussion.129-131 Following mTBI/concussion that has been assessed by a qualified health care professional, there is no need to keep a person awake.
CBR 135,136
Provide people who have experienced mTBI/concussion with guidance on fatigue management and age-appropriate sleep hygiene methods.
Further Evidence
Persisting amnesia (e.g. >24 hours) and/or abnormal neurological findings can indicate a moderate/severe TBI or alternative diagnosis and require different management. People should have a normal neurological examination before being discharged; this should include an examination for persisting amnesia, using a validated tool (e.g. the Abbreviated Westmead Post-traumatic Amnesia Scale), if possible, to ensure safe discharge. Normal mental status should be specifically assessed to ensure safe discharge.
Follow-up provides the opportunity for healthcare professionals to identify persisting post-concussive symptoms, which occur in 30-40% of children,140 and are also prevalent in adults141 and older people.142, 143
CT head is not indicated in people with mTBI/concussion presenting to the GP unless they have unexplained focal neurology, symptoms suggestive of raised intracranial pressure, or fulfills criteria for CT head (as indicated by the Canadian CT head injury/trauma rule, Nexus head CT instrument or PREDICT). If this is the case, refer to the emergency department.
EBR (Conditional) 119,120,144-148
All people discharged from hospital after presenting with mTBI/concussion should be advised to follow up with their primary health professional (e.g. general practitioner) within 1 to 2 weeks for assessment of post-concussive symptoms and monitoring of clinical status.
Practice points for Children and Adults
People (or their parents or carers) should be reassured that most post-concussive symptoms are not clinical indicators for imaging.
EBR (Conditional) 119,120,144
For people at high risk of persisting symptoms (see Box A), qualified health care professionals should consider earlier referral to specialist services for post-concussive symptom management.
The symptoms experienced by most people with mTBI/concussion resolve within 1 to 3 months of the injury24,149,150 but some people experience persisting symptoms and delayed recovery. People with mTBI/concussion who are at high risk for persisting symptoms or delayed recovery are more likely to require intervention than those at low risk.5 Early identification of these factors and their treatment may facilitate recovery.
A range of factors affect the severity and duration of persisting post-concussive symptoms.143 These include concurrent factors such as pain, anxiety, depression, post-traumatic stress and ligation.143 Pre-injury variables, including psychopathology, substance misuse, and other forms of acquired brain injury, can also affect recovery.143 Repetitive head trauma and greater severity of symptoms at initial presentation have been associated with symptoms persisting for more than one month, although the vast majority of these patients recover by three months.151
Practice points for Children and Adults 49,62-71,144,145,148,152,153
For people presenting with mTBI/concussion, health professionals should consider factors known to be associated with an increased risk of developing post-concussive symptoms (see Box A).
Further Guidance
Tools for assessing the risk of symptoms persisting are available from 5P study: Predicting and Preventing Post-concussive Problems in Pediatrics and the AUT Traumatic Brain Injury Network.
Practice Points for Children and Adults 24,28,126,154-158
Health care professionals should counsel people with mTBI/concussion and their families that, although some factors predict an increased or decreased risk for persisting symptoms, each person’s recovery from mTBI/concussion is unique and will follow its own trajectory.
Further Guidance