Initial diagnosis and assessment
Diagnosis of mTBI/concussion is the critical first step in successful management, leading to improved outcomes and prevention of further injury.30 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.38 Although it is recommended that a medical doctor confirm the diagnosis of concussion, this may be difficult in rural and remote regions. In these circumstances, virtual consultations and/or consultation with another appropriately qualified health care professional is warranted.
Following diagnosis of concussion, individuals and their support person(s) should be given written, verbal and/or pictorial education about management and prognosis. Plans need to be made to monitor progress and ensure that symptoms are improving as expected.30 Ideally, this information should be provided to their usual treating health care professional (e.g. general practitioner [GP], Aboriginal health team etc).
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 a qualified health care professional. Although it is recommended that a medical doctor confirm the diagnosis of concussion, this may be difficult in rural and remote regions. In these circumstances, virtual consultations and/or consultation with another qualified health care professional may be necessary.
EBR (strong) 39. Carney N, Ghajar J, Jagoda A, Bedrick S, Davis-O’Reilly C, du Coudray H, et al. Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery. 2014;75 Suppl 1:S3-15. doi: 10.1227/NEU.0000000000000433.
40. Patricios J, Fuller GW, Ellenbogen R, Herring S, Kutcher JS, Loosemore M, et al. What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review. Br J Sports Med. 2017;51(11):888-94. doi: 10.1136/bjsports-2016-097441.
41. Davis GA, Makdissi M, Bloomfield P, Clifton P, Echemendia RJ, Falvey EC, et al. International consensus definitions of video signs of concussion in professional sports. Br J Sports Med. 2019;53(20):1264-7. doi: 10.1136/bjsports-2019-100628.Adapted7,30 CBR 30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
39. Carney N, Ghajar J, Jagoda A, Bedrick S, Davis-O’Reilly C, du Coudray H, et al. Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery. 2014;75 Suppl 1:S3-15. doi: 10.1227/NEU.0000000000000433.
40. Patricios J, Fuller GW, Ellenbogen R, Herring S, Kutcher JS, Loosemore M, et al. What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review. Br J Sports Med. 2017;51(11):888-94. doi: 10.1136/bjsports-2016-097441.
41. Davis GA, Makdissi M, Bloomfield P, Clifton P, Echemendia RJ, Falvey EC, et al. International consensus definitions of video signs of concussion in professional sports. Br J Sports Med. 2019;53(20):1264-7. doi: 10.1136/bjsports-2019-100628.
42. Elbin RJ, Sufrinko A, Schatz P, French J, Henry L, Burkhart S, et al. Removal From Play After Concussion and Recovery Time. Pediatrics. 2016;138(3). doi: 10.1542/peds.2016-0910.Adapted30 Tools to guide identification of mTBI/concussion include the Concussion Recognition Tool, Sport Concussion Assessment Tool (SCAT6), and the Child Sport Concussion Assessment Tool (Child SCAT6). Tools to identify neck injury that requires investigation in adults include the NEXUS tool for neck assessment and the Canadian C Spine Rule. The PECARN clinical decision rule can be used as a prediction tools for cervical spine imaging in children.
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.43 These are identified as “red flags” in concussion recognition tools. Additional considerations apply for older people (see Glossary) due to the likely presence of comorbidities.
CBR 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head
injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
43. 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. doi: 10.1016/s0140-6736(09)61558-0.
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. doi: 10.1016/s0140-6736(09)61558-0.
44. Davis GA, Purcell L, Schneider KJ, Yeates KO, Gioia GA, Anderson V, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): Background and rationale. Br J Sports Med. 2017;51(11):859-61. doi: 10.1136/bjsports-2017-097492.
45. Echemendia RJ, Meeuwisse W, McCrory P, Davis GA, Putukian M, Leddy J, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale. Br J Sports Med. 2017;51(11):848-50. doi: 10.1136/bjsports-2017-097506.
46. Parameswaran A, Heitner S, Thosar D, Fowler A, Marks S, O’Leary F. Trial of life: Well infants presenting more than 24 h after head injury with a scalp haematoma: A 10-year review. J Paediatr Child Health. 2018;54(11):1193-8. doi: 10.1111/jpc.13932.
47. Snyder CW, Danielson PD, Gonzalez R, Chandler NM. Computed tomography scans prior to transfer to a pediatric trauma center: Transfer time effects, neurosurgical interventions, and practice variability. J Trauma Acute Care Surg. 2019;87(4):808-12. doi: 10.1097/TA.0000000000002258.
48. Yengo-Kahn AM, Hale AT, Zalneraitis BH, Zuckerman SL, Sills AK, Solomon GS. The Sport Concussion Assessment Tool: a systematic review. Neurosurgical focus. 2016;40(4):E6. doi: 10.3171/2016.1.Focus15611.Adapted7 Notes:
1 Severe mechanism of injury: motor vehicle accident with patient ejection, death of another passenger or rollover; pedestrian or bicyclist without helmet struck by motorised vehicle; falls of 1 metre 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.
2 A case of a single isolated vomit can be assessed in general practice.CBR 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne:
Paediatric Research in Emergency Departments International Collaborative; 2021.
43. 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. doi: 10.1016/s0140-6736(09)61558-0.Adapted7 CBR N/A New
Physical examination looks for objective signs of disorientation, amnesia or other dysfunction following mTBI/concussion and examines for other potential diagnoses.49, 50 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.51
A thorough assessment of a person with mTBI/concussion should be carried out by an appropriately qualified medical doctor to both assess the condition and to exclude potential neurosurgical or medical complications. The examination should include:30
– pre-injury history (e.g. prior concussion(s), premorbid conditions and medications)
– concurrent potential factors that could exacerbate symptoms or prolong recovery (e.g. comorbid medical conditions, Attention-deficit/hyperactivity disorder [ADHD], mental health difficulties, impact of associated concurrent injuries), migraine
– evaluation of current signs and symptoms
– consideration of all available diagnostic tests (if performed)
– evaluation of potential associated physical injuries through examination (e.g. neck injury).The use of a standardised tool with concussion-specific measures allows for consistent and standardised assessment, with the ability to follow and monitor the progression of recovery.
EBR (strong) 30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
40. Patricios J, Fuller GW, Ellenbogen R, Herring S, Kutcher JS, Loosemore M, et al. What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review. Br J Sports Med. 2017;51(11):888-94. doi: 10.1136/bjsports-2016-097441.
41. Davis GA, Makdissi M, Bloomfield P, Clifton P, Echemendia RJ, Falvey EC, et al. International consensus definitions of video signs of concussion in professional sports. Br J Sports Med. 2019;53(20):1264-7. doi: 10.1136/bjsports-2019-100628.
52. Broglio SP, Harezlak J, Katz B, Zhao S, McAllister T, McCrea M, et al. Acute sport concussion assessment optimization: a prospective assessment from the CARE Consortium. Sports Med. 2019;49(12):1977-87. doi: 10.1007/s40279-019-01155-0.
53. Coscia A, Stolz U, Barczak C, Wright N, Mittermeyer S, Shams T, et al. Use of the Sports Concussion Assessment Tool 3 in emergency department patients with psychiatric disease. J Head Trauma Rehabil. 2021;36(5):E302-E11. doi: 10.1097/HTR.0000000000000648.
54. Dagher JH, Richard-Denis A, Lamoureux J, de Guise E, Feyz M. Acute global outcome in patients with mild uncomplicated and complicated traumatic brain injury. Brain Inj. 2013;27(2):189-99. doi: 10.3109/02699052.2012.729288.
55. Fuller GW, Cross MJ, Stokes KA, Kemp SPT. King-Devick concussion test performs poorly as a screening tool in elite rugby union players: a prospective cohort study of two screening tests versus a clinical reference standard. Br J Sports Med. 2019;53(24):1526-32. doi: 10.1136/bjsports-2017-098560.
56. Fuller GW, Tucker R, Starling L, Falvey E, Douglas M, Raftery M. The performance of the World Rugby Head Injury Assessment Screening Tool: a diagnostic accuracy study. Sports Med Open. 2020;6(1):2. doi: 10.1186/s40798-019-0231-y.
57. Garcia GP, Broglio SP, Lavieri MS, McCrea M, McAllister T, Investigators CC. Quantifying the value of multidimensional assessment models for acute concussion: an analysis of data from the NCAA-DoD Care Consortium. Sports Med. 2018;48(7):1739-49. doi: 10.1007/s40279-018-0880-x.
58. Hartwell JL, Spalding MC, Fletcher B, O’Mara M S, Karas C. You cannot go home: routine concussion evaluation is not enough. Am Surg. 2015;81(4):395-403. doi:
59. Miller KJ, Ivins BJ, Schwab KA. Self-reported mild TBI and postconcussive symptoms in a peacetime active duty military population: effect of multiple TBI history versus single mild TBI. J Head Trauma Rehabil. 2013;28(1):31-8. doi: 10.1097/HTR.0b013e318255ceae.
60. Meares S, Shores EA, Smyth T, Batchelor J, Murphy M, Vukasovic M. Identifying posttraumatic amnesia in individuals with a Glasgow Coma Scale of 15 after mild traumatic brain injury. Arch Phys Med Rehabil. 2015;96(5):956-9. doi: 10.1016/j.apmr.2014.12.014.
61. Silverberg ND, Luoto TM, Ohman J, Iverson GL. Assessment of mild traumatic brain injury with the King-Devick Test in an emergency department sample. Brain Inj. 2014;28(12):1590-3. doi: 10.3109/02699052.2014.943287.Adapted30 EBR
(conditional)30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
49. Cnossen MC, Winkler EA, Yue JK, Okonkwo DO, Valadka AB, Steyerberg EW, et al. Development of a Prediction Model for Post-Concussive Symptoms following Mild Traumatic Brain Injury: A TRACK-TBI Pilot Study. J Neurotrauma. 2017;34(16):2396-409. doi: 10.1089/neu.2016.4819.
62. Madhok DY, Yue JK, Sun X, Suen CG, Coss NA, Jain S, et al. Clinical predictors of 3- and 6-month outcome for mild traumatic brain injury patients with a negative head CT scan in the emergency department: A TRACK-TBI pilot study. Brain Sci. 2020;10(5). doi: 10.3390/brainsci10050269.
63. Nelson LD, Furger RE, Ranson J, Tarima S, Hammeke TA, Randolph C, et al. Acute clinical predictors of symptom recovery in emergency department patients with uncomplicated mild traumatic brain injury or non-traumatic brain injuries. J Neurotrauma. 2018;35(2):249-59. doi: 10.1089/neu.2017.4988.
64. Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A, Schonberger M. Predictors of postconcussive symptoms 3 months after mild traumatic brain injury. Neuropsychology. 2012;26(3):304-13. doi: 10.1037/a0027888.
65. Schmidt BR, Moos RM, Konu-Leblebicioglu D, Bischoff-Ferrari HA, Simmen HP, Pape HC, et al. Higher age is a major driver of in-hospital adverse events independent of comorbid diseases among patients with isolated mild traumatic brain injury. Eur J Trauma Emerg Surg. 2019;45(2):191-8. doi: 10.1007/s00068-018-1029-1.
66. Silverberg ND, Gardner AJ, Brubacher JR, Panenka WJ, Li JJ, Iverson GL. Systematic review of multivariable prognostic models for mild traumatic brain injury. J Neurotrauma. 2015;32(8):517-26. doi: 10.1089/neu.2014.3600.
67. Sutton M, Chan V, Escobar M, Mollayeva T, Hu Z, Colantonio A. Neck Injury comorbidity in concussion-related emergency department visits: a population-based study of sex differences across the life span. J Womens Health (Larchmt). 2019;28(4):473-82. doi: 10.1089/jwh.2018.7282.
68. Yue JK, Cnossen MC, Winkler EA, Deng H, Phelps RRL, Coss NA, et al. Pre-injury Comorbidities Are Associated With Functional Impairment and Post-concussive Symptoms at 3- and 6-Months After Mild Traumatic Brain Injury: A TRACK-TBI Study. Front Neurol. 2019;10:343. doi: 10.3389/fneur.2019.00343.
69. Coffeng SM, Jacobs B, de Koning ME, Hageman G, Roks G, van der Naalt J. Patients with mild traumatic brain injury and acute neck pain at the emergency department are a distinct category within the mTBI spectrum: a prospective multicentre cohort study. BMC Neurol. 2020;20(1):315. doi: 10.1186/s12883-020-01887-x.
70. Cnossen MC, van der Naalt J, Spikman JM, Nieboer D, Yue JK, Winkler EA, et al. Prediction of persistent post-concussion symptoms after mild traumatic brain injury. J Neurotrauma. 2018;35(22):2691-8. doi: 10.1089/neu.2017.5486.
71. Roy D, Peters ME, Everett AD, Leoutsakos JS, Yan H, Rao V, et al. Loss of consciousness and altered mental state as predictors of functional recovery within 6 months following mild traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2020;32(2):132-8. doi: 10.1176/appi.neuropsych.18120379.Adapted30 EBR
(conditional)30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
40. Patricios J, Fuller GW, Ellenbogen R, Herring S, Kutcher JS, Loosemore M, et al. What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review. Br J Sports Med. 2017;51(11):888-94. doi: 10.1136/bjsports-2016-097441.
41. Davis GA, Makdissi M, Bloomfield P, Clifton P, Echemendia RJ, Falvey EC, et al. International consensus definitions of video signs of concussion in professional sports. Br J Sports Med. 2019;53(20):1264-7. doi: 10.1136/bjsports-2019-100628.
52. Broglio SP, Harezlak J, Katz B, Zhao S, McAllister T, McCrea M, et al. Acute sport concussion assessment optimization: a prospective assessment from the CARE Consortium. Sports Med. 2019;49(12):1977-87. doi: 10.1007/s40279-019-01155-0.
53. Coscia A, Stolz U, Barczak C, Wright N, Mittermeyer S, Shams T, et al. Use of the Sports Concussion Assessment Tool 3 in emergency department patients with psychiatric disease. J Head Trauma Rehabil. 2021;36(5):E302-E11. doi: 10.1097/HTR.0000000000000648.
54. Dagher JH, Richard-Denis A, Lamoureux J, de Guise E, Feyz M. Acute global outcome in patients with mild uncomplicated and complicated traumatic brain injury. Brain Inj. 2013;27(2):189-99. doi: 10.3109/02699052.2012.729288.
55. Fuller GW, Cross MJ, Stokes KA, Kemp SPT. King-Devick concussion test performs poorly as a screening tool in elite rugby union players: a prospective cohort study of two screening tests versus a clinical reference standard. Br J Sports Med. 2019;53(24):1526-32. doi: 10.1136/bjsports-2017-098560.
56. Fuller GW, Tucker R, Starling L, Falvey E, Douglas M, Raftery M. The performance of the World Rugby Head Injury Assessment Screening Tool: a diagnostic accuracy study. Sports Med Open. 2020;6(1):2. doi: 10.1186/s40798-019-0231-y.
57. Garcia GP, Broglio SP, Lavieri MS, McCrea M, McAllister T, Investigators CC. Quantifying the value of multidimensional assessment models for acute concussion: an analysis of data from the NCAA-DoD Care Consortium. Sports Med. 2018;48(7):1739-49. doi: 10.1007/s40279-018-0880-x.
58. Hartwell JL, Spalding MC, Fletcher B, O’Mara M S, Karas C. You cannot go home: routine concussion evaluation is not enough. Am Surg. 2015;81(4):395-403. doi:
59. Miller KJ, Ivins BJ, Schwab KA. Self-reported mild TBI and postconcussive symptoms in a peacetime active duty military population: effect of multiple TBI history versus single mild TBI. J Head Trauma Rehabil. 2013;28(1):31-8. doi: 10.1097/HTR.0b013e318255ceae.
60. Meares S, Shores EA, Smyth T, Batchelor J, Murphy M, Vukasovic M. Identifying posttraumatic amnesia in individuals with a Glasgow Coma Scale of 15 after mild traumatic brain injury. Arch Phys Med Rehabil. 2015;96(5):956-9. doi: 10.1016/j.apmr.2014.12.014.
61. Silverberg ND, Luoto TM, Ohman J, Iverson GL. Assessment of mild traumatic brain injury with the King-Devick Test in an emergency department sample. Brain Inj. 2014;28(12):1590-3. doi: 10.3109/02699052.2014.943287.
64. Ponsford J, Nguyen S, Downing M, Bosch M, McKenzie JE, Turner S, et al. Factors associated with persistent post-concussion symptoms following mild traumatic brain injury in adults. J Rehabil Med. 2019;51(1):32-9. doi: 10.2340/16501977-2492.
72. Ponsford J, Nguyen S, Downing M, Bosch M, McKenzie JE, Turner S, et al. Factors associated with persistent post-concussion symptoms following mild traumatic brain injury in adults. J Rehabil Med. 2019;51(1):32-9. doi: 10.2340/16501977-2492.
73. Grubenhoff JA, Kirkwood M, Gao D, Deakyne S, Wathen J. Evaluation of the standardized assessment of concussion in a pediatric emergency department. Pediatrics. 2010;126(4):688-95. doi: 10.1542/peds.2009-2804.
74. Lovell MR, Collins MW, Iverson GL, Field M, Maroon JC, Cantu R, et al. Recovery from mild concussion in high school athletes. J Neurosurg. 2003;98(2):296-301. doi:
75. Gioia GA, Schneider JC, Vaughan CG, Isquith PK. Which symptom assessments and approaches are uniquely appropriate for paediatric concussion? Brit J Sports Med. 2009;43(Suppl 1):i13-i22.Adapted30
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.76-78 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.
EBR (conditional) 30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
76. Cipriano A, Park N, Pecori A, Bionda A, Bardini M, Frassi F, et al. Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs. Intern Emerg Med. 2021;16(4):1061-70. doi: 10.1007/s11739-020-02576-w.
67. Riccardi A, Spinola B, Minuto P, Ghinatti M, Guiddo G, Malerba M, et al. Intracranial complications after minor head injury (MHI) in patients taking vitamin K antagonists (VKA) or direct oral anticoagulants (DOACs). Am J Emerg Med. 2017;35(9):1317-9. doi: 10.1016/j.ajem.2017.03.072.
78. Turcato G, Zannoni M, Zaboli A, Zorzi E, Ricci G, Pfeifer N, et al. Direct oral anticoagulant treatment and mild traumatic brain injury: risk of early and delayed bleeding and the severity of injuries compared with vitamin K antagonists. J Emerg Med. 2019;57(6):817-24. doi: 10.1016/j.jemermed.2019.09.007.
79. Ayaz SI, Thomas C, Kulek A, Tolomello R, Mika V, Robinson D, et al. Comparison of quantitative EEG to current clinical decision rules for head CT use in acute mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(4):493-6. doi: 10.1016/j.ajem.2014.11.015.
80. Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(3):320-5. doi: 10.1016/j.ajem.2014.11.005.
81. Klein AP, Tetzlaff JE, Bonis JM, Nelson LD, Mayer AR, Huber DL, et al. Prevalence of potentially clinically significant magnetic resonance imaging findings in athletes with and without sport-related concussion. J Neurotrauma. 2019;36(11):1776-85. doi: 10.1089/neu.2018.6055.
82. Sharp AL, Nagaraj G, Rippberger EJ, Shen E, Swap CJ, Silver MA, et al. Computed tomography use for adults with head injury: Describing likely avoidable emergency department imaging based on the Canadian CT Head Rule. Acad Emerg Med. 2017;24(1):22-30. doi: 10.1111/acem.13061.Adapted30 EBR (conditional) 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head
injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
83. Babl FE, Borland ML, Phillips N, Kochar A, Dalton S, McCaskill M, et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet. 2017;389(10087):2393-402. doi:
84. Badawy MK, Dayan PS, Tunik MG, Nadel FM, Lillis KA, Miskin M, et al. Prevalence of brain injuries and recurrence of seizures in children with posttraumatic seizures. Acad Emerg Med. 2017;24(5):595-605. doi:
85. Bertsimas D, Dunn J, Steele DW, Trikalinos TA, Wang Y. Comparison of machine learning optimal classification trees with the pediatric emergency care applied research network head trauma decision rules. JAMA pediatrics. 2019;173(7):648-56. doi:
86. Dayan PS, Holmes JF, Schutzman S, Schunk J, Lichenstein R, Foerster LA, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Annals Emerg Med. 2014;64(2):153-62. doi:
87. Ide K, Uematsu S, Tetsuhara K, Yoshimura S, Kato T, Kobayashi T. External validation of the PECARN head trauma prediction rules in Japan. Academic Emergency Medicine. 2017;24(3):308-14.Adopted7 EBR (conditional) 30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
76. Cipriano A, Park N, Pecori A, Bionda A, Bardini M, Frassi F, et al. Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs. Intern Emerg Med. 2021;16(4):1061-70. doi: 10.1007/s11739-020-02576-w.
78. Turcato G, Zannoni M, Zaboli A, Zorzi E, Ricci G, Pfeifer N, et al. Direct oral anticoagulant treatment and mild traumatic brain injury: risk of early and delayed bleeding and the severity of injuries compared with vitamin K antagonists. J Emerg Med. 2019;57(6):817-24. doi: 10.1016/j.jemermed.2019.09.007.
79. Ayaz SI, Thomas C, Kulek A, Tolomello R, Mika V, Robinson D, et al. Comparison of quantitative EEG to current clinical decision rules for head CT use in acute mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(4):493-6. doi: 10.1016/j.ajem.2014.11.015.
80. Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(3):320-5. doi: 10.1016/j.ajem.2014.11.005.
81. Klein AP, Tetzlaff JE, Bonis JM, Nelson LD, Mayer AR, Huber DL, et al. Prevalence of potentially clinically significant magnetic resonance imaging findings in athletes with and without sport-related concussion. J Neurotrauma. 2019;36(11):1776-85. doi: 10.1089/neu.2018.6055.
82. Sharp AL, Nagaraj G, Rippberger EJ, Shen E, Swap CJ, Silver MA, et al. Computed tomography use for adults with head injury: Describing likely avoidable emergency department imaging based on the Canadian CT Head Rule. Acad Emerg Med. 2017;24(1):22-30. doi: 10.1111/acem.13061.Adapted30 CBR 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head
injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
80. Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33(3):320-5. doi: 10.1016/j.ajem.2014.11.005.
82. Sharp AL, Nagaraj G, Rippberger EJ, Shen E, Swap CJ, Silver MA, et al. Computed tomography use for adults with head injury: Describing likely avoidable emergency department imaging based on the Canadian CT Head Rule. Acad Emerg Med. 2017;24(1):22-30. doi: 10.1111/acem.13061.
89. Gravel J, Gouin S, Chalut D, Crevier L, Décarie J-C, Elazhary N, et al. Derivation and validation of a clinical decision rule to identify young children with skull fracture following isolated head trauma. Can Med Assoc J. 2015;187(16):1202-8.Adapted7 CBR 5. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853. doi: 10.1001/jamapediatrics.2018.2853. Adopted5 Risk factors for intracranial injury All children
GCS 14 or other signes of altered mental status
Abnormal neurological examination
Severe mechanism of injury*
Post-traumatic seizuresAge <2 years
Palpable skull fracture
Non-frontal scalp haemotoma
History of loss of consciousness ≥5 seconds
Acting abnormally per parentAge >2 years
Signs of base of skull fracture
History of loss of consciousness
History of vomiting**
Severe headacheAny risk factors: Recommended observation period is up to 4 hours post injury including 1 hour return to normal High risk = imaging Intermediate risk = consider imaging or structured observation Low risk Very low risk Palpable skull fracture
OR
Signs of base of skull fracture
OR
Worsening signs or symptoms
OR
Persistent GCS 14
OR
Persistent signs of altered mental status≥ 2 risk factors
OR
Post-traumatic seizure(s)
OR
Persistent severe headache or persistent vomiting >4 hours post injuryNot intermediate or high risk
AND
improving signs and symptoms:
GCS 15, acting normally, no current signs of altered mental status, vomiting has stopped, severe headache resolvedNo risk factors Figure 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.Figure 2: The Canadian CT Head rule for adults with mTBI/concussion
* Signs of basal skull fracture Haemotympanum, ‘racoon’ eyes, CSF otorrhea/rhinorrhoea, Battle’s sign ** Dangerous mechanism Pedestrian struck by vehicle Occupant ejected from motor vehicle Fall from elevation ≥3 metres or 5 stairs CT head is only required for people with minor head injury with any one of these findings: Rule not applicable if: Non-trauma cases GCS <13 Age <16 years Anticoagulants or bleeding disorder Obvious open skull fracture High risk (for neurological intervention) 1. GCS score <15 at 2 hours after injury 2. Suspected open or depressed skull fracture 3. Any sign of basal skull fracture* 4. Vomiting ≥2 episodes 5. Age ≥65 years Medium risk (for brain injury on CT) 6. Amnesia before impact ≥30 min 7. Dangerous mechanism ** Figure 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.74For information regarding the need for neuroimaging in children who present to the emergency department in the Australia and Aotearoa New Zealand, please refer to the PREDICT guidelines.
The GDG endorses PREDICT guideline recommendations 7, 27, PP D, PP C, 22, PP N, 19, 20, 21.
Evidence from a study conducted among children suggests a 1% prevalence of new intracranial lesions on repeat neuroimaging in children with GCS of 14 and 0.5% prevalence of new intracranial lesions in those with GCS 15.91 Data in adults suggest that for mTBI patients with intracranial haemorrhage on initial head CT, who subsequently undergo clinical observation and repeat head CT with stable or improved clinical examinations and CT findings, the probability of death is low.92 Other studies have found that routine repeat head CT is not warranted in people with mTBI/concussion, even in people at higher risk of intracranial haemorrhage progression.93, 94
EBR (strong) 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
91. Holmes JF, Borgialli DA, Nadel FM, Quayle KS, Schambam N, Cooper A, et al. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation? Ann Emerg Med. 2011;58(4):315-22. doi: 10.1016/j.annemergmed.2011.03.060.
92. Kreitzer N, Lyons MS, Hart K, Lindsell CJ, Chung S, Yick A, et al. Repeat neuroimaging of mild traumatic brain-injured patients with acute traumatic intracranial hemorrhage: clinical outcomes and radiographic features. Acad Emerg Med. 2014;21(10):1083-91. doi: 10.1111/acem.12479.
93. Fadzil F, Mei AKC, Mohd Khairy A, Kumar R, Mohd Azli AN. Value of repeat CT brain in mild traumatic brain injury patients with high risk of intracerebral hemorrhage progression. Int J Environ Res Public Health. 2022;19(21). doi: 10.3390/ijerph192114311.
94. Battle B, Sexton KW, Fitzgerald RT. Understanding the value of repeat head CT in Elderly Trauma Patients on Anticoagulant or Antiplatelet Therapy. J Am Coll Radiol. 2018;15(2):319-21. doi: 10.1016/j.jacr.2017.09.021.
95. NICE: National Institute for Health and Care Excellence. Head Injury: Assessment and early management (NICE Guideline CG176). 2019.Adapted7 EBR (strong) 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021. Adapted6 Notes:
1 The initial head CT should be interpreted by a radiologist to ensure no injuries were missed.
2 Measured using an age-appropriate GCS, consider post-traumatic amnesia assessment for those that remain amnesic.
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.96-100 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.101 Risk factors for deterioration include anticoagulation, GCS<15, abnormal neurological examination, and significant extracranial injury.101 Evidence of intracranial injury or intracranial haemorrhage on head CT requires urgent neurosurgical consultation.
CBR 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
96. Bressan S, Marchetto L, Lyons TW, Monuteaux MC, Freedman SB, Da Dalt L, et al. A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children. Ann Emerg Med. 2018;71(6):714-7.24E+04.
97. Arrey EN, Kerr ML, Fletcher S, Cox CS, Jr., Sandberg DI. Linear nondisplaced skull fractures in children: who should be observed or admitted? J Neurosurg Pediatr. 2015;16(6):703-8.
98. Blanchard A, Cabrera KI, Kuppermann N, Dayan PS. Acute outcomes of isolated pneumocephali in children after minor blunt head trauma. Pediatric Emergency Care. 2018;34(9):656-60.
99. Hassan S, Alarhayema AQ, Cohn SM, Wiersch JC, Price MR. Natural history of isolated skull fractures in children. Cureus. 2018;10(7):e3078.
100. Kommaraju K, Haynes JH, Ritter AM. Evaluating the role of a neurosurgery consultation in management of pediatric isolated linear skull fractures. Pediatric neurosurgery. 2019;54(1):21-7.
101. Marincowitz C, Lecky FE, Townend W, Borakati A, Fabbri A, Sheldon TA. The risk of deterioration in GCS13-15 patients with traumatic brain injury identified by computed tomography imaging: A systematic review and meta-analysis. J Neurotrauma. 2018;35(5):703-18.Adopted7 Notes: 1Measured using an age-appropriate GCS e.g. for infants and non-verbal people. CBR 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
96. Bressan S, Marchetto L, Lyons TW, Monuteaux MC, Freedman SB, Da Dalt L, et al. A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children. Ann Emerg Med. 2018;71(6):714-7.24E+04.
97. Arrey EN, Kerr ML, Fletcher S, Cox CS, Jr., Sandberg DI. Linear nondisplaced skull fractures in children: who should be observed or admitted? J Neurosurg Pediatr. 2015;16(6):703-8.
98. Blanchard A, Cabrera KI, Kuppermann N, Dayan PS. Acute outcomes of isolated pneumocephali in children after minor blunt head trauma. Pediatric Emergency Care. 2018;34(9):656-60.
99. Hassan S, Alarhayema AQ, Cohn SM, Wiersch JC, Price MR. Natural history of isolated skull fractures in children. Cureus. 2018;10(7):e3078.
100. Kommaraju K, Haynes JH, Ritter AM. Evaluating the role of a neurosurgery consultation in management of pediatric isolated linear skull fractures. Pediatric neurosurgery. 2019;54(1):21-7.
101. Marincowitz C, Lecky FE, Townend W, Borakati A, Fabbri A, Sheldon TA. The risk of deterioration in GCS13-15 patients with traumatic brain injury identified by computed tomography imaging: A systematic review and meta-analysis. J Neurotrauma. 2018;35(5):703-18.Adapted7
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 (see Glossary) is appropriate in people who do not fulfil criteria for routinely available imaging and necessary in those requiring transfer to access appropriate imaging.
Practice points for children and adults:
7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021. Adapted7 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021. Adapted7 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021 Adapted7 Please refer to the PREDICT guidelines for details about observation and mild and moderate head injuries in children.
7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021. Adapted7 Further advice is available from:
- PREDICT guidelines for the management of childhood abusive head trauma in the emergency department.
- Royal Australian College of General Practitioners guideline “Abuse and violence – working with our patients in general practice”
- Health New Zealand Te Whatu Ora “Family violence guidelines.”
7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021. Adapted7
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).106-109 People without symptoms and a GCS of 15 may not need a head CT and instead undergo structured observation.110 However, people over 60 years are at higher risk of intracranial haemorrhage and have a higher mortality,108, 109 thus older people 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.111
Urgent anticoagulant reversal should be considered for people with acute intracranial haemorrhage, as ongoing bleeding and haemorrhage enlargement can cause neurologic deterioration, elevation in intracranial pressure, and poor functional outcome or death.112 Urgent reversal may not be necessary for a clinically stable person with a small, chronic subdural haemorrhage 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.
EBR (conditional) 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
106. Mina AA, Knipfer JF, Park DY, Bair HA, Howells GA, Bendick PJ. Intracranial complications of preinjury anticoagulation in trauma patients with head injury. J Trauma. 2002;53(4):668-72. doi: 10.1097/00005373-200210000-00008.
107. Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in anticoagulated patients. J Trauma. 2006;60(3):553-7. doi: 10.1097/01.ta.0000196542.54344.05.
108. Reynolds FD, Dietz PA, Higgins D, Whitaker TS. Time to deterioration of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality. J Trauma. 2003;54(3):492-6. doi: 10.1097/01.TA.0000051601.60556.FC.
109. Franko J, Kish KJ, O’Connell BG, Subramanian S, Yuschak JV. Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma. J Trauma. 2006;61(1):107-10. doi: 10.1097/01.ta.0000224220.89528.fc.
110. Kuczawski M, Stevenson M, Goodacre S, Teare MD, Ramlakhan S, Morris F, et al. Should all anticoagulated patients with head injury receive a CT scan? Decision-analysis modelling of an observational cohort. BMJ Open. 2016;6(12):e013742. doi: 10.1136/bmjopen-2016-013742.
111. Lee LK, Dayan PS, Gerardi MJ, Borgialli DA, Badawy MK, Callahan JM, et al. Intracranial hemorrhage after blunt head trauma in children with bleeding disorders. J Pediatr. 2011;158(6):1003-8 e1-2. doi: 10.1016/j.jpeds.2010.11.036.
112. Bower MM, Sweidan AJ, Shafie M, Atallah S, Groysman LI, Yu W. Contemporary reversal of oral anticoagulation in intracerebral hemorrhage. Stroke. 2019;50(2):529-36. doi: 10.1161/STROKEAHA.118.023840.
113. Giordano PN, A.; Lassandro, G.; Notarangelo, L.D.; Bressan, S.; Ramenghi, U.; Saracco, P.; Da Dalt, L.; Molinari, A.C. . Head injury in children with coagulation disorders a position paper by the Italian Society of Pediatric Emergency Medicine (SIMEUP) and the Italian Association of Pediatric Hematology and Oncology – Coagulation Disorders Working Group (AIEOP),. Ital J Pediatrics. 2020. doi:Adapted7
6. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021. Adapted6
6. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021. Adapted6
114. Fuller G, Sabir L, Evans R, Bradbury D, Kuczawski M, Mason SM. Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis. Emerg Med J. 2020;37(11):666-73. doi: 10.1136/emermed-2019-209307.
115. Park N, Barbieri G, Turcato G, Cipriano A, Zaboli A, Giampaoli S, et al. Multi-centric study for development and validation of a CT head rule for mild traumatic brain injury in direct oral anticoagulants: the HERO-M nomogram. BMC Emerg Med. 2023;23(1):122. doi: 10.1186/s12873-023-00884-w.
116. Rajesh S, Wonderling D, Bernstein I, Balson C, Lecky F, Guideline C. Head injury: assessment and early management-summary of updated NICE guidance. BMJ (Clinical research ed). 2023;381:1130. doi: 10.1136/bmj.p1130.New For guidance on the assessment of children with immune thrombocytopaenia or on anticoagulant therapy or other anticoagulants (e.g. direct oral anticoagulants) or antiplatelet therapy, please see the PREDICT guidelines.
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.117
CBR 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
117. Gunn BS, McAllister TW, McCrea MA, Broglio SP, Moore RD, Investigators CC. Neurodevelopmental disorders and risk of concussion: Findings from the National Collegiate Athletic Association Department of Defense Grand Alliance Concussion Assessment, Research, and Education (NCAA-DOD CARE) Consortium (2014-2017). J Neurotrauma. 2022;39(5-6):379-89. doi: 10.1089/neu.2020.7446.Adapted7
People with intoxication were excluded from studies exploring the requirement for neuroimaging in mTBI/concussion. Therefore, brain imaging decision rules may not have adequate sensitivity for people who present who are intoxicated.
CBR 7. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021. Adapted7