Guidelines Quick Access
Recognise and Assess
Initial Diagnosis and Assessment
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
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)39-41
Suspected mTBI/concussion should be recognised as soon as possible.
CBR39-42
Adults and children with suspected mTBI/concussion should be referred to a medical doctor for confirmation of diagnosis.
Tools and Resources
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 44-48
People with mTBI/concussion should be assessed in a hospital setting if the mechanism of injury was severe1 or if they develop red flags within 72 hours of injury:
- seizure or convulsion
- loss of consciousness
- deteriorating level of consciousness
- confusion
- not acting normally, including abnormal drowsiness, increasing agitation, restlessness or combativeness
- double vision, ataxia, clumsiness or gait abnormality
- weakness and tingling in arms or legs
- vomiting2
- presumed skull fracture (palpable fracture, ‘raccoon eyes’ or Battle’s signs, cerebrospinal fluid leak, otorrhea, rhinorrhoea)
- severe headache (children 2-18 years)
- occipital or parietal or temporal scalp haematoma (in children aged less than 2 years only).
CBR 43
Children with head injuries do not need to attend hospital for assessment and can be safely managed in primary care or at home if:
- the injury was sustained from ground-level falls or walking or running into stationary objects
- there is no loss of consciousness
- GCS score is 15
- there are no signs or symptoms of head trauma other than abrasions.
CBR
Special consideration needs to be made for older people who:
- had a fall/head trauma (witnessed or unwitnessed) or explicit significant injury
- are on anticoagulation/antiplatelet therapy with the above incidents.
Further Guidance and Tools
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
EBR (Strong) 40,41,52-61
A medical doctor should conduct a review of every person who has sustained mTBI/concussion to confirm diagnosis (children and adults)
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.
IEBR (Conditional) 49,62-71
Initial medical management of a person with mTBI/concussion should be based on a thorough history and physical examination, and concurrent potential contributing factors, such as co-morbid medical conditions and mental health conditions. (children and adults)
EBR (Conditional) 40,41,52-61,72-75
Consideration should be given to use of an age-appropriate standardised concussion symptom inventory tool. (children and adults)
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) 76,78-82
Neuroimaging should not be routinely used for the purpose of diagnosing mTBI/concussion.
EBR (Conditional) 83-87
In children with mTBI/concussion who have one or more risk factors for a brain injury, health care professionals should take into account the number, severity and persistence of signs and symptoms (see Figure 1), and family factors when choosing between structured observation and a head CT.
EBR (Conditional) 76,78-82
The need for neuroimaging of people with mTBI/concussion on acute presentation (within 24-48 hours post-injury) should be determined according to the Canadian CT Head rule (see Figure 2). People who are anticoagulated or who have bleeding disorders require extra consideration (adults).
CBR 80,82,88,89
Plain skull x-rays are not recommended for the purpose of diagnosing mTBI/concussion (children and adults)
CBR80,82,88,89
Health professionals should not use single-photon emission CT (SPECT) or quantitative electroencephalogram in the acute evaluation of suspected or diagnosed mTBI/concussion (children and adults)
Further Resources for Neuroimaging in Children
EBR (Strong) 91,95
After a normal initial head CT in people presenting to an acute care setting following mTBI/concussion, neurological deterioration should prompt urgent reappraisal, with consideration of an immediate repeat head CT and consultation with a neurosurgical service.
EBR (Strong) 91,95
People with a normal initial head CT1 who do not reach a GCS score of 152 within 6 hours of injury, should have senior clinical review to consider a further head CT or MRI and/or consultation with a neurosurgical service. The differential diagnosis of neurological deterioration or lack of improvement should take account of other injuries, drug or alcohol intoxication and non-traumatic aetiologies (children and adults)
Simple linear skull fractures do not require specific intervention if a head CT reveals no underlying injury. 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 96-100,102
Consultation with a neurosurgical service should occur in all cases with an intracranial injury shown on a head CT, other than in infants and children with an isolated, non-displaced, linear skull fracture on a head CT without intracranial injury and a GCS score of 15.1
Notes: 1Measured using an age-appropriate GCS e.g. for infants and non-verbal people.
CBR 96-100,102
Consultation with a neurosurgical service should occur in all adults with a base of skull fracture, or skull fracture and confusion, decreased conscious level, or neurological symptoms or signs.
Further notes and evidence
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
Where structured observation is undertaken, observation period should be 4 hours or greater and should include amnesia and orientation assessment.
Notes: 1Measured using an age-appropriate GCS e.g. for infants and non-verbal people.
Practice points for Children and Adults
If the GCS does not return to 15, repeat assessment should be performed.
Practice points for Children and Adults
Discharge criteria should be met, even if there is a normal head CT.
Further guidance
Family violence is a significant cause of brain injury, due to mTBI/concussion, hypoxia, and/or strangulation.103 It is important to recognise symptoms of abuse and violence and explore with sensitivity and empathic listening.104 Although family violence is common it is underrecognised; when present, it is usually repeated.105 Local and national guidelines should be used to guide the assessment and management.104
Mandatory reporting of child abuse is required throughout Australia and New Zealand. Some regions also mandate reporting in vulnerable adults.
Practice points for Children and Adults
Consider the possibility of abusive head trauma in all presentations of mTBI/concussion.
Further guidance
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.
Practice points for Children and Adults
In people with a ventricular shunt and mTBI/concussion, if there are local signs of shunt disconnection, shunt fracture (e.g. palpable disruption or swelling), or signs of shunt malfunction, consider obtaining a shunt series, and consultation with a neurosurgical service.
- 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.
- 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
EBR (Conditional) 111,113
For people with congenital or acquired bleeding disorders who have experienced mTBI/concussion, consider structured observation over immediate head CT if there are no risk factors for more serious forms of traumatic brain injury (see Figure 1 and Figure 2) and no symptoms consistent with intracranial bleeding.
If there is a risk factor for intracranial injury, a head CT should be performed.
If there is a deterioration in neurological status, a head CT should be performed urgently.
Practice points for Children and Adults
For people with a coagulation factor deficiency (e.g. haemophilia) who have experienced mTBI/concussion that results in presentation to an acute care setting, neuroimaging should not delay the urgent administration of replacement factor, with guidance from a haematologist sought as required.
Practice points for Children and Adolescents
For children with a bleeding disorder or on anticoagulant or antiplatelet therapy who have experienced mTBI/concussion that results in presentation to an acute care setting, health professionals should urgently seek advice from a haematologist.
Practice points for Adults
In adults on anticoagulant or antiplatelet therapy or who have known bleeding disorders, CT should be strongly considered. Qualified health care professionals should follow local protocols and guidelines for management of anticoagulation agents in trauma patients.
Further notes and guidance
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
It is unclear whether people with neurodevelopmental disorders have a different background risk for intracranial injury following mTBI/concussion. Consider performing a period of structured observation or a head CT because these people may be difficult to assess. Shared decision making with caregivers and the clinical team that knows the person is particularly important.
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
In people who are intoxicated with drugs or alcohol who have experienced mTBI/concussion, treat as if the neurological findings are due to the mTBI/concussion. A low threshold should be used to recommend head CT.