II. Management
- Follow-up
- One week follow-up clinic (or immediately if warning signs occur as below)
- Consider Concussion specific follow-up for persistent symptoms (e.g. sports medicine, neurology, physical therapy)
-
General precautions
- Avoid Alcohol and sedating medications for 3 days
- Remain with a reliable companion for 24 hours
- Avoid driving for at least the first 24 hours (and until most significant symptoms have resolved)
- Anticipatory Guidance
- See Postconcussion Syndrome
- Symptoms typically improve in the first 48 hours and mostly resolve over the next 1-2 weeks
- Common symptoms include Headache, Dizziness, Daytime Somnolence, Insomnia and inattention
- Emotional symptoms may include irritability, frustration, anger and restlessness
- Longstanding Postconcussion Syndrome may last months, and in some cases years
- Reduce the risk of longstanding symptoms by getting adequate physical and cognitive rest initially
- Symptoms should limit activity
- Symptomatic relief
- See Postconcussive Syndrome
- Sunglasses for photophobia
- Ear plugs or noise cancelling headphones for phonophobia
- Avoid Opioids (Narcotic Analgesics) due to worsening confusion and Nausea
- NSAIDs and Acetaminophen for Headache
- Avoid NSAIDs if risk of Intracranial Bleeding
- Warn patients regarding Analgesic Rebound Headache
- Manage other symptom causes
- Cognitive rest
- Decrease activites that require concentration or attention
- Limit school work, television, computer work as well as text messaging and video games
- Avoid excessive visual or auditory stimulation (e.g. Screen Time, movie theaters, stadiums)
- Example school restrictions
- Return to School in 1-2 days
- No school homework for 1 week
- No major school exams for 2 weeks
- Physical rest
- See Return to Play after Concussion
- Relative rest for first 24 to 48 hours
- Light activity (e.g. walking) is recommended to continue
- Decrease physical activities that exacerbate symptoms (avoid raising Heart Rate)
- Limit aerobic Exercise, weight lifting, household chores, sexual activity
- However, early return to non-contact light activity may speed recovery and protect against Postconcussion Syndrome
- Get adequate sleep
- See Sleep Hygiene
- Melatonin 3-10 mg each evening
- Expect increased Sleepiness
- Expect increased difficulty initiating and maintaining sleep
- School recommendations
- Allow for reduced work load
- Allow more time for homework completion
- Allow more time for, or delay test taking
- Allow student to obtain class notes or outlines prior to class if possible
- Allow the student to take breaks in a quiet area or nurses office as needed to control Concussion symptoms
- Allow for early hallway pass
- Excuse from physical education and music classes
- Provide a quiet area for eating lunch
- Allow sunglass use during the school day
- Reduced computer Screen Time is recommended, to be adjusted as tolerated.
- Work Recommendations
- Allow for reduced work load.
- Allow the worker to take breaks (e.g. 15 to 20 min) in a quiet area as needed to control Concussion symptoms
- Avoid significant exertion
- Provide a quiet area for lunch and breaks.
- Allow use of Sunglasses during the work day.
- Reduced computer Screen Time is recommended, to be adjusted as tolerated.
III. Management: Return or call immediately for
- Difficult to awaken
- Awaken every 2-4 hours from sleep
- Excessive Sleepiness
- Convulsions or Seizures
- Bleeding or watery discharge from ear or nose
- Severe Headache
- Weakness or loss of feeling in arm or leg
- Slurred speech
- Repeated Vomiting
- Confusion or strange behavior
- Eye changes
- One pupil larger than the other (Anisocoria)
- Peculiar eye movements (Nystagmus, saccades)
- Double Vision
- Slow pulse (<50/minute) or rapid pulse (>110/minute)
- Unusual breathing pattern
- Urinary Incontinence or bowel Incontinence
IV. References
- Bengtzen, Novak and Chesnutt (2016) Crit Dec Emerg Med 30(5): 3-10
- Lawler (1996) J Head Trauma Rehabil 11:18-28 [PubMed]