I spoke with a mother this week of her 14-year old daughter who wanted an urgent appointment—the same day—for a concussion evaluation after her daughter sustained a concussion playing soccer. Unable to see the daughter the same day, the mother stated “She could die before tomorrow.” I realized that the mother was confusing the acute, emergency assessment and evaluation with the second phase of evaluation and management which begins 24-48 hours after a concussion. As I spoke with the mother, I learned her daughter had been evaluated in the acute phase, and was cleared from an acute threat such as a bleed to the brain. (A bleed in the brain can occur hours, days and in some persons, usually the elderly, a week or so after an initial injury, but most often occurs soon after the concussion impact).
Let’s review the ABC’s of concussion evaluation and management.
Acute Assessment: This usually occurs on the field in sports or in the emergency room in other circumstances. When an athlete has a possible concussion, the athletic trainer or team physician usually conducts an on-the-field acute assessment. Some forms of assessment are the Acute Concussion Evaluation by Gioia and Collins, the Sport Concussion Assessment Tool-2 among others. The first 24-48 hours are crucial for observation in order to prevent an acute, life threatening condition such as a bleed inside the head (hematoma). A CT or MRI scan will rule this out.
NeuroBehavioral Evaluation: After the acute phase, the concussed patient should be seen by a concussion specialist to assess the presence and severity of symptoms and guide the patient (and parent, if appropriate) on how to manage the symptoms to promote the fastest recovery possible. Mismanagement can result in not only a prolonged recovery, but a worsening of symptoms. This evaluation will usually consist of an interview, brief cognitive testing such as ImPACT, testing of balance and eye movements, and assessment of mood.
Cessation or Resolution of Symptoms: The patient is usually followed until the symptoms have largely resolved and the patient can be cleared to return to play and/or return to school. This must follow a generally gradual path from little activity to increasing levels of activity until a return to normalcy without active symptoms is achieved.
Management of concussion is critical for the player, athlete or patient to return to life as normal as quickly as possible and to prevent other serious, potentially life threatening complications such as Second Impact Syndrome. We’ll discuss these issues later.
