II. Management

  1. Follow-up
    1. One week follow-up clinic (or immediately if warning signs occur as below)
    2. Consider Concussion clinic (sports medicine)
  2. General precautions
    1. Avoid Alcohol and sedating medications for 3 days
    2. Remain with a reliable companion for 24 hours
    3. Avoid driving for at least the first 24 hours (and until most significant symptoms have resolved)
  3. Anticipatory Guidance
    1. Symptoms typically improve in the first 48 hours and mostly resolve over the next 1-2 weeks
      1. Common symptoms include Headache, Dizziness, daytime Somnolence, Insomnia and inattention
      2. Emotional symptoms may include irritability, frustration, anger and restlessness
    2. Longstanding Postconcussion Syndrome may last months, and in some cases years
      1. Reduce the risk of longstanding symptoms by getting adequate physical and cognitive rest initially
      2. Symptoms should limit activity
  4. Symptomatic relief
    1. See Postconcussive Syndrome
    2. Sunglasses for photophobia
    3. Ear plugs or noise cancelling headphones for phonophobia
    4. Avoid NSAIDs if any risk of intracranial bleeding (use Acetaminophen instead)
    5. Avoid Opioids (Narcotic Analgesics) due to worsening confusion and Nausea
  5. Cognitive rest
    1. Decrease activites that require concentration or attention
    2. Limit school work, television, computer work as well as text messaging and video games
    3. Avoid excessive visual or auditory stimulation (e.g. screen time, movie theaters, stadiums)
    4. Example school restrictions
      1. Return to School in 1-2 days
      2. No school homework for 1 week
      3. No major school exams for 2 weeks
  6. Physical rest
    1. See Return to Play after Concussion
    2. Decrease physical activities that exacerbate symptoms (avoid raising Heart Rate)
    3. Limit aerobic Exercise, weight lifting, household chores, sexual activity
  7. Get adequate sleep
    1. See Sleep Hygiene
    2. Expect increased Sleepiness
    3. Expect increased difficulty initiating and maintaining sleep

III. Management: Return or call immediately for

  1. Difficult to awaken
    1. Awaken every 2-4 hours from sleep
  2. Excessive Sleepiness
  3. Convulsions or Seizures
  4. Bleeding or watery discharge from ear or nose
  5. Severe Headache
  6. Weakness or loss of feeling in arm or leg
  7. Confusion or strange behavior
  8. Eye changes
    1. One pupil larger than the other (Anisocoria)
    2. Peculiar eye movements (Nystagmus, saccades)
    3. Double Vision
  9. Slow pulse (<50/minute) or rapid pulse (>110/minute)
  10. Unusual breathing pattern
  11. Urinary Incontinence or bowel Incontinence

IV. References

  1. Bengtzen, Novak and Chesnutt (2016) Crit Dec Emerg Med 30(5): 3-10
  2. Lawler (1996) J Head Trauma Rehabil 11:18-28 [PubMed]

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