Concussion and mild traumatic brain injury are common clinical problems. Mild concussion may involve no, or very brief, loss of consciousness. Severe concussion may involve prolonged loss of consciousness with a delayed return to normal. Concussion results from closed blunt force trauma to the head, such as in a fall, car accident, sports injury or being struck on the head.
The relationship between concussion and minor traumatic brain injury is not clear. Although most patients with concussion recover within days to weeks, some 10 per cent develop persistent signs and symptoms of post-concussion syndrome.
There are no scientifically established treatments for these conditions and so rest and cognitive rehabilitation are traditionally used, with limited effectiveness.
1. The GP's role
Many cases of head injury are not seen by GPs because as acute traumatic episodes they are dealt with in A&E. But the GP may often be asked about the significance of minor head injury retrospectively, or be called out to rest homes where a resident has had a fall, or have to deal with minor head injuries where a period of loss of consciousness is uncertain.
GPs may also be asked about longer-term consequences and to advise on persistent symptoms after a recent head injury (post-concussion syndrome).
A GP may be called to a nursing home if a resident has a fall (Photograph: SPL)
2. Assessing head injury
A detailed history is essential. It should include how and when the injury occurred and what symptoms have been experienced since the injury. Specifically, the patient or observer should be asked about loss of consciousness, vomiting, headache, visual disturbance, neck pain and alcohol or drug intake.
The examination should assess the person's level of consciousness using the Glasgow Coma Scale,1 in which patients are scored according to their best visual, verbal and motor responses. The lowest possible score is three (deep coma or death) and the highest 15 (fully awake).
Any neurological deficit or signs of physical trauma to the head and neck should be recorded. Although it is rare, the GP should consider the possibility of abuse if a child has a head injury in the absence of major confirmed accidental trauma, especially in those under three years, and if there are other bone or soft tissue injuries.
Scores should reflect actual observed activity without attempting to make allowance for intoxication. There is a separate scale for pre-verbal children.
3. When to refer?
Immediate referral to A&E is indicated if there is or has been an altered level of consciousness. This can be objectively assessed using the Glasgow Coma Scale; any score of 14 or less indicates emergency referral. Also refer if there has been any loss of consciousness after the injury, even if they appear normal when seen. Other signs or symptoms that require referral are listed in the box below.
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Symptoms and signs indicating referral include (note this list is not exhaustive):
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The patient can be left at home if the clinical history and examination indicate a low risk of brain injury and the referral criteria are not met. Patients will need competent supervision at home, and should be given verbal and written self-care advice. This should include telling adults to stay within easy reach of help and to be near to a telephone for the first 48 hours, to have plenty of rest and avoid stressful situations. Alcohol and non-prescribed drugs, sedatives, or tranquillisers should be avoided.
It is advisable to tell patients to avoid contact sports for three weeks. They should also not drive or operate machinery until they are completely recovered. They should report to their doctor or to A&E if there is any change in consciousness, confusion, abnormal drowsiness, visual disturbance or problems with walking or balance. Worsening headache, vomiting or seizures must also be reported.
Parents can be told that a child may take simple painkillers if required for mild headache, avoid too much excitement and not be overwhelmed with well-meaning visitors.
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4. Persistent symptoms
Obvious evidence of complications, such as altered consciousness, requires urgent referral, but in most cases the patient will have imprecise symptoms. These might include headache, dizziness, generalised weakness, tinnitus, nausea, poor memory, poor sleeping and fatigue.
In the absence of any other abnormality, the patient can be reassured that these symptoms are not uncommon after a mild head injury. They do not usually have a serious underlying cause and normally resolve within three months. Patients should be encouraged to make an effort to return gradually to normal activity.
Treatment may be required for sleep deprivation, headache and depression. Refer to a neurologist, psychiatrist or endocrinologist (if hypopituitarism is suspected) if symptoms are persistent or severe.
The cause of relatively minor symptoms that do not resolve within three months is not known, but there is little evidence to suggest a neurological basis. About 8% of patients have symptoms for at least a year, and sometimes they are permanent.
Of those with permanent symptoms, up to 14% are disabled and cannot work. There is evidence that psychological interventions can be helpful in these situations. Reassurance and education in the first few weeks of minor head injury significantly improves post-concussion symptoms.2
- Dr Barnard is a former GP from Fareham, Hampshire
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References
1. Glasgow Coma Scale: www.le.ac.uk/pa/teach/va/case_1/gcs.html
2. Wade DT, King NS, Wenden FJ et al. Routine follow up after head injury: a second randomised controlled trial. J Neurol Neurosurg Psychiatry 1998; 65(2): 177-83.
