Patients who visit the emergency room after an accident that may have resulted in a mild traumatic brain injury (mTBI; commonly known as concussion) undergo a standardized examination based on guidelines set forth by the American College of Emergency Physicians (ACEP). Based on the patient’s score on the Glasgow Coma Scale, an assessment metric that is administered to determine the severity of injury, they may or may not receive neuroimaging such as a CT scan or an MRI scan. Most patients with concussion show no obvious radiological deficits as a result of their injury, but that doesn’t mean that they haven’t suffered damage. Concussion can occur even without direct head impact, and the high-energy head and neck movements that often occur during an accident can cause imperceptible damage to the brain.
According to the ACEP, the majority of patients with concussions can be safely discharged from the hospital, but research has shown that a period of physical and cognitive rest is critical for full recovery from a concussion. We know that the ACEP provides guidelines for treating and diagnosing patients in the ER, but do recommendations exist patients who are sent home after moderate to severe injury is ruled out? If so, do these recommendations adequately emphasize the importance of rest following a concussion?
In 2003, the Centers for Disease Control and Prevention (CDC) launched Heads Up, an initiative to increase education of and awareness for concussion for patients, physicians, and families. (For more details on Heads Up, visit https://www.cdc.gov/headsup/index.html.) As part of their standard of care in treating concussion, the ACEP promotes the use of Heads Up materials. The ACEP website provides such resources as guidelines and talking points for clinicians, as well as take-home instructions and information for patients on what to expect following a concussion.
Clinician guidelines include a series of risk-assessment questions that determine whether a patient needs to receive a CT or MRI scan. Once the patient is deemed safe to discharge, the suggested talking points are intended to help physicians provide information to patients about self-care following a concussion, including warning signs that may require further medical assistance. The suggested talking points are to:
- explain what a concussion is;
- explain typical symptoms and tell patients most symptoms go away over time;
- advise patients to avoid strenuous activities and those that require a lot of concentration;
- tell patients to not return to sports until talking to a doctor; and
- advise patients to see a doctor if symptoms persist or more than one week.
The ACEP “Patient Take-Home Instructions” is a document that explains to the patient the treatment they received and provides a detailed explanation of potential symptoms. They emphasize that it is normal to experience symptoms and that most go away with time.
These guidelines are comprehensive: they provide education about the injury and potential symptoms, and they instruct patients to rest, which research has shown is the most effective treatment for a concussion. Yet these materials have several gaps. They don’t emphasize that it is common to experience post-concussive symptoms (PCS), some of which may not appear immediately following injury. Furthermore, by stressing the point that most symptoms are not long-lasting and by minimizing the likelihood and severity of PCS, they establish a stigma against reporting symptoms. Patients may not be likely to report their symptoms because they assume that they will go away without intervention.
Critically, the materials don’t sufficiently explain why both physical and cognitive rest are important for reducing long-term deficits after concussion. Physical rest prevents repeat injury, while cognitive rest compensates for the brain’s energy-deprived state as it attempts to repair itself. Finally, the ACEP provides these materials as suggestions, which means that patients may or may not receive any of these documents, and there is likely variability in whether they are used and how they are administered.
It is clear that these educational resources would be most effective if they were administered with context and detailed explanations about symptoms, risks, and optimizing recovery. Standardizing ACEP materials across emergency departments could significantly improve individuals’ understanding of concussion symptoms and maximize their potential to fully recover from their injuries.