Concussion/Brain Injury Referral Guidelines for Physicians in ED/UCC

Use the following guidelines to asses children that may have suffered a concussion

boy practicing football tackle white framing element
boy practicing football tackle white framing element

Definition of Concussion

Any direct or indirect trauma to the head and/or neck that results in any of the following symptoms:

  • Loss of consciousness
  • Headache
  • Nausea
  • Vomiting
  • Balance problems
  • Dizziness
  • Lightheadedness
  • Fatigue
  • Drowsiness
  • Sensitivity to light or noise
  • Feeling more emotional
  • Numbness or tingling
  • Feeling like "in a fog"
  • Difficulty concentrating
  • Difficulty remembering/amnesia
  • Visual problems

For children who exhibit one symptom for a brief period of time, this may be a liberal definition. However, there are some children who recover initially but with subsequent exertion have delayed onset ot symptoms.

Who Needs to Be Referred to the Concussion/Brain Injury Clinic?

  1. All children who meet the above criteria for concussion, even if they appear “normal” at the time of discharge. There can be an asymptomatic interval between concussion and symptoms, usually brought on by cognitive or physical exertion, e.g., going to school.
  2. All children with GCS < 15
  3. All children who meet criteria for a brain CT for CHI whether positive or negative for TBI. The rationale is that if they appear acute enough to need a brain CT or meet the PECARN criteria for CT, they need follow up.
  4. All children with an abnormal brain CT, including skull fracture.
  5. All sports related injuries that require return to play clearance in compliance with Florida law requiring all athletes to obtain written clearance from a LHCP before returning to play.
  6. All kids with a history of prior TBI/concussion.
  7. Mild TBI or concussion patients discharged from ED/UCC should initially be sent to the Concussion/Brain Injury Clinic. Neurosurgical referrals will then be made as needed.

Rationale for Early Concussion Evaluation and Management:

  1. Education and reassurance of family and child.
  2. Early intervention to decrease duration and severity of symptoms and reduce returns to ED.
  3. Implement return-to-school protocol with individualized accommodations as needed. Concussion clinic personnel communicate with the TBI specialist for Miami-Dade public schools and school personnel to ensure implementation of classroom accommodations.
  4. Implement safe return-to-play protocol
  5. Appropriate referrals for vestibular, exertional, oculomotor and general physical therapy, as well as neuropsychological and psychological assessment and treatment.
  6. Repeated follow up clinic visits to maximize recovery and achieve best outcome.
  7. Detailed report sent to all PCPs and referring physicians after evaluation.