Physical Examination and Testing

History and physical examination are crucial to making the diagnosis of concussion. Understanding the mechanism of injuries allows the health care provider to decide if further radiologic testing is required. A normal neurologic examination is somewhat reassuring that no major structural injuries to the brain have occurred.

Glasgow Coma Score (GCS)

The GCS was developed to quickly assess a patient's neurologic status based on speech, eye opening, and movement. The scale is used as part of the initial evaluation of a patient. Since it "scores" the level of coma, the GCS can be used by healthcare providers with different skill levels to assess changes in patient status.

Computerized Tomography (CT scan)

Not everyone who has sustained a blow to the head needs a CT scan. The Canadian Head CT Rules were developed to minimize the number of brain scans that were done with little chance of finding bleeding in the brain and requiring an operation. There is no need for CT scanning if none of the following high or medium risk criteria are met.

High risk for bleeding:

• Glasgow Coma Score less than 15 at two hours after injury.
• Suspected open or depressed skull fracture.
• Any sign of basal skull fracture [blood behind the eardrum, "raccoon eyes" or bruising around the eyes, cerebrospinal fluid leaking from the nose or ears, or Battle's sign (bruising behind the ear)].
• More than two episodes of vomiting.
• Age greater than 65 years.

Medium risk for bleeding:

• Amnesia before impact greater 30 minutes. This refers to loss of memory prior to the trauma (retrograde amnesia).
   
  • Amnesia can be retrograde (loss of memory of events prior to the injury) and antegrade (where the person cannot remember events that have occurred after he injury). Antegrade amnesia is common and not an indicator of significant brain trauma. Retrograde amnesia of more than 30 minutes is a risk for brain bleeding.
• Dangerous mechanism of injury (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height greather than three feet or five stairs).

These indications are valid for those patients aged 2 to 65.

X-rays of the skull are not indicated in minor head trauma, since normal X-rays do not correspond to a normal brain.

Since concussion is defined as a temporary change in brain function, it is important to examine the patient on more than one occasion. Brain function may or may not correlate with the resolution of symptoms. Neuropsychologic testing can be used to assess brain function to decide when to allow a patient to return to full activity.

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