What are the key clinical features to assess when diagnosing a concussion in a primary care setting?

When assessing for a concussion in a primary care setting, key clinical features to evaluate include a detailed history of the injury and current symptoms, a thorough physical examination, and specific signs of concussion or post-concussion syndrome ¹,². It is also crucial to identify any red flags that necessitate emergency referral ².

• History Taking:
• Ascertain the mechanism and timing of the head injury, noting if it involved a high-energy event such as a fall from over 1 metre or 5 stairs, or a high-speed motor vehicle collision ¹.
• Inquire about current symptoms since the injury, including any loss of consciousness, confusion, amnesia for events before or after the injury, seizures, vomiting (and number of episodes), headache, neck pain, or visual disturbances like double vision ¹,².
• Gather relevant past medical history, such as recent alcohol or drug intake, current anticoagulant medication, pre-injury level of functioning, bleeding disorders, previous brain surgery, or prior head trauma ¹,².
• Physical Examination:
• Assess the level of consciousness using the Glasgow Coma Scale (GCS) ¹. A GCS score of less than 15 on initial assessment is a risk factor for emergency referral ².
• Check vital signs for indicators like hypoxia or signs of shock (e.g., tachycardia, hypotension) ¹.
• Examine for visible trauma to the scalp, skull, head, and neck ¹.
• Perform a neurological assessment, including cranial nerves (pupil size and reactivity), and look for signs of focal neurological deficit such as problems with vision, speech, balance, walking, muscle power, or abnormal reflexes ¹,².
• Assess for signs of a basal skull fracture (e.g., clear fluid leaking from ears/nose, periorbital haematoma, bleeding from ears, Battle's sign) or cervical spine injury (e.g., midline neck tenderness, inability to rotate neck 45 degrees) ¹.
• Specific Concussion Symptoms (Post-Concussion Syndrome):
• Sensory and Motor Symptoms may include headache, dizziness, nausea, changes in vision (e.g., blurred vision, 'seeing stars'), visual processing problems, difficulties staying awake or chronic fatigue, unusual sensitivity to noise (hyperacusis) or bright lights (photophobia), and difficulties with balance, coordination, or speech ².
• Cognitive Symptoms often described as 'brain fog', can involve problems finding words or numbers, difficulty speaking, slowed responsiveness, short-term memory issues, difficulty concentrating, problems processing information (e.g., following conversations), difficulties with executive functions (organising, planning), and amnesia ².
• Red Flags for Emergency Referral from Primary Care:
• Any GCS score less than 15 on initial assessment ².
• Any loss of consciousness or seizure since the injury ².
• Any focal neurological deficit or suspicion of a complex skull fracture or penetrating head injury ².
• Persistent headache or any vomiting episodes since the injury ².
• Amnesia for events before or after the injury ².
• Previous brain surgery, a high-energy head injury, or a history of bleeding/clotting disorders ².
• Current anticoagulant or antiplatelet treatment (excluding aspirin monotherapy), or current drug/alcohol intoxication ².
• Safeguarding concerns (e.g., possible non-accidental injury) ².
• Irritability or altered behaviour, particularly in babies and children under 5 ².
• Continuing concern by the professional, injured person, or their family/carer about the diagnosis ².