Concussion Aftercare Guidelines for the ED

One important aspect of concussion management for the emergency clinician is the provision of adequate aftercare instructions at the time of discharge from the ED. This requires a paradigm shift for the emergency clinician, as discharging a head-injured patient was primarily focused on providing precautions for potential deterioration.

Patients with severe symptoms may be concerned about their ability to recover and the long-term implications, due to heightened media attention on concussion. An understanding of the expected course of recovery can be very helpful to the patient and family, providing reassurance that the majority of patients with concussion will recover fully.

Instructions for aftercare may include a period of rest, but should allow for limited, progressive cognitive and physical activity as tolerated by the patient and as symptoms improve. Emergency clinicians should not create disability by recommending strict rest. Several studies have found no benefit in the prescription of strict rest when compared to the resumption of moderate cognitive or physical activity. Brown et al demonstrated improved recovery in children who were provided with moderate cognitive rest compared to no cognitive rest, but there was no additional benefit with extremes of cognitive rest. It has also been shown that patients who resumed moderate levels of cognitive or physical activity recovered better than those with strict rest or resumption of high levels of activity.

While strict rest may inhibit recovery, the discussion with the patient must be balanced by maintaining a healthy respect for the vulnerability of the concussed brain. Rodent studies have clearly demonstrated that there is a window of vulnerability after a concussion, during which even a mild repeat injury significantly increases the risk of a complicated recovery. MRI spectroscopy studies in humans have demonstrated neurometabolic changes that persist beyond apparent clinical resolution of the concussion, but the clinical implications of these findings are not yet clear. Patients should be counseled on the risks of re-injury and should not return to sport or high-risk physical activities, such as bike riding, until cleared from the concussion during a follow-up medical visit.

When providing aftercare instructions, the emergency clinician should advise patients and caregivers that return to school is appropriate once severe symptoms have improved. Return to school typically can take place within 48 to 72 hours after the injury. Academic adjustments may be needed to support recovery in the school environment. The primary care clinician or concussion specialist is more suited than the emergency clinician to work with the patient’s school on specific plans for return to school. It is not necessary to keep students out of school until they are symptom free, as doing so increases the risk for development of social isolation, stress from missed school work, and/or school avoidance behaviors.

Sleep disturbance is almost universal in concussion and can be a significant source of disability and delayed recovery. The emergency clinician should counsel patients on sleep hygiene to help prevent a disturbed sleep cycle, as patients may spend more time than normal sleeping during the early course of recovery. Approximately 1 to 2 weeks after the injury, increased sleep often gives way to day-night reversal, difficulty falling asleep, and difficulty staying asleep.

Patients should be advised to eliminate napping within a few days after the injury and should be counseled that proper sleep hygiene techniques should be implemented within a week of the injury. The burden of electronic device use by patients should not be underestimated, as this can contribute to sleep disturbance even without concussion. Constant audible alerts and emission of blue light from electronic devices can contribute to sleep disturbance. Proper sleep hygiene techniques are outlined in Table 7.

Table 7. Proper Sleep Hygiene Techniques

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Last Updated on October 15, 2021

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