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Concussion Care Pathway

Date of last update: May, 2024

Signs or Symptoms of Pathology (Red Flags)

 

Clinical Cornerstone: Consider asking additional questions that help evaluate for the presence of red flags in concussion. Red flags are symptoms or signs that may indicate a serious pathology and should be deliberated in the clinician’s differential diagnosis.

  • Spinal fracture

    • Red flags include: history of osteoporosis, corticosteroid use, severe trauma or dangerous mechanism, female sex, older age, history of spinal fracture, history of cancer, history of falls, ≥65 years of age, paresthesia in extremities, inability to actively rotate the neck 45 degrees to the left and right, midline tenderness on palpation (Canadian C-Spine Rule).

    • Action: to appropriate provider for immediate imaging.

 

  • Intracranial/Brain Lesion

    • Red flags include: sudden and intense onset headache (thunderclap headache), seizure, vomiting (two or more episodes), nystagmus, new difference in pupil size, falls due to imbalance, extreme drowsiness, slurred speech, unusual confusion or irritability or behaviors, anterograde amnesia (<30 minutes). (Canadian CT Head Rule)

    • Action: Refer to an appropriate provider.

  • Vertebral/Carotid Artery Dissection

    • Red flags include: severe neck pain and/or headache (described as the worst pain ever), double vision, difficulty initiating swallowing, dizziness, drop attacks, facial numbness, difficulty walking, nausea, nystagmus.

    • Action: Immediate emergency referral.

  • Cranial Fracture

    • Red flags include: history of osteoporosis, corticosteroid use, severe trauma or dangerous mechanism deformity, female sex, older age, history of spinal fracture, history of cancer, history of falls, ≥65 years of age, severe headache, signs of basal fracture (leakage of fluids from ears or nose, “racoon eyes”, Battle’s sign). (Canadian CT Head Rule).

    • Action: Immediate emergency referral.

  • Spinal Malignancy

    • Red flags include: history of cancer, unexplained weight loss, unexplained significant night sweats, pains worse at night, progressive headaches worse with exertion.

    • Action: Refer to an appropriate provider.

  • Cervical Myelopathy

    • Red flags include: gait disturbances, hand clumsiness, non-dermatomal numbness, weakness or numbness and weakness involving lower extremity / bowel / bladder, coordination problems.

    • Action: Immediate emergency referral.

  • Meningitis

    • Red flags include: neck stiffness, severe generalized headache that is worse with flexion, neck pain or headache with fever or  vomiting or rash,  altered mental status, photophobia.

    • Action: Immediate emergency referral.

  • Neurological disorders (e.g., MS, ALS, neurodegenerative disorders)

    • Red flags include: upper/lower motor neuron findings, clonus.

    • Action: Refer to appropriate provider.

Orange Flags

 

Clinical Cornerstone: Orange Flags are symptoms or signs that may represent the presence of serious psychiatric disorder (e.g., major depression, major personality disorders, post-traumatic stress disorders [PTSD], substance addiction and abuse). In the event such disorders are present, referral to a psychiatric specialist would be indicated over usual care in the presence of non-major disorders such as anxiety. Screening can include:

Conduct patient assessment

Red flags or Orange flags present

Red flags or Orange flags present

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Refer to appropriate emergency or healthcare provider

No

Yes

Acute mTBI

  • Structured patient education

  • Self Care

  • Return to work / school

  • Return to driving

  • Return to sport / activity

Persistent mTBI

  • Monitoring and Reassessment

  • Tailored clinical management of symptoms:

    • Headache
    • Neck Pain
    • Sleep Disturbance
    • Fatigue
    • Emotional / Behavioural
    • Cognitive Disorders
    • Vestibular Disorders

Differential Diagnosis

Diagnosis

 

Diagnosis

Follow-up

Follow-up

(Align with patient goals, Criteria for discharge)

Major symptom/sign change

Goals not achieved

Discharge

No

Yes

Re-evaluate

Adjust treatment and management plan or refer

References or links to primary sources

  • Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. CDC Heads Up [Internet]. CDC February 2022. Available from: https://www.cdc.gov/headsup/index.html.

  • David L. MacIntosh Sports Medicine Clinic, University of Toronto. Post-Concussion Return to Activity Guidelines. EMPWR Our Toolkit [Internet]. EMPWR Foundation 2019. Available from: https://empwr.ca/our-toolkit.

 

Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

Disclaimer:

These care pathways are intended to provide information to practitioners who provide care to people with musculoskeletal conditions. The care pathways on this website are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. As knowledge and healthcare practices evolve, these pathways may be updated to ensure they remain current and evidence driven. These pathways are not intended to replace advice from a qualified healthcare provider.

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