STEP 2: Concussion Live Course - October 21-22, 2025, in Salt Lake City, UT-Assessing Concussion in the Emergency Department

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This document, authored by Dr. Charlie Kenyon, provides a comprehensive overview on assessing concussion in the emergency department (ED) setting. Concussion diagnosis is complex, relying on a detailed history, clinical examination, and high clinical suspicion, as symptoms can be broad and nonspecific. Key historical factors include the injury mechanism, level of consciousness, duration of loss of consciousness, amnesia, and risk modifiers like intoxication, prior concussions, headaches/migraines, and mental health issues. Pediatric risk for persistent symptoms can be predicted in part by initial symptom burden.<br /><br />Physical examination should include thorough neurological assessment and palpation of temporal and mastoid bones. The "big three" serious missed diagnoses related to brain injury are vascular events, infections, and cancers.<br /><br />Imaging plays a crucial role primarily to rule out more serious intracranial pathology such as bleeding or skull fracture. CT brain without contrast is preferred in the acute setting due to rapid availability, guided by clinical decision rules like PECARN, New Orleans, NEXUS, and Canadian CT Head Rule. MRI offers greater sensitivity for subtle injuries like diffuse axonal injury or contusions, but is less accessible emergently. Repeat CT versus observation decisions should consider risks such as anticoagulation use.<br /><br />Biomarkers (e.g., S100B) currently show low-quality evidence and are not recommended for routine use in isolation to guide imaging or diagnosis.<br /><br />The presentation highlights inequities in concussion diagnosis and management across race and gender, emphasizing the need to address these care gaps.<br /><br />The summary stresses that the ED evaluation focuses on ruling out serious injuries rather than definitively diagnosing concussion, which often requires follow-up. Effective concussion management involves communication and coordinated transitions of care among emergency, athletic trainers, primary care, and specialty providers.<br /><br />Practical recommendations include immediate removal from play if concussion or red flags present, initial rest with limited screen time, use of standardized assessments (e.g., SCAT6), early light aerobic activity, and progressive return to school and sport with serial monitoring to evaluate risk factors for prolonged symptoms.<br /><br />Overall, concussion assessment in the ED demands a careful balance of clinical suspicion, history-taking, physical exam, selective imaging, and collaborative follow-up to optimize patient outcomes.

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Charlie D. Kenyon, DO, MS

Keywords

concussion assessment

emergency department

clinical examination

imaging in concussion

PECARN rule

pediatric concussion

neurological examination

concussion biomarkers

healthcare disparities

concussion management