Concussion: Why Nurses Need to Understand This Hidden Injury

Ann Worley


Pediatr Nurs. 2019;45(5):235-243. 

In This Article

Assessment and Recognition

No single test exists today to diagnose a concussion in standard medical practice (Rivera, Roberson, Whelan, & Rohan, 2015). An accurate diagnosis is made on a combination of clinical history, mechanism of injury, and reported symptoms, and is therefore a medical decision based on clinical judgment (McCrory et al., 2013). Identifying when a concussion has occurred can be challenging because the child may exhibit few or no outward visible physical signs and his/her symptoms can be numerous, variable, and subtle. Onset of symptoms may not occur for several hours, or in the minority of cases, 1 to 2 days after the injury (McCrory et al., 2017; Putukian, 2017). Furthermore, failure to lose consciousness does not eliminate the possibility of a concussion; in fact, 90% of concussions do not result in loss of consciousness (CDC, 2015a).

A concussion does not appear on standard neuro-imaging, which is usually ordered for the purpose of ruling out more serious injuries, such as skull/cervical spine fractures or hemorrhage (Halstead & Walter, 2010). According to Jacobs and colleagues (2010), CT images are very poor predictors of outcome after mTBI. A key recommendation of the recent Pediatric TBI Guideline is to reduce routine diagnostic imaging when possible, utilizing validated clinical decision rules to weigh clinical risk factors against risks for radiation exposure and possible sedation (CDC, 2018).

Signs and Symptoms

Signs and symptoms are key for assessing and diagnosing concussion severity (CDC, 2016d; Gillooly, 2016). Symptoms classified as 'common' vary widely and encompass physical, cognitive, emotional, and sleep-related effects (see Figure 1). Headache is the most common of these symptoms and occurs in about 80% of cases (Norton et al., 2013). A concussed child may experience several of these symptoms or only a few, and some of these mimic other disorders, such as depression or post-traumatic stress disorder (PTSD). In fact, because symptoms can be mild, a person may suffer a concussion and not even realize it occurred (Norton et al., 2013). Onset of depression and preoccupation with brain damage are common during the recovery period (McCrory et al., 2013).

Figure 1.

Concussion Signs and Symptoms
Sources: CDC, 2019a, b.
Note: This listing may not be comprehensive. A child may experience only one or two (or even none) of these symptoms. Onset of some symptoms may be delayed by hours or even several days, some symptoms may mimic other disorders, and some may be so subtle as to be undetectable by either the child, parent, or evaluator.

Some symptoms, however, can be considered worrisome, indicating the presence of a more complex, even life-threatening injury. All concussed patients, their caregivers, and clinical providers should be made aware of the dangerous or red flag symptoms. These signs, usually occurring within 24 to 72 hours post-injury, suggest neurological deterioration, an indication for the victim to seek immediate emergency medical intervention because these signs can indicate an intracranial bleed, skull fracture, or other structural pathology (Gioia et al., 2008). A few of these red-flag signs, such as headache, irritability, and vomiting, initially present as common symptoms, but if persistent, can indicate more serious injury.