Concussion: Why Nurses Need to Understand This Hidden Injury

Ann Worley


Pediatr Nurs. 2019;45(5):235-243. 

In This Article

Standardized Diagnostic Tools

Systematic assessment of the presenting symptoms and specifics of the injury is essential to proper management and reduced morbidity and mortality (Gioia et al., 2008). To assist nurses in various settings (ED, schools, primary and urgent care) in assessing an individual with a suspected concussion, evidence-based standardized tools have been developed.

Assessment at the Scene Of Injury

A suspected concussion is an "evolving injury in the acute phase" (McCrory et al., 2017, p. 2) and requires immediate action. Any person who sustains a blow to the head or body and exhibits any indication of a symptom of a concussion should be removed from play until cleared by a health care provider (Guskiewicz & Valovich-McLeod, 2011). If the child is down on the field, the first responder should perform an immediate airway, breathing, and circulation assessment followed by a cervical spine evaluation (Halstead & Walter, 2010). If the player is able to walk to the sidelines, a test for balance and orientation should be administered.

The new CDC Pediatric Guideline emphasizes the importance of validated, age-appropriate scales to be used by trained providers to assess severity of injury at the sideline (CDC, 2018). Common brief symptom sideline tools include the Sport Concussion Assessment Tool (the SCAT 5 or Child version of the SCAT 5), the ImPACT or Pediatric ImPACT test, and the Standardized Assessment of Con cussion (SAC) (Concussion Awareness Training Tool, 2018; Impact Applications Incorporated, 2019). Despite some variations, these tools generally identify loss of consciousness, memory, and balance/coordination (see Figure 2). Considered one of the most reliable sideline assessment tools, the SCAT 5 includes the Mad docks orientation questions that pertain to the current venue, such as "What half is it?", "Who scored last in this match?", and "Did your team win the last game?" (McCrory et al., 2017). Scoring on these tools should not be used as a stand-alone method to identify a concussion. However, as a patient's symptoms evolve over time, these tools can also be useful to measure recovery and are helpful in making return to play decisions (Echemendia et al., 2017).

Figure 2.


A variety of apps can be downloaded to guide the user in assessing a head injury and deciding a course of action. The following are two user-friendly apps that can guide responders through a series of questions, the answers to which are scored and then tallied to direct the course of action:

  • The Concussion Assessment and Response (CARE) Sport app guides health care providers through assessment of signs and symptoms, cervical spine evaluation, and cranial nerve assessment (Mihalik & Gioia, 2019).

  • The Concussion Recognition and Response (CRR) app leads a non-medical user through a symptom checklist, prompting them to record facts about the injury, the athlete's history, parental contact information, and prompts them to photograph the injured child (Brainline, 2019; Gioia & Mihalik, 2019).

Other concussion apps offer capabilities, such as locating a nearby neurologist and viewing the return to play (RTP) laws of a particular state (see Figure 2).

Initial Presentation in the Emergency Department

Recorded evidence from the scene of injury from a tool or app can assist ED providers in developing a comprehensive assessment when a potentially concussed patient presents in the ED. A thorough history should be taken for any patient initially seen for a suspected concussion; this entails a description of the injury and details about the patient's reaction at the scene. Upon presentation, a typical concussed patient's score on the commonly used Glasgow Coma Scale (which measures consciousness and severity of head injury) is typically 13 to 15, indicating mild temporary or no impairment (Sarmiento et al., 2018). The Acute Concussion Evaluation (ACE), ED version 1.4, is a checklist-type tool for guiding ED providers in developing a diagnosis (CDC, 2016a). This tool derives a score based on injury characteristics, symptoms, and concussion/headache history. Based on findings, the clinician may discharge the patient with referral to his/her primary care physician or recommend consultation with a specialist for further testing. The ACE series also provides a version for the primary care/clinician's private office (CDC, 2016c) with associated home/school instructions for early management (CDC, 2016b), as well as an observation checklist for the school nurse (CDC, 2017a).

Emerging Technologies to Improve Diagnosis and Outcomes

Although evidence-based tools, along with clinical judgment, are the standard for diagnosing concussions, technologies are emerging that appear to have promise in improving diagnosis. New imaging technologies, such as functional MRI (fMRI) and diffusion tensor imaging (DTI), have shown some potential for predicting outcomes (Jeter et al., 2013). However, per the recent Pediatric Guideline recommends, single-use photon emission CT (SPECT) should not be used in suspected acute mTBI because no evidence suggests any benefit over standard imaging (Lumba-Brown et al., 2018). A notable biomarker development is the use of the Brain Trauma Indicator, a measure of two serum proteins (GFAP and UCH-L1) released from the brain within 12 hours of injury (Papa et al., 2016). Due to its high consistency with CT findings in detecting lesions, this technology may be useful in the future in eliminating the need for neuroimaging (Brooks, 2018). In addition to a multitude of serum biomarkers, microRNA changes detected in saliva correlate with corresponding changes in cerebrospinal fluid (Hicks et al., 2018). The CDC maintains that many of these new technologies are not yet ready for standardized clinical use but may be adjuncts in certain cases (Register-Mihalik, Sarmiento, Vander-Vegt, & Guskiewicz, 2019).