CDC Concussion Management Tool
Medicine for the Outdoors
Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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CDC Concussion Management Tool

The Centers for Disease Control (CDC) has a tool kit posted on the Internet designed to assist clinicians with recognition and management of persons suffering from concussion. Given the number of minor and major head injuries that occur each year in outdoor settings, this is a very important topic. The tool kit is useful and well-prepared information.

Entitled "Heads Up: Brain Injury in Your Practice," the information and tools include a booklet with information on diagnosis and management of mild traumatic brain injuries, an Acute Concussion Evaluation patient assessment tool, a care plan to help guide a patient's recovery, fact sheets in English and Spanish on preventing concussion, a palm card for on-field management of sports-related concussion, and more.

I'm beginning to work on a revision of my book Medicine for the Outdoors, and will include the following information, and more, on head injuries:

One method to categorize victims of head injury is to consider them to be divided into two groups, according to whether or not they have lost consciousness. If a victim has not lost consciousness, this implies a lesser injury, but like everything in medicine, is not infallible. If someone has lost consciousness, even for a few seconds, the red flag is up for a potentially serious injury. Always be aware that the dazed or unconscious victim cannot protect his airway; you must be vigilant in your observation. The most common dangerous complication of head injury is obstruction of the airway with the tongue, blood, or vomitus. The most common associated serious injury is a broken neck.

Loss of Consciousness

If a person struck in the head has lost consciousness, he has suffered at least a concussion. The following signs and symptoms are commonly associated with a concussion: unaware of what happened; confusion; loss of memory; loss of consciousness; headache or sensation of pressure in the head; dizziness; balance problems; nausea; vomiting; feeling “foggy,” “dazed,” or “stunned;” visual problems (e.g., seeing stars or flashing lights, or seeing double); hearing problems (e.g., ringing in the ears); irritability or emotional changes; slowness or fatigue; inability to follow directions or slow to answer questions; easily distracted or poor concentration; inappropriate emotioinal behavior; glassy-eyed or vacant starting; slurred speech; seizure.

1. Protect the airway and cervical spine.

2. If the victim wakes up after no more than a minute or two and quickly regains his normal mental status and physical abilities, he has probably suffered a minor injury—so long as there is no relapse into unconsciousness or persistent lethargy, nausea or vomiting, or severe headache. If the victim is far from help, he should undertake no vigorous activity and be kept under close observation for at least 24 hours. Normal sleep should be interrupted every 2 to 3 hours to briefly ensure that his condition has not deteriorated. Confusion or amnesia for the event that caused the blackout is not uncommon and not necessarily serious, so long as the confusion does not persist for more than 30 minutes. Because a serious brain injury may not become apparent for hours, the wilderness traveler who has been "knocked out" should not venture farther from civilization for 24 hours. If headache and/or nausea persist beyond 2 to 3 hours, or if the victim seems in any way altered with respect to mental status, the victim should begin to make his way (assisted by rescuers) to medical care.

If the injury is minor and evacuation is not undertaken, advance the victim’s activity as follows: no activity and complete rest until without symptoms; next, light walking without any heavy lifting or resistance activity; next, mild exercise with slight resistance; finally, full activity. Do not progress beyond one “level” each 24 hour period.

3. If the victim wakes up and is at first completely normal, only to become drowsy or disoriented, or lapses back into unconsciousness (typically, after 30 to 60 minutes of normal behavior), he should be evacuated and rushed to a hospital. This may indicate bleeding from an artery inside the skull, causing an expanding blood clot (epidural hematoma) that compresses the brain. Frequently, the unconscious victim with an epidural hematoma will be noted to have one pupil significantly larger than the other.

4. If the victim awakens but has a severe headache, bleeding from the ears or nose with no obvious external injury to those organs, clear fluid draining from the ear or nose, unequal-sized or poorly reactive (do not constrict promptly upon exposure to bright light) pupils, weakness, bruising behind the ears or under the eyes, vomiting, or persistent drowsiness, he might have a skull fracture. Such signs mandate immediate evacuation to a medical facility.

5. If the victim suffers a seizure after a head injury, no matter how brief, he should be transported to a medical facility.

6. If the victim does not wake up promptly after a head injury (unconscious for more than 10 minutes), has bleeding from an ear, has unequal or nonreactive (do not constrict to bright light) pupils, has clear fluid from the nose, has a profound headache, is weak in an arm or leg, is disoriented, or has a fluctuating level of consciousness (normal one minute, drowsy the next), he may have suffered a significant brain injury and should be immediately rushed to a medical facility. Because there is a high incidence of associated neck injuries, any person with a serious head injury should have his cervical spine immobilized. Head injuries often cause vomiting. Therefore, be prepared to turn the victim on his side so that he doesn’t choke.

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.