Mild TBI (mTBI)

  • Head injury due to contact and/or acceleration/deceleration forces
    • Mild : GCS 13 to 15, measured at approximately 30 minutes after the injury


  • The immediate and transient symptoms of mTBI, not explained by drug/alcohol/medication or other injuries (C-spine, peripheral vestibular dysfunction, psychological medical conditions)
    • Somatic (headache)
    • Physical signs (loss of consciousness, amnesia, neurological deficit)
    • Balance impairment (gait unsteadiness)
    • Behavioral changes (irritability, emotional lability)
    • Cognitive impairment (slowed reaction times, feeling ‘in a fog’, difficulty concentrating)
    • Sleep/wake disturbance (somnolence, drowsiness)
  • Initial assessment and follow-up progression of symptoms with SCAT 5 or Child SCAT 5


  • Consider imaging any patient with neuro deficit, seizure, or bleed risk (anticoagulated)

CT Head Rules in >16yo, Head CT not required if NONE of the following are present

  • Excludes: Age<16,
    • High risk (neurosurgical intervention)
      • GCS <15 two hours after injury
      • Suspected open or depressed skull fracture
      • Any sign of basilar skull fracture: hemotympanum, raccoon eyes (intraorbital bruising), Battle's sign (retroauricular bruising), or CSF leak, oto/rhinorrhea
      • ≥ 2 episodes of vomiting
      • Age ≥ 65
    • Medium risk (normally require admission)
      • Retrograde amnesia (past memories) to the event ≥ 30 minutes
      • Dangerous mechanism (pedestrian struck by motor vehicle, ejected from motor vehicle, fall from ≥3 feet or ≥5 stairs)
  • Note may consider CT (New Orleans or Nexus II rule) as well in:
    • Anticoagulation
    • Seizure
    • Persistent anterograde amnesia (deficits in short-term memory)
    • Visible trauma above the clavicles
    • Drug or Alcohol Intoxication (may consider observing/deferring head CT)

PECARN, CATCH2, CHALICE for children, Head CT not required if NONE of the following are present

  • GCS 14 or altered mental status or palpable skull fracture or signs of basilar skull fracture
  • <2yo
    • Non-frontal (occipital/parietal/temporal) scalp hematoma
    • History of LOC ≥ 5 seconds
    • Severe mechanism (pedestrian or bicyclist without helmet struck by motor vehicle, fall ≥1m or ≥3 feet, head struck by high-impact object)
    • Not acting normally
  • >2yo
    • History of LOC
    • History of Vomiting (consider observation if no other indication = 0.2% risk of cTBI)
      • In CATCH2, ≥ 4 episodes of vomiting was added
    • Severe mechanism of injury (as above but fall ≥2m or ≥5 feet,
    • Severe headache


  • Treat cervical/vestibular symptoms
  • Consider 1-2 days of complete rest (cognitive/physical rest) - may require temporary absence from school
    • >14 days of non-contact, non-risk gradual progressive sub-symptom threshold activity
        • Prolonged rest can prolong symptoms
        • >24 hours for each step of the progression
          • If any symptoms worsen, the athlete should go back to the previous step
        • Repeated TBI can be life-threatening and lead to neuropsychological sequelae
  • Consider individualized aerobic exercise program for 20 minutes a day during the first week (may speed recovery)
    • Exercise bike or treadmill at target heart rate 80% of the point of symptom exacerbation

Post-injury assessment within 48h

  • Neurological
  • Cervical spine
  • Vestibular exam
  • Oculomotor exam

Risk for slower recovery

  • Severity of initial symptoms
  • History or development of migraine headaches
  • Depression or other mental health problems
  • Adolescence (girls>boys)

Persistent Post-Concussive Symptoms (PPCS)

  • >2w in adults
  • >4w in children/adolescents
  • Treatment
    • Referral to concussion expert (sports medicine specialist, physiatrist or neurologist)
    • Treat co-existing pathologies
    • Limited evidence for rest
    • Individualized sub-symptom threshold activity
    • Physiotherapy/vestibular rehabilitation

Patient Handout: INESSS