Concussion & Mild TBI

The CT scan comes back normal, but the patient is still confused and vomiting. A concussion doesn't show on imaging — so how do you catch what's going wrong?

A concussion is a functional brain injury caused by rotational or acceleration-deceleration forces. Glasgow Coma Scale (GCS) is 13–15, and standard CT is typically normal because the damage is metabolic, not structural. Loss of consciousness is NOT required for diagnosis — brief confusion, amnesia around the event, or feeling 'foggy' qualifies. The hallmark concern is post-concussive deterioration: worsening headache, repeated vomiting, increasing confusion, unequal pupils, or declining GCS. These red flags suggest evolving intracranial pathology and require urgent re-imaging. For uncomplicated concussion, nursing management centers on serial neurological assessments (neuro checks every 1–2 hours initially), maintaining a low-stimulation environment (dim lights, limit screens, reduce noise), and educating the patient and family about return precautions. Physical and cognitive rest is the cornerstone of recovery — no return to sports or strenuous activity until symptom-free for at least 24 hours at each step of a graded stepwise return-to-activity protocol. Acetaminophen is preferred for headache; NSAIDs and aspirin are avoided initially due to bleeding risk. Discharge teaching must include explicit warning signs that require immediate return: worsening headache, seizures, slurred speech, weakness on one side, repeated vomiting, or inability to be awakened.

Key Distinctions

Don't confuse concussion (normal CT, GCS 13–15, metabolic dysfunction) with epidural or subdural hematoma (structural bleeding visible on CT with progressive neurological decline). Students often think loss of consciousness is required — it is not. A brief period of confusion or amnesia alone qualifies. Post-concussive syndrome (symptoms lasting weeks to months) is distinct from acute deterioration, which signals a new or worsening bleed requiring emergent intervention.

Clinical Pearl

Normal CT does not mean normal brain. Serial neuro checks are your imaging — a declining GCS after concussion means something structural is brewing until proven otherwise.