a Red Flags : 1. Progressively declining level of conscious 2. Progressive declining neurological exam 3. Pupillary asymmetry 4. Seizures 5. Repeated vomiting 6. Clinician Verified GCS < 15 7. LOC Greater than 5 minutes 8. Double vision 9. Worsening headache 10. Neurological Deficit: Motor or Sensory 11. Cannot recognize people or disoriented to 12. Neurological Ataxia c Primary Care Management: 1. Give educational sheet to all mTBI patient 2. Headache management - use Acetominophen 3. Avoid tramadol, narcotics, NSAID’s, ASA, o other platelet inhibitors until cleared f 4. Consider Neurology referral or evacuate to higher level if clinically indicated 5. Screen for anxiety and depression 6. Document concussion diagnosis in EMR d Primary Care Management of Concussion (mTBI) in a Deployed Setting e Exertional Testing Protocol 1. 65-85% Target Heart Rate (THR = 220-age) -using push-up, step aerobic, treadmill, h 2. Assess for symptoms (headache, vertigo, photophobia, balance, dizziness, nausea, tinn visual changes, response to bright light or l Are Amber Flags b Present? Primary Care Management (Level 1 or above) 1. Manage and document symptoms c 2. Profile – 3 days light duty and REST 3. Repeat Concussion Examination in 1-3 days No No Concussion Examination (Level 1 or above) 1. Evaluate for Red Flags a 2. Perform Neuro Exam, evaluate for Amber Flags b Yes Positive symptoms with exertional testing? Yes No Urgent referral to Level 3. Obtain CT Scan. TRAUMATIC EVENT OCCURS ~Concussion Suspected~ 1. Administer MACE HISTORY only —Questions I-VIII (page 1). 2. Confirm concussion (Assessed by medic or higher) must meet both criteria: a. Head Injury Event (blast, fall, motor vehicle accident, head impact). b. Alteration of Consciousness (dazed, confused, or loss of consciousness). 3. Ask unit if they’ve noticed any post concussive problems in the individual. Yes Perform Exertional Testing e Yes No Evaluate for other condition Complete MACE EXAMINATION (Questions IX-XIII) Is it more than 7 days post-injury? Yes No d ICD-9 Codes 850.0 concussion w/o LOC 850.11 Concussion w/ LOC < 30 min 850.12 Concussion w/ LOC 31-59 min E979.2 Injury from terrorist explosion blast Are Red Flags a present? EVAC to designated Level 3 for specialty evaluation and rest away from unit EVAC to Level 4 Yes Is it more than 14 days post-injury? No Meets criteria for concussion? b Amber Flags (Persisting beyond initial traumatic event): 1. Confusion 2. Slurred speech 3. Unusual behavior 4. Unsteady on feet 5. Weakness 7. Vertigo/Dizziness 8. Headache f Psychology Consult 1. If a psychologist or other provider can conduct neurocognitive testing at the current location, refer the patient for testing. 2. If no neurocognitive test available at current location, contact the nearest psychologist to discuss the best option. Subsequently, the psychologist in conjunction with the provider and patient’s Command will weigh the costs and benefits of transporting the patient for further testing versus further rest in place. Version:30APR 08 Document in Electronic Medical Record Guideline Only/Not a substitute for clinical judgment MACE = 24 or less (impaired)? Yes Rest for 24-48 hours. Repeat MACE Examination (Use alternate MACE Form). No Provide Education. May Return to Duty. Follow up as necessary. Consult with a Psychologist or other behavioral health provider for disposition. f No Yes MACE = 24 or less (impaired)?

A Red Flags: 1. Progressively declining level of consciousness 2. Progressive declining neurological exam 3. Pupillary asymmetry 4. Seizures 5. Repeated

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Page 1: A Red Flags: 1. Progressively declining level of consciousness 2. Progressive declining neurological exam 3. Pupillary asymmetry 4. Seizures 5. Repeated

a Red Flags:1. Progressively declining level of consciousness 2. Progressive declining neurological exam3. Pupillary asymmetry4. Seizures5. Repeated vomiting6. Clinician Verified GCS < 157. LOC Greater than 5 minutes 8. Double vision9. Worsening headache10. Neurological Deficit: Motor or Sensory11. Cannot recognize people or disoriented to place12. Neurological Ataxia

c Primary Care Management: 1. Give educational sheet to all mTBI patients2. Headache management - use Acetominophen3. Avoid tramadol, narcotics, NSAID’s, ASA, or other platelet inhibitors until cleared for RTD 4. Consider Neurology referral or evacuate to higher level if clinically indicated5. Screen for anxiety and depression 6. Document concussion diagnosis in EMR d

Primary Care Management of Concussion (mTBI) in a Deployed Setting

e Exertional Testing Protocol 1. 65-85% Target Heart Rate (THR = 220-age) -using push-up, step aerobic, treadmill, hand crank2. Assess for symptoms (headache, vertigo, photophobia, balance, dizziness, nausea, tinnitus, visual changes, response to bright light or loud noise)

Are Amber Flags b Present?

Primary Care Management (Level 1 or above)1. Manage and document symptoms c

2. Profile – 3 days light duty and REST3. Repeat Concussion Examination in 1-3 days

Concussion Examination (Level 1 or above)1. Evaluate for Red Flags a

2. Perform Neuro Exam, evaluate for Amber Flags b

Yes

Positive symptoms with

exertional testing?

Yes

Urgent referral to Level 3. Obtain CT Scan.

TRAUMATIC EVENT OCCURS ~Concussion Suspected~1. Administer MACE HISTORY only—Questions I-VIII (page 1).2. Confirm concussion (Assessed by medic or higher) must meet both criteria: a. Head Injury Event (blast, fall, motor vehicle accident, head impact). b. Alteration of Consciousness (dazed, confused, or loss of consciousness).3. Ask unit if they’ve noticed any post concussive problems in the individual.

Yes

Perform Exertional Testing e

Yes

No Evaluate for other condition

Complete MACE EXAMINATION (Questions IX-XIII)

Is it more than 7 dayspost-injury? Yes

Nod ICD-9 Codes850.0 concussion w/o LOC850.11 Concussion w/ LOC < 30 min850.12 Concussion w/ LOC 31-59 minE979.2 Injury from terrorist explosion blast

Are Red Flags a

present?

EVAC to designated Level 3 for specialty evaluation and rest away from unit

EVAC to Level 4

Yes

Is it more than 14 dayspost-injury?

Meets criteria for concussion?

b Amber Flags (Persisting beyond initial traumatic event):1. Confusion2. Slurred speech3. Unusual behavior4. Unsteady on feet5. Weakness7. Vertigo/Dizziness8. Headache

f Psychology Consult 1. If a psychologist or other provider can conduct neurocognitive testing at the current location, refer the patient for testing. 2. If no neurocognitive test available at current location, contact the nearest psychologist to discuss the best option. Subsequently, the psychologist in conjunction with the provider and patient’s Command will weigh the costs and benefits of transporting the patient for further testing versus further rest in place.

Version:30APR08

Document in Electronic Medical Record

Guideline Only/Not a substitute for clinical judgment

MACE = 24 or less (impaired)?

Yes

Rest for 24-48 hours.Repeat MACE Examination(Use alternate MACE Form).

No Provide Education.May Return to Duty.Follow up as necessary.

Consult with a Psychologist or other behavioral health provider for disposition.f

YesMACE = 24 or less (impaired)?