BC Guidelines

The Concussion / Mild Traumatic Brain Injury (mTBI) guideline provides recommendations for the primary care assessment, diagnosis, and management of concussion/mild traumatic brain injury (mTBI) for patients of all ages. This guideline is not appropriate for use with moderate or severe brain injuries.

Key Recommendations

Assessment and Diagnosis

• Assess all individuals suspected of concussion as soon as possible, ideally within 72 hours, and before potential re-exposure to head trauma.
• Triage patients with red flags for emergency department evaluation.
• Screen patients to identify those at risk of persisting symptoms.
• Routine neuroimaging is not recommended unless specific red flags are present.
• Evaluate patients for other relevant conditions (e.g., mental health or mood disorders, attention-deficit/hyperactivity disorder (ADHD), chronic headache, substance use). Manage these while also treating for concussion.

Management

• Counsel all patients to observe relative rest for 24-48 hours.
• Reassure patients of likelihood of good prognosis but highlight importance of early recognition and management of persisting symptoms.
• Advise patients that they can gradually return to activities even in the presence of mild symptoms. This should be at a pace with no more than mild and brief symptom exacerbation.
• Advise patients to avoid activities that risk reoccurrence of head trauma until medically cleared.
• Prescribe aerobic exercise interventions to decrease concussion-related symptoms and reduce the risk of persistent symptoms. Begin with 55% max heart rate then progress to 70%.
• Focus early management strategies on 1) headache, 2) sleep, and 3) mood.
• Conduct a follow-up assessment, ideally within two weeks of diagnosis.
• Refer patients at risk of or experiencing persisting symptoms to interdisciplinary care.
• Provide patient education in verbal and written formats.
• Where possible, co-manage patients

Special Considerations

• Consider interpersonal violence and child abuse/neglect with trauma-related presentations. Report and refer as required.
• Consider specialist involvement to assess/manage patients with neurological conditions or injuries (e.g., Parkinson’s disease, multiple sclerosis, spinal cord injury).
• Maintain a high index of suspicion for mental health sequelae, screen and manage appropriately.

• Please access the draft guideline HERE and submit your feedback via the online questionnaire HERE by November 8, 2024.
• Additional comments/questions can be directed to HLTHguidelines@gov.bc.ca.

Extended Learning Document: Primary Care Approaches to Addressing the Impacts of Trauma and Adverse Childhood Experiences (ACEs)

All individuals experience trauma throughout their lives. These traumatic experiences may be previous events, or they may be current. The health care community’s understanding of trauma’s impacts on our health continues to evolve, particularly in the context of the In Plain Sight Report  highlighting the experiences of Indigenous peoples in Canada, the ongoing toxic drug crisis, and mass traumatic events, such as natural disasters, warfare and genocide. Primary care providers are encouraged to learn how trauma affects an individual's and community’s health, as well as their utilization of the health care services, and health care experiences.

This extended learning document seeks to introduce primary care providers to the concept of trauma-informed practice (TIP). It provides information about tools including, but not limited to, the Adverse Childhood Experiences (ACEs) questionnaire. This document also provides additional resources for ongoing learning and professional/ personal development. 

This is not a clinical practice guideline as research in this area is still evolving, especially the evidence for the use of the ACEs questionnaire in clinical practice. The focus of the document is on adults. While some resources are referenced for the pediatric population, history taking and management of adverse childhood experiences in children and adolescents are outside the scope of this guideline.

Key Learnings

• Build a strong, ongoing, consistent, and trusting relationship with patients. This is important to successfully address difficult topics in a culturally safe way and to support an individual’s ability to make positive changes over time. This enables primary care practitioners providing longitudinal care to better support their patients to improve their well-being, address past experiences, and give hope. While an ongoing relationship is important, there will be episodic encounters where practicing in a trauma-informed way will be imperative, to ensure patients return to seek care (e.g., walk-in or emergency department setting).

• Recognize and respect the prevalence of historical, intergenerational and current trauma, as well as the many ways that trauma can be experienced. See Indian Hospitals in Canada to learn more.

• Be sensitive to trauma-informed principles in patient interactions.

• Practice a reflective, continuous commitment to ongoing education, which is an important aspect of trauma-informed practice (TIP).

• Practice trauma-informed care, including considerations for staff and clinicians who have experienced trauma in their own lives. This trauma may come from personal experiences, or it could be secondary trauma experienced during exposure to another individual's traumatic experiences.

• It is important that healthcare providers build an informal system of peer support that they can draw on or contribute to. Skills, such as “The Four Cs,” can support care providers’ well-being while delivering TIP. The Physician Health Program (PHP) offers a confidential 24-hour intake and crisis support line (1-800-663-6729).

• It is not enough to have cultural awareness and cultural sensitivity to improve access and quality of health care services.  It is imperative that all these concepts are applied in practice as practitioners continue their cultural safety and humility journey and learning.

Minor revisions to the Direct Oral Anticoagulants (DOACs) (2023) guideline to reflect new PharmaCare coverage for Apixaban and FRAIL-AF randomized control trial results.

Venous Thromboembolism – Diagnosis and Management (2024) provides recommendations for the diagnosis and management of venous thromboembolism (VTE) in adults aged ≥ 19 years with hemodynamic stability. It includes lower limb deep vein thrombosis (DVT) and pulmonary embolism (PE) diagnosis in the outpatient setting and management of acute VTE.

Superficial thrombophlebitis and thrombosis in unusual sites (e.g., cerebral venous thrombosis, splanchnic vein thrombosis, upper extremity thrombosis) are outside the scope of this guideline. For information refer to the Thrombosis Canada Guidelines.

Key Recommendations include:

When DVT/PE is suspected, first calculate the Wells Score to determine the likelihood of DVT/PE as “likely” or “unlikely” before ordering any testing.

• For outpatients with suspected DVT/PE:

  • Do not order D-dimer if DVT/PE is deemed “likely” per Wells Score. Proceed directly to imaging.

  • Order D-dimer when deemed ‘unlikely’ per Wells Score because a negative test indicates imaging is not necessary and DVT/PE is excluded.

• For inpatients, proceed directly to imaging because risk stratification using D-dimer has not been validated.

• While awaiting objective imaging to diagnose VTE, start empiric anticoagulant therapy in Patients with higher likelihood (“likely”) of DVT/PE.

• Most patients with hemodynamically stable VTE can be treated on an outpatient basis.

• Direct Oral Anticoagulants (DOACs) are considered as first line therapies for most outpatients. They are contraindicated in pregnancy, breastfeeding, liver failure (Child-Pugh class C), dialysis, or triple-positive antiphospholipid syndrome (i.e., has lupus anticoagulant, anticardiolipin and antibeta-2-glycoprotein-1 antibodies).

• Ensure appropriate anticoagulant dosage is used for the specific treatment phase (initial therapy, primary treatment, secondary prevention).

• Minimum duration of anticoagulation is 3-6 months for all patients with an acute DVT/PE.

• Referral to a thrombosis specialist is recommended to help determine optimal duration of anticoagulation. Continue anticoagulation therapy while awaiting referral.

• Avoid elective surgeries during the first 3-6 months of treatment.

• Hereditary thrombophilia testing and occult cancer screening are not indicated in most patients with thrombosis because results rarely influence management.

Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management in Primary Care (2024) provides recommendations for adults with chronic obstructive pulmonary disease (COPD) in primary care.

Key Recommendations include:

Diagnosis

• Confirm all presumptive, symptom-based diagnoses of COPD one time with spirometry postbronchodilator ratio of FEV1/FVC < 0.7.
• Understand asthma and COPD are distinct diagnoses and may exist in the same patient. [NEW, 2024]
• CT is not needed to diagnose COPD but may be useful for screening lung cancer. [NEW, 2024]

Management

• Encourage all patients who smoke to quit or decrease use as treatment for COPD.
• Manage COPD early in order to slow disease progression. [NEW, 2024]
• Investigate and manage possible comorbidities to optimize outcomes.
• Refer patients, especially those with moderate to severe COPD, to a respiratory therapist for education and/or pulmonary rehabilitation.
• Provide appropriate immunizations to reduce the risk of exacerbation and mortality. [NEW, 2024]
• Consider checking baseline blood eosinophil count prior to commencing inhaled corticosteroid (ICS). [NEW, 2024]

Environmental Impact and Climate Change

• Consider medication options with lower environmental impact. Metered-dose inhalers (MDIs) contribute disproportionately to climate change, which in turn can affect COPD. [NEW, 2024]
• Prepare for climate events such as wildfire and extreme heat, which can exacerbate COPD symptoms. [NEW, 2024]

Education

• Prescribe appropriate controller and rescue medications along with a COPD action plan.
• Evaluate the patient's inhaler adherence and technique regularly.