Closed Head Injuries

Question 1

Red Flags for Concussions

Answer 1

• -neck pain
• -double vision
• -Weakness/tingling/numbness in legs
• -Severe or increasing HA
• -Seizure
• -LOC
• -Deteriorating conscious state
• -Vomiting
• -Increasingly restless/agitated

Question 2

Concussion: Definition, Return to Play, complications, S/sxs, & Dx

Answer 2

• Definition: mild traumatic brain injury leading to alteration in mental status +/- LOC
• Return to Play:
  
  • law requires student athletes with possible concussion to be removed from play & receive a written note from a provider before return. Increase risk of concussion if full recovery from previous concussion was not completed. No sooner than 7 days after concussion diagnosis.
• Complications:
  
  • in the days following a concussion the brain cells are vulnerable & the brain doesn’t function normally temporarily
• S/sxs:
  
  • *Some may appear immediately, some may take time to develop/appear later
  • -HA, disorientation, slow or slurred speech, poor balance/coordination
  • -Poor concentration
  • -Photophobia/phonia
  • -Drowsiness, change in sleep pattern
  • -Fatigue
  • -Sadness or nervousness
• Dx:
  
  • *No definitive diagnostic test
  • -MRI/CT: no visible damage
  • Assessment Tools:
    
    • SCAT-2 or SCAT-5
  • Key History:
    
    • seen by provider within 72 H, date of injury, mechanism of injury, LOC, location of impact, retrograde or anterograde amnesia, immediate or delayed onset of sxs
• Most concussions resolve within 3-4 weeks. Return to normal is a stepwise process

Question 3

Concussion: Tx

Answer 3

• First Response:
  
  • Remove from any activity, monitor s/sxs, do not give meds, evaluation by provider, no return to play until cleared
• First 24-48 hours:
  
  • rest, avoid strenuous strenuous activity, do not drive x 24H, no EtOH, acetaminophen = okay (no ASA or NSAIDs), no sports
• Return to Learn:
  
  • 1. Daily activities at home
  • 2. Homework/reading
  • 3. Part-time school
  • 4. Full-time school
  • *Parachute’s Protocol: move forward to next stage only when sx free for 24H, if sxs reappear they should go back to previous stage, contact provider immediately if sxs worse
• Return to Play:
  
  • 1. Daily activities
  • 2. Light aerobic activity
  • 3. Sport-specific activity
  • 4. Non-contact training drill
  • 5. Full contact practice
  • 6. Return to sport
  • *Each step takes a minimum of one day

Question 4

Post-Concussion Syndrome

Answer 4

• Definition:
  
  • concussion sxs lasting beyond the expected recovery period after initial injury
• Etiology:
  
  • unknown; structural damage, psychological factors
• **Usually goes away within a few days/weeks. However, persistent sxs may last for months-years
• S/sxs:
  
  • -Mood swings, irritability
  • -Anxiety, depression
  • -Foggy thinking
  • -Memory Issues
  • -Difficulty with attention
  • -Dizziness, nausea
• PE:
  
  • Tinnitus
  • -Balance problems
  • -difficulty making decisions
  • -changes in sleeping patterns
  • -Mild headaches
  • -Photophobia/phonia
• Dx:
  
  • clinical dx
• Tx:
  
  • Headache: sleep/rest, take a break from activities requiring concentration, pain relievers (APAP)
  • Memory Issues: write things in notebook, have family/friends remind you of important things

Question 5

Traumatic Brain Injury: definition, etiology, severity, primary vs secondary injury

Answer 5

• Definition:
  
  • sequelae from an external force injuring the brain (head trauma)
• Etiologies:
  
  • Falls (35%) → #1 cause for children too; MVA (17%) → highest deaths; struck by object (16%), assaults (10%), other
• Severity:
  
  • -Mild (80%): GCS 13-15, need repeat eval
  • -Moderate (10%): GCS 9-12, need admission
  • -Severe (10%): GCS 3-8
• Primary vs Secondary Injury:
  
  • Primary: occurs at the time of the impact & results in altered LOC
  • Secondary: physiologic responses to the initial injury; hypoxia, ischemia, hypotension, hematoma expansion, cerebral edema, brain compression, intracranial HTN, seizure, fever
• Sports-Related Injury: Collision Sports, F:M 2:1 (may be d/t cultural differences)

Question 6

Traumatic Brain Injury Pathology: Types of things that occur in/to the brain/skull

Answer 6

• Subdural Hematoma:
  
  • (typically involve a vein) crescent-shaped mass, venous bleed – slow, crosses suture line
• Epidural Hematoma:
  
  • (typically involve an artery) lentiform (looks like a lense), arterial bleed – fast, does not cross suture lines, ipsilateral dilated pupil; lucid interval after period of unconsciousness, surgery. “Talk and die kids” → need to get them in the OR within an hour of onset of symptoms!!
• Hemorrhagic Cerebral Contusion:
  
  • salt & pepper appearance
• Open Skull Fracture:
  
  • intracranial air
• Brain Herniation:
  
  • non-reactive pupil, extensor posturing, progressive decline in neuro exam, Cushing’s response (HTN, bradycardia, irregular respiration)

Question 7

Glasgow Coma Scale

Answer 7

Eyes opening (4); 4. spontaneously, 3. to speech, 2. to pain, 1. none

• Best Verbal (5): 5. oriented, 4. confused, 3. inappropriate word, 2. incomprehensive sounds, 1. none
• Best Motor (6): 6. follows commands, 5. localizes pain stimulus, 4. withdraws from pain, 3. flexion to pain, 2. extension to pain, 1. none → MOST IMPORTANT SCORE
• Mild (80%): GCS 13-15, need repeat eval
• Moderate (10%): GCS 9-12, need admission
• Severe (10%): GCS 3-8

Question 8

Traumatic Brain Injury: Dx & Tx

Answer 8

• Dx:
  
  • Evaluate damage & severity: x-rays, CT, MRI
  • -CT guidelines: LOC, severe HA, vomiting, age >65yo, drug/EtOH intoxication, GCS < 14, signs of basilar skull fracture, neuro deficits, amnesia, seizure, dangerous mechanism (ie significant MVA),, coagulopathy
• Tx:
  
  • ABCs: Airway, Breathing, Circulation, Disability, Exposure/Environment
  • **No drugs protect the delicate tissue of the brain
  • Limit secondary damage: maintain oxygen supply to the brain, prevent seizures (give Keppra [levetiracetam], prevent fever (meds if > 39C), reducing swelling/inflammation/pressure
  • Surgery:
    
    • if needed to remove blood clots or reduce pressure, need to remove entire skin flap
  • Epidural hematoma:
    
    • operate within an hour of ipsilateral dilated pupil or > 30cm3, >15mm thick, or > 5 mm midline shift
  • Transient hyperventilation:
    
    • decreases ICP by causing vasoconstriction in the brain → more room to swell
  • Hyperosmolar therapy:
    
    • mannitol or hypertonic saline, fluid shift from intracellular to extracellular → low ICP
  • **Steroid are contraindicated

Question 9

Traumatic Brain Injury: Dx & Tx

Answer 9

• Dx:
  
  • Evaluate damage & severity: x-rays, CT, MRI
  • -CT guidelines: LOC, severe HA, vomiting, age >65yo, drug/EtOH intoxication, GCS < 14, signs of basilar skull fracture, neuro deficits, amnesia, seizure, dangerous mechanism (ie significant MVA),, coagulopathy
• Tx:
  
  • ABCs: Airway, Breathing, Circulation, Disability, Exposure/Environment
  • **No drugs protect the delicate tissue of the brain
  • Limit secondary damage: maintain oxygen supply to the brain, prevent seizures (give Keppra [levetiracetam], prevent fever (meds if > 39C), reducing swelling/inflammation/pressure
  • Surgery:
    
    • if needed to remove blood clots or reduce pressure, need to remove entire skin flap
  • Epidural hematoma:
    
    • operate within an hour of ipsilateral dilated pupil or > 30cm3, >15mm thick, or > 5 mm midline shift
  • Transient hyperventilation:
    
    • decreases ICP by causing vasoconstriction due to decreased serum CO2 levels in the brain → more room to swell
  • Hyperosmolar therapy:
    
    • mannitol or hypertonic saline, fluid shift from intracellular to extracellular → low ICP
  • **Steroid are contraindicated

Question 10

When to consult Neurosurgery for a TBI

Answer 10

• moderate-severe TBI
• mild TBI with extracranial injuries
• skull fracture
• CSF leak,
• lateralizing signs on neurologic exam
• C-spine injury
• cerebrovascular injury

Question 11

Seizure Prophylaxis for a TBI

Answer 11

• Start within 24 hours of injury & continue x 7 days
• -Phenytoin, Levetiracetam (Keppra)