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נאורו של קליניק > Coma > Flashcards

Coma Flashcards

1
Q

COMA

practice pattern

A

Practice Pattern 5I: Impaired arousal associated with coma, near coma, or vegetative state

When working with them, assume that they know everything that is being said around them

They can undertand but couldn’t respond
Don’t talk about how sad the situation is

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2
Q

COMA

1) what is it
2) what must be activated to maintain consciousness
3) what regulates alertness and consciousness

A

1) The inability to respond purposely or become consciously aroused by external or internal stimuli (Upward facilitation to “arouse” the cerebral cortex )

2) The cerebral cortex must be activated to reach and maintain conscious arousal
(Could be high levels of alcohol, meds)

3) Alertness and consciousness are regulated by the RAS in the brainstem
- –Has to be bilateral involvement for coma to occur

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3
Q

The Reticular Activating System (RAS)

A

AROUSAL
network of cells in brainstem (with projections to thalamus, hypothalamus, and cortex)
[a set of connected nuclei in the brains responsible for regulating wakefulness and sleep-wake transitions.]

can be activated by various sensory inputs

A feedback mechanism between the RAS and the cerebral cortex maintains consciousness

Bilateral damage to the ascending RAS or brainstem will result in some level of coma

**awareness is mediated by the cerebral cortex

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4
Q

Define Coma (5)

A
  1. UNRESPONSIVE
  2. CANNOT OBEY COMMANDS
  3. CANNOT RESPOND VERBALLY
  4. CANNOT OPEN EYES AND VISUALLY TRACK
  5. LACK OF SLEEP-WAKE CYCLES
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5
Q

Associated Levels of Severe TBI

A

1) Minimally Conscious State (light coma) – may present with reflex, primitive or disorganized responses to stimuli
2) Deep Coma – no response to painful or any stimuli

• Less descriptive terms:
3) Lethargic – drowsiness, easily aroused with light stimuli

4) Stupor – arousal only with persistent or vigorous stimuli, and arousal is incomplete

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6
Q

Minimally Conscious State

A

(light coma) – may present with reflex, primitive or disorganized responses to stimuli

o May be inconsistent but there are true responses

o Communicate with family members and see if they get an responses

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7
Q

Deep Coma

A

no response to painful or any stimuli

ie nail bed pressure
Even a reflexive response is better than no response

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8
Q

Lethargic

A

drowsiness, easily aroused with light stimuli

can be awakened

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9
Q

Stupor

A

arousal only with persistent or vigorous stimuli, and arousal is incompete

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10
Q

Vegetative state: (3)

A
  1. State of arousal without behavioral evidence of awareness or ability to interact with external environment
    (responses but not associated with stimuli)
  2. Rudimentary and apparent sleep-wake cycles
  3. May have spontaneous eye opening, but NO real visual tracking or purposeful limb movements
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11
Q

Minimally Conscious State

what can they do (4)

A
  1. Minimal but some purposeful AWARENESS
  2. GESTURE or VERBAL responses, even if not correct
  3. VERBALIZATION of any words, even if not correct
    - -mumbling – better than no response, anything you can classify as a response
  4. MOVEMENT or BEHAVIORS that are environmentally TRIGGERED, NOT REFLEXIVE
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12
Q

Locked-In Syndrome

what it is
cause
what cant they do
what can they do

A

NOT COMA

1) Patient appears to be in a coma, but has all HIGHER CORTICAL FUNCTION INTACT

2) Extensive LESIONS in corticobulbar and corticospinal tracts,
but higher Central Nervous System function intact

3) Cannot speak, move or breathe

***Only response you may see is controlled blinking. Cranial nerve response. NOT COMA.

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13
Q

Coma

1) eye opening
2) spontaneous movement
3) response to pain
4) visual response
5) affective response
6) commands
7) verbalizations

A

1) NONE eye opening
2) NONE spontaneous movement
3) posturing/NONE response to pain
4) NONE visual response
5) NONE affective response
6) NONE commands
7) NONE verbalizations

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14
Q

Vegetative

1) eye opening
2) spontaneous movement
3) response to pain
4) visual response
5) affective response
6) commands
7) verbalizations

A

1) eye opening: SPONTANEOUS
2) spontaneous movement: REFLEXIVE
3) response to pain: posturing/WITHDRAWAL
4) visual response:
5) affective response: random
6) commands: none
7) verbalizations: random

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15
Q

Minimally conscious

1) eye opening
2) spontaneous movement
3) response to pain
4) visual response
5) affective response
6) commands
7) verbalizations

A

1) eye opening
2) spontaneous movement
3) response to pain
4) visual response
5) affective response
6) commands
7) verbalizations

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16
Q

Causes of Coma

A

1) Falls or direct trauma
o Children
o Stairs
o Falling backwards is more of a risk

2) Motor vehicle accident
3) Motorcycle and bicycle

4) Stroke
o Especially hemorrhagic

5) Carbon monoxide poisoning

6) Near drowning
o Winter is the best time to have a near drowning experience because of the decreased brain metabolism due to the cold

7) Toxicity – alcohol, meds

8) Blast injuries
o Veterans

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17
Q

Glasgow Coma Scale

A

Eye Opening (1-4)

Motor Response (1-6)

Verbal Response (1-5)

E + M + V =
best possible of 15 / worst possible of 3

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18
Q

Glasgow Coma Scale

Eye opening response

A

4: spontaneous
3: to speech/call
2: to pain
1: none

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19
Q

Glasgow Coma Scale

Motor response

A

6: obey command
5: localize pain
4: normal flexion withdrawel
3: abnormal flexion: DECORTICATE
2: extension: DECEREBRATE
1: None: FLACCID

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20
Q

Glasgow Coma Scale

Verbal Response

A

5: oriented
4: confused conversation
3: inappropriate words
2: incomprehensible sounds
1: none

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21
Q

Glasgow Coma Scale Scores

A

E + M + V =

best possible of 15 / worst possible of 3

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22
Q

DECORTICATE

A

decorticate posturing
abnormal flexion
motor response of 3

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23
Q

DECEREBRATE

A

decerebrate posturing
extension of all 4 limbs
motor response of 2 (worse than decorticate)

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24
Q

Significance of Score on Admission and Outcome

COMA

A

the higher the glasgow coma score, the better the outcome for the patient in terms of disability/vegetative state/death

o CHART Significant of Score on Admission and Outcome page 110

Cant predict if they will come out of it or when

Look at the highest score, total from all 3

As the numbers are going up, coming out of coma (essentially)

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25
Q

Pupillary Response to light

A

1) Optic pathways to optic tract, midbrain and parasympathetic fibers to CN III.

** Intact responses are positive signs for reversible coma

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26
Q

Oculocephalic

A

Oculocephalic – (doll’s head): eyes should move in opposite direction to rapid passive head rotation

for normal response:PONS and MIDBRAIN must be intact (and brainstem)

TESTING:
move the head, do eyes move in the opposite direction or stay in the middle of the orbit or
• Eyes should move in opposite direction to rapid passive head rotation
• Non healthy patient – eyes stay fixed in the center
• Pons and midbrain must be intact for normal response

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27
Q

Oculovestibular Response

  1. procedure
  2. results expected
  3. interpretation of results
A

COWS

1) Cooling air indirectly stimulates the reticular formation –>
2) slow, tonic conjugates deviation of the eyes toward the irrigated side

FOLLOWED BY RAPID NYSTAGMUS TO MIDLINE

cool the semicircular canals to get the perilymph to move to get a tonic deviation to the side–brainstem intact

3) Interpretation of Response:

  • Awake or light coma patient: rapid nystagmus away from stimulated ear (CNS intact)
  • Unconscious patient: no return nystagmus (pons, midbrain intact)
  • PONS, MIDBRAIN LESION: no response to testing = deep coma
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28
Q

Occulovestibular Testing

awake/light coma

unconscious

deep coma

A

Occulovestibular Testing

Interpretation of Response:

  • Awake or light coma patient: rapid nystagmus away from stimulated ear (CNS intact)
  • Unconscious patient: no return nystagmus (pons, midbrain intact)

o PONS, MIDBRAIN LESION: no response to testing = deep coma

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29
Q

Motor Testing

IN COMA

A

1) Assess quality of each response!
o Blink your eyes

o Look to the right and left

o Show me two fingers – one UE or bilateral?

o Wiggle your toes – one LE or bilateral?
• Check all 4’s to see if it s a hemi problem
• Dr’s are looking at the big picture, do tests to determine specific deficits

o IF no response, use noxious stimuli

CROSSING MIDLINE TO REMOVE A NOXIOUS STIMULI IS PURPOSEFUL AND BETTER COMPARED TO A WITHDRAWAL RESPONSE*

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30
Q

Sensory Testing

IN COMA

–when can it be performed

–what is it important to assess (3)

A

can only be performed if patient can respond to cues

important to assess the

  1. parietal lobe
  2. spinal cord,
  3. PNS function or injury
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31
Q

Factors Affecting Outcome in Coma (4)

A

1) SEVERITY OF INITIAL BRAIN INJURY–are structures intact to maintain life?
- —If they survive the first 24 hours, it means they did not have enough brain damage to kill them, medical management should be able to keep them alive

2) HYPOXEMIA – inadequate oxygen saturation
3) ARTERIAL HYPOTENSION

4) INTRACRANIAL PRESSURE (ICP) – would result in brain ischemia
—Tested with device put into the skull
(Working with someone with this in place – see if anything you do with them increases the pressure, if goes up – may be in response to them being handled and not the actual action)

5) Cellular responses secondary to injury
- –ie reduce swelling to prevent secondary breakdown

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32
Q

Ranchos Los Amigos Scale of Cognitive Functioning

A

10 levels of cognitive functioning used extensively to document status of patient and plan for medical/rehabilitative intervention

SCALE FOR REHAB LEVEL OF RECOVERY

33
Q

Ranchos Los Amigos Scale

1-10

A

LEVEL 4 CAN DO PHYSICAL THERAPY

  1. No response: lowest, no response to any stimuli
  2. Generalized Response: to stimuli, may be reflexive/delayed/gross body movements
  3. Localized Response: motor withdrawal, turning toward stimuli, vocalization
  4. Confused/agitated: purposeful or random movements, aggressive responses, very inconsistent behaviors
  5. Confused/innapropriate: NON-AGITATED: need MAX assist. Is alert. Agitated if overstimulated, not oriented to person/place/time. Impaired judgement, needs structural environment.
  6. Confused/appropriate: needs MOD assist. Inconsistently oriented; can attend to familiar tasks in controlled environment, IMPULSIVE
  7. Automatic, appropriate: MIN ASSIST with ADL. oriented in familiar environments, poor self-awareness
  8. purposeful, appropriate: need standby assist, low frustration, better self awareness, continued rehab needed with psych support
  9. purposeful, appropriate: needs stand by assist on request, self awareness greatly improved, socialization still difficult
    10: purposeful appropriate: modified independent: still need psych support, socialization more appropriate
34
Q

Ranchos Los Amigos Scale

1-3

A
  1. No response: lowest, no response to any stimuli
  2. Generalized Response: to stimuli, may be reflexive/delayed/gross body movements
  3. Localized Response: motor withdrawal, turning toward stimuli, vocalization
35
Q

Ranchos Los Amigos Scale

4-6

A
  1. Confused/agitated: purposeful or random movements, aggressive responses, very inconsistent behaviors
  2. Confused/innapropriate: NON-AGITATED: need MAX assist. Is alert. Agitated if overstimulated, not oriented to person/place/time. Impaired judgement, needs structural environment.
  3. Confused/appropriate: needs MOD assist. Inconsistently oriented; can attend to familiar tasks in controlled environment, IMPULSIVE
36
Q

Ranchos Los Amigos Scale

7

A
  1. Automatic, appropriate: MIN ASSIST with ADL. oriented in familiar environments, poor self-awareness
37
Q

Ranchos Los Amigos Scale

8-10

A
  1. purposeful, appropriate: need standby assist, low frustration, better self awareness, continued rehab needed with psych support
  2. purposeful, appropriate: needs stand by assist on request, self awareness greatly improved, socialization still difficult
    10: purposeful appropriate: modified independent: still need psych support, socialization more appropriate
38
Q

PT Related Assessment in Coma (7)

A
  1. Rule out fractures, especially to C spine
  2. Note spontaneous movements

—no matter what they are or how often you see it. document – if you don’t write it, it didn’t exist

  1. Response to external stimul
    i
    —everything you do until you leave the room, can be helpful or a hindernece
  2. Respiratory pattern

—Cheyne Stokes breathing – controlled by CO2 receptors in CNS: When there is imbalance, this pattern of breathing (shallow breath, each following breath a little bit deeper, comes down, a period of apnea, then goes back up again) Oxygen saturation

  1. ROM: prevent contracture and skin breakdown
  2. Tone
  3. Pathological Posturing

decorticate–>decerebrate–>falccid (worst)

39
Q

Decorticate Posturing

A

lesion of cotico-spinal tracts at the THALAMUS and INTERNAL CAPSULE

*FLEXION of UE’s and *EXTENSION of LE’s

40
Q

Decerebrate Posturing

A

lower pons and vestibular nucleus intact???

TONE influenced by tonic neck reflexes and vestibular reflexes

*EXTENSION OF ALL FOUR EXTREMITIES

41
Q

Motor Responses:

A to F

A
  • A = purposeful
  • B = withdrawal to noxious stimuli
  • C = decorticate
  • D = Decerebrate
  • E = partial decerebrate
  • F = flaccid
42
Q

COMA Treatment Approaches

6

A

1) ROM

2) Sensory Stimulation
A lot of stimulation is too much – will shut off from too much

3) Orientation
4) Prevent Contractures, deformity
5) Neck and trunk mobility

6) Educate the family!
• Recovery is slow–We do not know, let’s see how the brain heals
• Everyone expects recovery
• Look for members who are willing to participate
• Look at your performance/attitude through the eyes of the family
• Respect the patient
• Dealing with external conflicts of family – work caring for others, wanting to stay versus needing to be elsewhere..

43
Q

Coma Stimulation Program

A

—facilitate neuronal reorganization by providing meaningful stimuli
Used during first few weeks post injury (once medically stable)

—Tries to produce a patient response

—Decreases sensory deprivation

—In order to reverse an elevated threshold of activation of the RAS, controlled stimulation is used

o An appropriate amount of stimuli
o Ascending Reticular Activating System – goes to cerebral cortex to activate it and wake it up
• How we wake up in the morning – internal clock
• Problem in coma – threshold is elevated – need to get facilitation in there to lower the threshold

44
Q

Coma Stimulation Program

Precautions

A

Precautions:
1) Patient must be neurologically stable!
• Talk to neurologist about POC

2) ICP (Intracranial pressure) must be WNL’s, which is below 20 mmHg
• Monitor them if they are higher than 20 mmHg

45
Q

Coma Stimulation Program

Indications

A

Indications
1) Patient is in ranchos los amigos Scale levels 1, 2, or 3

If RLA scale 4 or higher, needs a structure oriented program

General rationale for a Stimulation Program
—–ASSUME THE PATIENT CAN HEAR AND PROCESS ALL SENSORY INPUT
THIS INCLUDES ALL SPOKEN WORDS

Involve the family members in this program

Document any and all patient reponses, especially unfavorable responses

If vital signs change, stop the activity!

46
Q

General rationale for a Stimulation Program

A

—–ASSUME THE PATIENT CAN HEAR AND PROCESS ALL SENSORY INPUT
THIS INCLUDES ALL SPOKEN WORDS

Involve the family members in this program

Document any and all patient reponses, especially unfavorable responses

If vital signs change, stop the activity!

47
Q

Types of Coma Stimulation

Noxious Stimuli

A

only as a LAST OPTION

vary duration each day

individually based upon family interview and patient responses

48
Q

Types of Coma Stimulation

Sensory stimuli seeking a favorable response (6)

A

1) TACTILE – skin lotions, soft/rough tectures, familiar objects
• Ones they like – ask family

2) KINESTHETIC – ROM, changing best positions, tilt table
• Putting themi in wc

3) GUSTATORY – brushing teeth, various flavors
• Mix flavors into ice – cold + flavor
• Find out what flavors they like

4) OLFACTORY – perfume, food smells

5) AUDITORY – music, speaking to patient, pets
• Family, friends voices

6) VISUAL – photographs, visitors, light (tracking)
• Pictures on ceiling
• Anything you know they like or will stimulate them
• Put it in their visual field

• Purpose is to get a response
o Good responses – purposeful movements
o Negative – medical responses
]

49
Q

POSITIONING

what position

what to use

indication

what needs to be ruled out before beginning ROM

A
  • The position of comfort leads to the position of deformity!
  • Position (with splints if necessary), in the opposite position at rest
  • Soft tissue changes become physiological shortening sooner if associated with localized injury
  • Rule out SCI and orthopaedic injuries before beginning ROM
50
Q

How can Positioning help pt post TBI

A

• Patients with TBI are potentially influenced by pathological reflexes due to loss of inhibitory control through higher CNS systems
o Not abnormal synergy (that is movement)
o Ex: tonic labyrinth
• If you put their head into neutral, does it help
• Put head in neck collar if they can’t keep it neutral

• It is important to identify the presence of involuntary reflexes that influence posturing of the trunk, head, and extremities

51
Q

Benefit of positioning with orthotics and other positioning devices

A

Positioning with orthotics and other positioning devices can help prevent the onset of contractutres and skin breakdown

52
Q

How does intervention of positioning etc change once loss of ROM begins to occur

A

Once loss of ROM begins to occur, interventions focuses on preventing further deterioration, rather than preventing deformity

• Positioning for High extension Tone :
o In supine but then in abudction – block in between legs: against adduction and IR

o Same thing in sitting

53
Q

Knee Splint

A

to extend the knee
• For increased flexor tone in LE

  • Add Multi Podus Boot or other AFO (hold foot and ankle in neutral, heel off bed)
  • Can use a small one on someone’s arm to hold it extended for a period of time
54
Q

Multi Podus Boot

A

o Heel protection + extension tone control – multi podus

55
Q

LE positioning techniques

supine to counter flexion tone

A

What are the potential sequelae of poor positioning? contracture

o Flexion/adduction synergy – pelvis is retracted

  • Pillow to elevate affected pelvis and reduce ER but align leg in neutral (not IR)
  • Assess flexor withdrawal reflex as a cause
  • Progressive stimulation/weight bearing on plantar surface of foot
56
Q

LE positioning techniques

Countering extension tone

A
  • Evaluate position of head/neck and influence of pathological reflexes – Bobath, try to get them towards neutral
  • As above, plus slight abduction, add small pillow under knee–get out of extension tone to prevent extension tone overall
  • Abduction wedge (abduct and ER) for high extension tone
  • Flex hip, knee and/or ankle to break up extension tone

• AFO for preventing PF while protecting the heel
—–Multi-podus boot is best

57
Q

Positioning Sidelying

UE

LE

Head and trunk

A

1) UE: Scapula protracted, elbow straight, supination
(like stroke intervention)
dont let scapula retract

2) LE: Pelvis protracted, neutral hip, slight knee flexion, pillow between knees
3) Head and trunk – neutral alignment

58
Q

Dyasplint

A

for TBI with contractures: reverse it, even if it is a chronic contracture, to remodel tissue and restore range
–change it each day (not worn all the time)

reverse contractures, getting into remodeling of connective tissue to help restore range

59
Q

Elbow and Hand Positioning Orthotics

A
  1. Allows fixation of amximum angle of stretch and progressive increase in ROM

BAD:
1) Hand cone – indication vs. contraindications
• Triggers more grasp and flexion tone (not good)

GOOD
1) Functional hand splint: Holds webspace open

2) Anti spasticity ball splint
• To maintain stability in the arch
• Has troughs for each finger to maintain finger spread

60
Q

• Slide with PICTURE – page 117

o What would you do for this patient?

A
  • Head and neck – he is laterally flexed and rotated – put him in neutral
  • Philadelphia collar – would help but so much tone that he could break down in the jaw and skin from keeping this on
  • Move his head manually to let tone melt down then could do splinting of his arms and leg
  • Arm – he is adducted and IR
  • His L leg – he’s doing an involuntary SLR, quads and adductors of firing
  • He had release of gastroc done because of a bad PF contracture
  • Hip and knee – abduction pillow wedge (see what it does for his knee)
  • Multipodus boot to position foot into neutral (before gastroc surgery)
  • Hand orthotics
  • Want to prevent them from getting worse
61
Q

Severe Posturing – Assessment and Interventions

what to rule out

what medication to use

A

1) r/o medical deterioration
- –seizures
- –Increased Cerebral Spinal Fluid Pressure

2) Medications such as
- –Baclofen–Oral or intracranial
- –Botox for smaller muscles

62
Q

TBI

who is in this group

A
  • Any patient with blunt injury to the head.
  • May include whiplash (acceleration injury), deceleration injury, gunshot wound, motor vehicle accidents, sports injuries or a fail

o Acceleration – boxer being hit, head accelerated back

o Deceleration – body is moving and hits a non-moving object

  • Any patient who was in coma, or unconscious after a trauma to the head, is a patient with a TBI
  • Early diagnosis after any trauma is very important for the prognosis and immediate care of this patient
  • Early diagnosis of a skull fracture, hematoma is of major importance
63
Q

Signs for TBI

A

1) Decreased level of consciousness

2) Loss of consciousness
(Even someone loses consciousness, even for 30 seconds, they have had a TBI)

3) Pupillary dilation unilateral or bilateral
- Usually bilateral

4) Motor weakness
- ——Unless it is SCI or peripheral nerve involvement, usually related to CNS

5) Confusion, disorientation
- –If they are developing a small hematoma, they have to be closely monitored to pick this up after any kind of a trauma (even mild)

6) Severe headache
7) Blurred vision, vertigo

64
Q

Lesions outside the brain

A

1) epidermal hematoma
2) subdural hematoma
3) subarachnoid hemorrhage

65
Q

epidermal hematoma

A

lesion outside brain

Bleeding between the inner skull and the dura mater

—Tends to result in arterial bleed with fast onset symptoms
• Tend to come on a little quicker
• Is the onset of confusion within a few
hours or 2 or 3 days later

—Brain itself is not in contact with this hematoma, not as severe

66
Q

subdural hematoma

A

lesion outside brain

Bleed between the dura and arachnoid
• Can progress in days or even two weeks

Still outside the brain itself but under the skull
A “space occupying lesion” - blood going into space = pressure on brain regardless of where it is
More pressure, more restriction of blood flow
If lesion is not evacuated, brain will gel and permanently get deformed because of pressure (like when a tumor grows)

67
Q

subarachnoid hemorrhage

A

lesion outside brain

Bleed between the arachnoid and pia mater

o	Variable progression
o	Most common site of hemorrhage
o	AVM, aneurysm, trauma
o	Worst headache ever
oMVA

o On CT – star like shape becomes brighter is blood is present in the subarachnoid space

68
Q

Lesions inside the Cerebral Cortex

A

CONCUSSION

69
Q

Concussion:

A

brief loss of consciousness
o Look for confusion as well
o If you get hit in the head w/o LOC = still a concussion but not even a grade 1
• Possibly associated with memory loss
o Anterograde amnesia: memory loss post injury
o Retrograde amnesia: memory loss before injury

70
Q

Grade 1 Concussion

A

transient confusion
o No loss of consciousness (LOC = took a few seconds to minutes to come around)
o Symptoms resolve within 15 minutes
o One or two not a big deal, but multiple grade 1’s can have a cumulative affect

• “Dings” are not insignificant!
o Still can’t go back to activity right away

• Grade a concussion based upon injury and time to recovery

• Frequency of concussions:
o 1.6 to 3.8 million per year (Langlois, 2006)
o 6-10% of all sport related injuries, especially high school and contact sports

71
Q

Grade 2 Concussion

A

Grade 2 – same as above, but resolves in greater than 15 minutes

**All activity should stop and no return to activity until a week after any symptoms have cleared

————because brain has to heal from this incident – a mild (grade 1) concussion soon after can produce a much greater affect
may need to have no stimulation during healing time

72
Q

Grade 3 Concussion

A

Loss of consciousness, seconds or minutes. IMMEDIATE HOSPITALIZATION

Second Impact Syndrome – sustaining a second injury soon after the first

  • –If brain is still healing, can result in severe hematoma formation, possible coma ad death
  • –Second impact syndrome can occur in sports where grade 1 and 2 concussions are overlooked

Post-concussion syndrome – dizziness, impaired memory and concentration, sensitivity to light, headache and irritability: It may take weeks or months to completely resolve

73
Q

Second Impact Syndrome

A

– sustaining a second injury soon after the first

  • –If brain is still healing, can result in severe hematoma formation, possible coma ad death
  • –Second impact syndrome can occur in sports where grade 1 and 2 concussions are overlooked
74
Q

Post-concussion syndrome

A
  1. dizziness
  2. impaired memory and concentration
  3. sensitivity to light
  4. headache
  5. irritability:

It may take weeks or months to completely resolve

75
Q

Post – Concussion Sx Checklist

A

• Grade each symptom from absent to severe, monitor improvement or decline

o No return to activity until NO SYMPTOMS FOLLOWING EXERTION

  • Any symtpom still present, can’t do anything that is going to stress your brain
  • Being cleared at rest is not good enough, have to BE CLEARED WHEN STRESSING THE BODY
  • Headache
  • Nausea/vomitting
  • Balance problems
  • Dizziness
  • Sensitivity to light
  • Blurred bision
  • Sensitivity to noise
  • Nervousness (That is above what is normal for that person)
  • Numbness/tingling
  • Feeling slowed down
  • Difficulty concentrating
  • Difficulty remembering
  • Neck pain
  • Fatigue/ drowsiness
  • Difficulty sleeping
  • Sadness
  • Irritability
76
Q

Concussion Eval

A

1) Baseline testing and Basic survey
o ABC??

2) Secondary: Injury eval; neuro deficits?

3) Eval includes: Mechanism of injury, symptoms, cognitive, postural history, concussion history
****Mild concussions do not show up on MRI
o Postural history – changes, guarding

4) Post concussion symptom checklist – do search
5) No return to sports while any symptoms present

6) 38% reports not symptoms but deficits appear on neuro eval
o NEED TO DO TESTING, cant just ask the patient

77
Q

Concussion tx Summary:

A

Summary:
1) Serial evaluations at 1-3 hours and 24 hours

2) If symptomatic: rest, monitor signs and symptoms, imaging if not improving

3) If asymptomatic for 24 hours, then exertion TESTING, and if OK, then testing and if OK, then return to play after 24 more hours
o Team of people working with them

4) Risk of further concussions increases after each concussion
o This increases more and more after a second and third concussion

78
Q

Short and Long Term Consequences of Mismanaged Concussions and TBI:

A

1) Repeat concussion with post concussion syndrome if reinjured before initial concussion has healed
2) Second Impact Syndrome – occurs when an athlete sustains a second head injury before sx from first have resolved
3) Undiagnosed, cumulative “dings” (concussions) often lead to early dementia, cognitive deficits, intellectual decline, memory deficits, and general decrease in mental processing

79
Q

Undiagnosed, cumulative “dings” (concussions) often lead to

A
  1. early dementia
  2. cognitive deficits
  3. intellectual decline
  4. memory deficits,
  5. general decrease in mental processing

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