Concussion Flashcards
Acquired brain injury–> includes both TBI and non-TBI
-after birth
-adults and children
-can occur via traumatic causes such as injury or non-traumatic causes such as disease, stroke, and infection
-NON-TBI: stroke, brain tumor, hypoxia, anoxia, dementia, encephalitis
-TBI: diffuse or focal
–diffuse: concussion, diffuse axonal injury, hypoxia, anoxia
–focal: subdural hematoma, epidural hematoma
Key CDC guidelines for pediatric mTBI:
1.) do not routinely image patients to diagnose mTBI
2.) use validated, age-appropriate symptom scales to diagnose mTBI
3.) assess evidence-based risk factors for prolonged recovery
4.) provide patients with instructions on return to activity customized to their symptoms
5.) counsel patients to gradually return to non-sports activities after no more than 2-3 days rest
Concussion definitions:
-traumatic brain injury induced by mechanical forces that disrupts normal brain functioning
-It may be caused by either a direct blow to the head, face, neck or an indirect blow to the body that transmits forces to the head
- functional disturbance rather than structural injury
-may or may not result in a loss of consciousness
-Clinical signs and symptoms cannot be explained by drug, alcohol, medication use or other injuries, comorbidities, psychological factors, co-existing medical conditions
-These direct or indirect forces result in acceleration, deceleration,
and/or rotation of the brain inside the skull and the initiation of a complex
pathophysiologic process that alters neurometabolism.
Why are concussions called mTBIs?
-they are usually not life threatening
Prior concussion history makes ____ more likely to sustain a
second
3 times
Maximum score on Glasgow Coma Scale (most severe):
3 points
CATEGORIES:
-eye opening
-verbal response
-motor response
Mild TBI on the Glasgow Coma Scale score:
13-15
-can have a perfect score and still have a concussion
Moderate score Glasgow coma scale:
9-12
Severe score Glasgow coma scale:
8 or less
top three most common mechanisms of TBI:
1.) FALLS
2.) MVA
3.) OTHER: unintentionally being struck, intentional self harm, assault
Concussion risk factors associated with longer recovery or poorer outcomes:
-prior history of concussion
-female
-collegiate versus high school athlete
-posttraumatic migraine
-history of psychiatric disorders or learning disability
-dizziness on field (associated with prolonged recovery)
-cognitive deficits in the first few days
-increased severity of acute and subacute symptoms is the most consistent predictor of slowed recovery
-impact/collision sports have a greater risk –> higher risk in games than practice
General return to play guidelines:
-athletes need to be immediately removed from play when a concussion is suspected
-no athlete should be permitted to return to play on the same day as the suspected concussion
-to return, need to be symptom free and taking no symptom modifying medications
-to return, athletes should participate in a graduated return to play protocol , after which normal symptoms and no return of symptoms are confirmed
Describe the physiological mechanism of concussion:
-alteration of the neuronal membrane
-increased cellular demand for ATP
-increased glucose demand
-demand may be greater than supply—> cellular energy crisis
-leads to altered cognition and sensory interpretation
-structural damage is microscopic, cannot be seen on imaging
-exercise tolerance is impacted
-MRI should NOT be used to diagnose concussion
Concussion prognosis:
-recovery: typically within 24 hours, up to 7-10 days
-prolonged recovery: 10-30 days
-PCS: > 30 days
Dizziness and vestibular dysfunction after concussion:
-Dizziness is common after concussion and can result in a 6.4 times greater likelihood of prolonged recovery
-Dizziness can be a result of visual, peripheral and central vestibular disturbances
-imbalance and gaze stability deficits are common in athletes
- Vestibular dysfunction
manifesting as imbalance in up to 30% of those with concussion
How much greater is the risk of another concussion with a LOC on the first?
6x greater
Second impact syndrome
- Rare but life threatening
- Results from a second injury when the brain is vulnerable
- Brain is still healing from the initial injury and is unable to regulate blood flow
- ICP builds in the brain and brainstem herniation can occur
–> due to another impact to the brain in a short amount of time - High fatality rate in young athletes–> remove them from play if there is ANY suspicion of head injury
Post Concussive Syndrome
-10% of those with concussion
-persistence of at least 3 symptoms for > 4 weeks
-Can be related to neuroinflammation and altered cerebral blood flow
-may be more likely in a setting of having previous TBIs
*the majority of those with concussion lose symptoms within 1 month
Prognosis of concussion in children:
- Graded symptom checklist reliably identified mTBI for children ages 6 and older
- Patients with AMS (altered mental status) at time of injury had increased number and severity of symptoms
- More research is needed to identify cognitive deficits and classify severity in children
-Standardized Assessment of Concussion in a Pediatric Emergency Department
Chronic Traumatic Encephalopathy
- Diagnosed after death with autopsy
- Degenerative brain disease found in athletes, military veterans and others with repeated brain trauma
- Families may report mood, behavioral or cognitive changes that progressively develop following consecutive injuries
Signs and symptoms of concussion:
-rapidly occurring, short lived
and resolve spontaneously
- Resolution of symptoms
typically follows a sequential
course, but may be prolonged
SOMATIC:
-headache
-n/v
-cervical pain
-balance problems/dizziness
-sensitivity to light/noise
-numbness and tingling
-blurred vision/diplopia/flashing lights
-tinnitus
NEUROBEHAVIORAL:
-drowsiness
-fatigue/lethargy
-sadness/depression
-nervousness/irritability
-sleeping more than usual
-trouble falling asleep
COGNITIVE:
-feeling slowed down
-feeling in a fog or dazed
-difficulty concentrating
-difficulty remembering
COMMON ACUTE SIGNS:
-impaired conscious state or brief loss of consciousness
-confusion
-vacant stare/glassy eyes
-amnesia: retrograde or anterograde
-slow to answer questions or follow directions: easily distracted/poor concentration
-poor coordination or balance; unsteady gait
-personality change; inappropriate emotion
-slurred speech
-gross observable incoordination
-n/v
-headache
-dizziness
Common sleep alterations with concussion
excessive sleep
fragmented sleep
difficulty falling asleep
BESS
Assessment of static postural stability
20-second trials in each (all with eyes closed):
-double limb support
-single limb support
-tandem stance
-double limb support on foam
-single limb support on foam
-tandem stance on foam
SCAT-5
Gold standard for assessment of individuals with concussion
AGE: 13-65 years
child SCAT can be used for children 12 and younger
-SAC- Standardized Assessment of Concussion
–best when compared to a known baseline
-measures: orientation, immediate memory, neurologic function, concentration, delayed recall
-mBESS- Modified Balance Error Scoring System
-assessment of static postural stability
The first 3 of the 6 conditions of original BESS with 20-second trials in each (all with eyes closed):
-double limb support
-single limb support
-tandem stance
-Glasgow Coma Scale
-symptom evaluation
-Maddock’s score
-cognitive and physical evaluation
-neck exam
-coordination exam
-delayed recall
How SCAT-6 is different than SCAT-5:
-modified instructions to symptoms scale
-dual task tandem gait measure added
-creating a new sequence of increasing complexity for the administration of postural control measures
-revised return-to-sport and return-to-learn progressions
-enhanced instructions and resources for clinicians
