concussion Flashcards
what is a sports related concussion
- traumatic brain injury induced by biomechanical forces
what high school sports have highest rates of concussion
- wrestling
- ice hockey
- girls soccer
- football
- boys basketball
- lacrosse
primary injury in concussion
- accel/decel injury: coup contrecoup
- unrestricted head movement -> shear, tensile and compressive forces on brain
- closed head injry
secondary injury in concussion
- injury that happens immediately but clinical si/sx takes minutes or hours to manifest
- neurochemical cascade
metabolic changes with concussion
- hyperacute influx of K and Ca
- release of excitatory neurotransmittors
- acute hyperglycolysis
- inflammation
- decreased cerebral BF for days - weeks
sx associated with frontal injury
- irritability
- inappropriate tearfulness
sx associated with parietal injury
- HA
- nausea
sx associated with occipital injury
- dizziness
- disequilibrium
- visual sx
sx assoc with injury to the top of the head
- LOC
double hit
- checked in head then hits the ice
second hit
- previous unreported or undetected blow to head in same day/ game, or days-weeks prior
- lowers threshold for more severe concussion
high risk mechanisms for concussion
- double hit
- second hit
- trauma with rotational forces
lowered threshold for concussion
- dehydration
- fatigue or sleep deprivation
- malnutrition
- concurrent illness
- illicit drug use
what are the hallmarks of concussion
- confusion
- amnesia
- most often dont have LOC
when do si/sx of concussion occur
- may be immediate
- may evolve over minutes/ hours
physical si/sx of concussoin
- HA
- N/V
- balance problems
- incoordination
- dizziness
- visual problems
- phono/photophobia
- numbness, tingling
- neck pain
cognitive si/sx of concussion
- confusion
- disorientation
- blank stare
- difficulty concentrating
- slurred, slowed speech
- amnesia
emotional si/sx of concussion
- irritability
- sadness
- emotional lability
- nervousness
sleep related si/sx of concussion
- drowsiness
- sleeping too much
- insomnia
assessment tools for concussion
- helmet sensors- really just in research
- SCAT-5
- non-healthcare concussion recognition tool 5 (CRT5)
- concussion assessment and response (CARE)
- sideline assessment of concussion (SAC)
- graded sx checklist
what is assessed on field with the SCAT5
- red flags
- observable signs
- memory assessment, maddock’s questions
- glasgow coma scale
- c spine assessment
what is assessed off field with the SCAT5
- athlete background
- sx eval
- cognitive screening
- neuro exam
- delayed recall of list of words
- decsions
components of the typical neuro exam
- read and follow instructions
- full ROM of neck pain free
- finger to nose
- tandem gait
- modified balance error scoring system (mBESS)
- CN testing
- strength and sensation
diagnosis of concussion
- clinical dx
- hx of trauma
- si/sx soon after injury
- std assessment of sx, balance and neurocognitive function
- exclusion of structural intracranial injuries
indications for ER evaluation with concussion
- prolonged LOC
- possible c spine injury
- risk of intracranial bleed
- exam suggesting skull fx
- post trauma seizure
- vomiting
- severe or increasing HA
- increasing agitation, restlessness, combative
- confusion
- double vision
- weakness, tingling
- deteriorating condition
management for concussion in the ER
- neuro exam q 30 min
- observe for 4 hours
- can manage HA and nausea
- dont usu need imaging, no abnormalities seen on imaging
indications for CT in concussion
- LOC
- abnormal neuro findings
- deteriorating condition
management of concussion
- prevent additional injury
- never return to play same day
- avoid recreational activities that cause head injury
- no estab definition for brain rest
- physical rest until no sx
- can manage HA
- adult observation 6-8 hours, no wake up
what is imPACT testing
- immed post concussion assessment and cognitive testing
- tracks recovery
- helps make decision about academic needs
- baseline testing q2 years
return to learn
- occurs BEFORE return to play
- 30-45 min of concentration on a task
- limited course load
- shortened classes/ school day
- increased rest
- supplemental tutoring
- postponed testing
- 504 plan
return to play
- sx free, off meds
- normal neuro exam
- graduated return
- must be sx free during and after exertion at an activity lev before progressing to next level
- remain at each stage for 24 hours
- if sx then drop down a lev
post concussion syndrome
- sequelae of TBI
- sx prolonged longer than usual
- severity of injury doesnt correlate with PCS
sx of post concussion syndrome
- HA
- dizziness
- neuropsych sx
- cognitive impairment
management of post concussion syndrome
- amitriptyline
- infusions of dihydroergotamine and metoclopramide
- occipital blocks
- propranolol
- indomethacin
second impact syndrome
- death or devastating neuro injury d/t massive brain swelling
- second head injury before full recovery
- 50% mortality
traumatic encephalopathy syndrome
- clinical syndrome assoc with CTE pathology
- changes in mood, behavior, cognition, somatic sx
- in severe cases: parkinson type sx and dementia
chronic traumatic encephalopathy (CTE)
- occurs in pts with multiple concussions
- extensive tau changes
where do tau proteins accumulate in CTE
- neurons and astroglia around small BV in cortical sucli
how is CTE dx
- post mortum
- neuropathologic dx
what are the types of intracranial bleeds
- subdural hematoma
- epidural hematoma
what causes subdural hematoma (SDH)
- forms between dura and arachnoid membranes
- d/t tearing of bridging veins
- rupture -> bleeding
- bleeding stops d/t increased ICP or direct pressure from a clot
si/sx of SDH
- usu LOC or coma for acute onset
- insidious onset with chronic: HA, dizziness, cognitive impairment, seizures
acute SDH
- 1-2d after trauma
subacute SDH
- 3-14 d after trauma
chronic SDH
- > 15 d after trauma
dx of SDH
- CT
- see crescent shape on imaging
- MRI more sensitive for smaller bleed
managemetn of SDH
- acute= neuro emergency, often requires surgery
- evacuation via burr hole or craniostomy
- if small bleed/ stable dont need surgery
causes of SDH
- trauma- most common
- MCV
- falls
- assaults
epidural hematoma (EDH)
- occur in space btwn dura and skull
- d/t shearing and rotational forces, blows to the side of the head
- usu on same side as blow
- from meningeal arteries
- more common in young pts
si/sx of EDH
- pt is usu lucid
- rapid deterioration
- severe HA
- vomiting
- seizure
dx of EDH
- CT imaging of choice
- LP C/I
- MRI for small bleeds
management of EDH
- neuro emergency
- usu requires surgery- craniotomy or burr hole
- small bleeds treated non-surgically
- reversal of coag with unactivated prothrombin complex concentrates
