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Neuro > Concussions > Flashcards

Concussions Flashcards

1
Q

Concussion is also known as?

Due to what?

A
  • mild TBI
  • may be due to direct blow, countercoup, or rotational/acceleration injury
  • due to changes in brain physiology rather than structural changes
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2
Q

Most concussion resolve over what time period?

A
  • 80-90% resolve in 7-10 days
  • most HS athletes are fully recovered in 14-21 days
  • may have long term, even fatal sequelae
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3
Q

Coup - mech of injury
Countercoup?
rotational?
- do you need direct trauma to head?

A
  • coup: direct blow-skull driven into brain
  • countercoup: brain driven into far skull
  • rotational: features of both
  • can happen without direct trauma= deceleration injury
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4
Q

PP of concussions?

A
  • disruption in neuronal membrane and depolarization
  • leads to release of excitatory NTs: K+ efflux and Ca2+ influx
  • leads to impairment of glucose metabolism, cerebral blood flow, and axonal fxn
  • structural changes are rare- CT, MRI, EEG usually normal
  • concussive effects are cumulative!!!
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5
Q

How do you dx a concussion?

A
  • based on hx, signs, sxs, exam findings, neurocog testing, balance testing
  • neuroimaging usually normal, not reqd for dx (MRI for persistent/disabling sxs to R/O other causes)
  • simple or complex?
  • LOC - seen in 10%: presence of amnesia more predictive of sxs and neurocog deficits than LOC (retrograde amnesia correlates more with injury)
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6
Q

Cognitive sxs of a concussion?

A
  • fellings dinged, foggy or dazed, just not with it
  • inability to focus attention - easily distracted
  • cognitive slowing, confusion, amnesia
  • memory dysfxn: disorientation - repeatedly asking the same ?
  • inappropriate emotions: sadness, irritability, anger
  • fatigue
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7
Q

Physical sxs of a concussion?

A
  • double vision, seeing stars, light sensitivity
  • HAs, ringing in ears, nausea
  • balance problems and dizziness
  • difficulty falling asleep or sleeping less than usual
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8
Q

Physical signs of a concussion?

A
  • vacant stare
  • poor coordination or unsteady gait
  • slow to answer ?s or follow commands
  • poor concentration
  • slurred or incoherent speech
  • behavior or personality changes
  • diminished ability or reckless playing behavior
  • LOC or seizure
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9
Q

What is included in the initial eval for concussion?

A

mental status testing:

  • orientation: time, place, person, situation
  • concentration: subtraction or months backwards
  • memory: details of contest, recent newsworthy events

gait assessment and balance:

  • have pt walk away and back -ataxia?
  • tandem gait
  • romberg sign
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10
Q

What are signs that demand emergency action?

A
  • increasing HA, N/V
  • progressive impairment of consciousness
  • gradual rise in BP
  • diminution of pulse rate
  • blown pupil
  • disorientation
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11
Q

What signs and sxs warrant a emergent referral?

A
  • suspicion for hematoma
  • C-spine injury
  • worsening LOC
  • focal motor weakness
  • transient quadriparesis
  • seizure
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12
Q

What signs and sxs warrant a refferal?

A
  • persistent HA for longer than 7 days
  • PCS lasting longer than 2 weeks
  • abnorm neuropsych testing
  • hx of mult high grade concussion
  • clinical judgment
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13
Q

What disorders can a concussion mimic?

A
  • substance abuse/dependency
  • intermittent explosive disorder
  • suicidal ideation/tendencies
  • depression
  • mood disorder
  • impulse control
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14
Q

Severe brain injuries?

A
  • focal neuro deficit
  • IICP: HA, vomitng, papilledema, brain stem herniation (1 pupil dilated)
  • skull fracture
  • hematoma:
    epidural
    subdural
    subarachnoid
  • spinal cord injury
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15
Q

Correlation b/t athletes and concussions?

A
  • head injuries are on the rise for athletes at all levels of play
  • est 4-5 mill concussions annually
  • increasing in middle school athletes, players are bigger, faster, stronger
  • can occur in football, wrestling, soccer, cheerleading, hockey
  • many don’t realize that have concussion
  • coaches don’t recognize injury either
  • mild injury can be sig: up to 15% can have long term sequelae
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16
Q

What is a part of on field evaluations?

A
  • ABCs first!
  • any LOC, tx as cervical spine injury (C-spone precautons and immobilization)
  • any signs of neuro deficits = immediate transfer to ER
17
Q

Sideline eval?

A
  • signs, sxs
  • mental status: orientation, concentration, memory
  • gait assessment and balance
18
Q
  • problems with sideline eval:
A
  • players/coaches/parents know consequences of concussion - no play
  • can happen on all plays, injury may not be seen
  • concussions don’t only happen on big hits
  • dx difficult if athlete doesn’t report and changes are not noted
  • coaches and athletes reluctant to report sxs
  • if any sxs reported, suspect concussion
19
Q

Post game eval?

A
  • similar to sideline
  • can determine if add tesing needed - emergent or not
  • should include take home instructions
  • coord the care and f/u of injured athletes
  • discuss status of athlete with parents, ATs, and coaching staff
20
Q

What are indications for transfer to ED?

A
  • LOC
  • poss cervical spine injury or skull fracture
  • high risk for intra-cranial bleed
  • post-traumatic seizure
  • acute worsening of mental status
21
Q

What is impt to remember about young and adolescent athletes? (protocols and sx resolution)

A
  • use a longer sx-free period b/f starting exertion protocols
  • extend length of graded exertion protocol
  • don’t return to play or practice same day
  • consult trained neuropsychologists
  • age specific phsyical and cognitive rest issues (no over stim: no txting, video games, tv)
  • sx resolution may take longer
22
Q

Tx of mild concussions?

A
  • while sx: rest, fluids, and good nutrition
  • physical rest: sleep is good, no training, playing, exercise or chores for a week
  • cog rest:
    no TV, video games, txting, music, studying spanish (lol)
  • avoid NSAIDs first 48hrs ( increase bleeding risk)
  • avoid recreational activities that have risk for head injury)
23
Q

When can a concussed athlete return to play?

A
  • not until full recovered - varies
  • must pass exertional tests w/o sxs
  • is athlete eager to return or still not feeling it?
  • consider protective equip.
  • career ending: 2 or 3 high grade concussions
24
Q

What is the rule of 3’s?

A
  • 1 concussion: out of game/full practive for 7-10 days
  • 2 concussions: out for the season
  • 3 concussions: out of sport
25
Q

steps of progression for return?

A
  • recurrence of sxs at any pt - drop back
  • aerobic exercise: light walking, biking
  • sport specific activities w/o opponent: dribbling, shooting, throwing, kicking
  • non-contact drills
  • full-contact drills
  • return to game play
26
Q

What is secondary impact syndrome?

A
  • second impact to brain during vulnerable metabolic cascade - sudden, severe swelling
  • this occurs following head injury/concussion
  • occurs prior to healing of initial injury
  • may be minor/incidental injury
  • can lead to worsening mental status and death
  • 30-40 deaths in high school aged athletes over last decade
27
Q

Prevention of sports related concussions?

A
  • can’t condition brain but can strengthen neck muscles
  • rule changes if there is clear cut cause - spearing in football
  • protective equipment may lead to more risky behavior
  • promote fair play and respect and develop team awareness
  • teach players to play under control, how to fall, how to protect themselves
  • helmets do decrease risk of skull fracture and intracranial hemorrhage
  • mouth guards decrease risk of dental and oral trauma
28
Q

What is imPACT?

downside of it?

A
  • immediate post concussion assessment and cognitive thinking
  • compute based neurophysiologic testing
  • records players sxs
  • scores verbal and visual memory, processing speed, reaction time
  • need baseline testing q 2 yrs (SD2 - freshmen and juniors)
  • admin by trained personnel: usually ATs
  • random variation of forms to inhibit learning at the test
  • athletes can game the test
  • time and dollar costs are high
29
Q

other testing tools for concussions?

A
  • SCAT2 (sport concussion assessment tool 2)
  • SAC (std assessment of concussion: test orientation, concentration, delayed recall, immediate memory, exertional maneuvers, neuro screening
30
Q

Consequences of repetitive injury? What are you more likely to develop?

A
  • athletes 3-6x more likely to have 2nd concussion
  • 2nd impact syndrome
  • don’t recover as quickly or fully from another concussion
  • add concussions tend to be more severe
  • 4-7x more likely to get knocked unconscious
- more likely to develop;
PCS
HAs and sleep disorders
depression and dementia
CTE
31
Q

What is PCS? (Post concussive syndrome)

A
  • chronic cognitive and behavioral sxs following injury: may take months to resolve
  • HAs, fatigue, sleep difficulties, concentration issues, emotional problems, and dizziness
  • affect sport, academics, life
  • need physical and cognitive rest
  • PT may be helpful (balance and proprioception), canalith repositioning maneuvers
  • beware of depression
  • if injury heals, no indication of long term problems
32
Q

Link b/t concussions and depression in NFL players?

A
  • 20% of football players who recalled sustaining 3 or more concussions were dx with depression
  • 3x rate of players without concussions
33
Q

What is CTE?

A
  • progressive degenerative disease found in individuals who have been subjected to multiple concussions and other forms of head injury
  • linked to memory loss, confusion, impaired judgement, paranoia, impulse control problems, aggression, depression, and progressive dementia
  • can only be dx posthumously via autopsy
  • characteristic streaks of dark tau protein on brain
34
Q

Evolving concussion guidelines?

A
  • Natl hockey association: 1997: baseline available, but not reqd
    2011 - league bans head hits, baseline testing in diff room for players who sustained head hits
  • MLB: 2007: medical staff must eval player with suspected injury on field
    2011: neurocognitive ImPACT baseline testing mandatory, players with dxd concussion on 7 day disabled list

NFL: 2007 - eval on field,
2009 - baseline testing mandatory if injury suspected, only asx players can return to play

35
Q

What is dylan steiger’s law?

A
  • passed by Montana legislature in 2013

key provisions:

  • educate coaches, athletes, parents on dangers of concussions
  • may not play with signs, sxs, or behaviors of concussion
  • must get medical clearance b/f returning to play/practice
  • decreases chance of long term injury by allowing for full recovery (doesn’t reduce number of concussions)

Neuro (19 decks)

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