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
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
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
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!!!
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)
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
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
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
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
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
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
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
13
Q
What disorders can a concussion mimic?
A
- substance abuse/dependency
- intermittent explosive disorder
- suicidal ideation/tendencies
- depression
- mood disorder
- impulse control
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
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
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)
