Concussions

Question 1

What is the definition of concussion (McCrory et al)?

Answer 1

• traumatic brain injury
• complex pathophysiological process affecting the brain
• causes by biomechanical forces

Question 2

What are the common features of concussion?

Answer 2

1. direct blow to head/face/neck by an ‘impulsive force’
2. rapid onset of short lived neuro impairments with spontaneous resolution; in some cases S/Sx evolve over minutes/hours
3. FUNCTIONAL disturbance rather than structural (no changes seen on imaging)
4. graded set of clinical s/sx (that aren’t explained by drugs/meds/other injuries/comorbidities)

Question 3

What are the 5R’s of concussion management?

Answer 3

Recognize (signs, SCAT5, CRT5)
Remove (10 mins min to perform SCAT5 in distraction free place; if concussion suspected remove immediately - should NOT be allowed to RTS same day)
Rehab
Re-evaluate (
Return to sport

Question 4

What are observable signs of concussion during the on field assessment?

Answer 4

1. lying motionless on the field
2. blank or vacant look
3. facial injury after head trauma
4. disorientation/confusion/inability to respond to questions
5. balance/gait abnomalities/motor incoordination

Question 5

What are the 3 components of the GCS and what do the scores mean?

Answer 5

Eye response
Verbal response
Motor response

<9 = severe 
9-12 = moderate
>13 = mild head injury

Question 6

What are the S/Sx of concussion?

Answer 6

headache
fogginess
lability
gait unsteadiness
LOC
amnesia
irritibility 
drowsiness
slowed reaction times

Question 7

Describe the short term management of concussions (1-2 days)

Answer 7

• don’t leave alone and monitor for deterioration

- avoid alcohol, rx or non-rx drugs, don’t drive

Question 8

What are signs of deterioration to watch out for?

Answer 8

• worsening headache
• vomiting
• seizures
• drowsiness
• inability to recognize faces/places
• confusion/irritability
• gait unsteadiness

Question 9

What are the 3 steps for re-evaluation of the athlete?

Answer 9

1. thorough assessment - hx + neuro exam
2. determine clinical status - better/worse since onset?
3. determine need for imaging
4. neurospsychological assessment

Question 10

What is the 3 step process to dx or r/o concussion within 48hr of injury?

Answer 10

1. Assessment+SCAT5 immediately post injury
2. Assessment+SCAT5 within 3h of injury
3. Assessment+SCAT3+neurocognitive+balance eval - 36-48 hrs post injury

Question 11

Describe the graduated RTS strategy and how long each stage should last

Answer 11

1. Perform ADLs that don’t provoke symptoms
2. LIght aerobics that dont provoke sx (no resistance training)
3. Sport specific ex - running/skating (but no head impact)
4. Non contact training drills - intro resistance training
5. Full contact practice -
6. RTS

• each stage lasts 24hrs - if one stage elicits sx’s that revert back to lower symptom free stage
• *BUT findings suggest that changes in brain persist even after symptoms are gone

Question 12

What are risk factors for worse outcome after concussion?

Answer 12

1. LOC >1 min
2. Concussion convulsion
3. Recent concussion/repeated concussion/injuries close together
4. Concussions with progressively less required force and slower recovery
5. <18 yrs old
6. Migraine, mental health disorders, learning disabilities, sleep disorders
7. Psychoactive drugs, anticonvulsants
8. Dangerous style of play/high risk activity
9. Lots of concussions/high severity/long duration of sx’s

Question 13

What is second impact syndrome?

Answer 13

• pt receives 2nd blow to the head before the first blow has healed
• potentially catastrophic
• loss of cerebrovascular autoregulation - BRAIN SWELLING
• more in younger athletes
• mortality almost 100%!