Concussions Flashcards
Concussion - Definition
Clinical syndrome characterized by an immediate and transient impairment of normal neurological function
Brain injury defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces
Concussion facts
Functional disturbance rather than a structural disturbance
Majority resolve in 7-10 days
Caused by direct or indirect forces - over 100 G-forces in football impacts
Typically rapid onset, but some s/s may take a few hours to develop
Typically s/s do not significantly worsen over time and new ones to do not appear
Clinical neurological signs typically are not present
A concussion will not show on dx imaging
Clinical domains of a concussion
Physical signs
Behavior changes
Cognitive impairment
Sleep disturbance
Physical signs of concussion
Loss of consciousness Loss of balance Vomiting Visual Ha
Behavior changes associated with concussion
Irritability
Aggression
Sadness
Cognitive impairment associated with concussion
Delayed reaction
Lack of concentration
Amnesia
DDX
Concussion
Diffuse axonal injury
Vascular rupture
Fx - laceration of brain
Concussion dx
Dx of exclusion - need to r/o more serious pathology
R/o non-trauma and other trauma related conditions
R/o non-trauma related causes
Stroke Tumor Meningitis Aneurysm Heat stroke DM conditions
R/o other trauma related conditions (direct or indirect)
Cranial fx Intracranial hemorrhaging (increased intracranial pressure) - subdural hematoma - epidural hematoma - intra-cerebral hematoma
Concussion - dx and managment (in a nutshell)
- Primary survey? CABs
- Hx
- Observation
- Palpation?
- Special Testing
- r/o s/s of increased ICP
- symptomatic baseline testing
Concussion - hx
When did injury occur?
MOI
PMH of injury (frequency, duration, etc)
Basic s/s check
Concussion - observation
Behavior
Thought process
Movement quality
Concussion - Palpation
Fx?
Special tests
R/o increased intracranial pressure
Baseline concussion assessment
Increased intracranial pressure
S/s of increased intracranial pressure (red flags) Pathological reflex present - decorticate /decerebrate rigidity - Babinski's sign Increased DTR (hypereflexia) Hypertonicity (spasticity and rigidity) Decreased/absent superficial reflexes CN dysfunction S/s progressively worsening Blurring of optic disc and hemorrhaging of retina Increased BP and PP Slow irregular pulse Prolonged loss of consciousness Seizure Overall deterioration GCS <15
GCS Categories
Eye Opening response
Best verbal response
Best motor response
GCS - eye opening responses
Spontaneously - 4
To speech - 3
To pain - 2
No response - 1
GCS - Best verbal response
Oriented to time place & person - 5 Confused - 4 Inappropriate words - 3 Incomprehensible sounds - 2 No response - 1
GCS - Best motor response
Obeys commands - 6 Moves to localized pain - 5 Flexion withdrawal from pain - 4 Abnormal flexion (decorticate) - 3 Abnormal extension from pain (decerebrate) - 2 No response - 1
GCS Scoring
Best response - 15
Comatose client = 8
Totally unresponsive - 3
CN Testing
Vision Visual fields Eye tracking Facial sensation Muscles of facial expression Muscles of mastication Hearing / balance Swallowing Upper trap / SCM strength Tongue protrusion Pupil reflexes
Symptomatic Baseline Testing - Tests available
ImPACT SAC SCAT 5 CogSTate ANAM CogSport
ImPACT
Immediate Post-concussion assessment and cognitive testing
SAC
Standardized assessment of concussion
SCAT
Sport concussion assessment tool Free Easy to administer Developed by leading experts Portions are valid/reliable
ANAM
Automated neuropsychologial assessment metrics
When to do symptomatic baseline testing
Pre-season baseline testing
Symptomatic baseline testing - not for dx, but for managment
Managment
Cornerstone is cognitive and physical rest
Graduated return to activity when s/s reside
Graduated return to sport
No activity until s/s free for 24-48h Light aerobic exercise Sport specific skills Non-contact raining drills Full contact drills Return to full, unrestricted play 24h for each stage if not return of s/s
Return to learn
Gradual return to learning activities
Rest from cognitive strain
VOMS
Vestibular Ocular Motor System
Testing & tx
Provocation of s/s
Helps with dysfunction between eyes & ears
Concussion management modifiers
Age Seizure d/o Depression Extended LOC Significant amnesia Duration of s/s
Prevention
Equipment of little benefit in most sports
Rule enforcement and rule changes
Common sense
Grading
Not a concern with newer guidelines
Second impact syndrome
Patho Loss of auto-regulation of blood and CSF Rapid increased ICP and brain herniation Brain stem failure in 2-5 minutes Rare and difficult to determine incidence rate
Chronic Traumatic Encephalopathy (CTE
Patho
Atrophy of the brain
Neuronal loss
Protein build-up
