Concussions and Bleeds Flashcards
concussion more common in what gender?
males
according to Zurich Consensus, SRC may be caused by what?
either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head
SRC typically results in the rapid onset of ___ that resolves ___
SRC typically results in the rapid onset of short-lived impairment of neurological fxn that resolves spontaneously
what changes may SRC result in?
neuropathological changes
what type of injury is SRC? what type of injury is it NOT?
functional injury, NOT a structural injury -> can’t see it on MRI/CT
does SRC involve LOC?
Most of the time SRC does NOT result in LOC
the signs/sx’s of SRC must not be explained by ___
drugs, alcohol, meds, etc.
ANYTHING ELSE
what type of dx is SRC?
a clinical dx
what is the most well established sideline evaluation for SRC? how long does it take to do?
SCAT 5
takes 10min or more to go thru
dx of SRC is what type of a decision?
a medical decision - no one else can make the dx
is there evidence for brain rest for >24-48hrs post acute phase for SRC?
NO!!! - do not need brain rest >24-48 hrs post-acute phase for SRC
what are persistent sx’s defined as in time for SRC in adults and children?
> 10-14 days in adults and >4 weeks in children
what interventions for persistent SRC sx’s?
psychological, vestibular, and cervical rehab
what is the strongest and most consistent predictor of slower recovery for SRC?
the initial severity of the person’s sx on the first day or first few days
-more severe = long/slower recovery
what are risk factors for SRC?
dehydration (spinal fluid low, so less cushion)
fatigue/sleep deprivation
malnutrition
concurrent illness
illicit drug use
what is primary injury mechanism of SRC?
acceleration/deceleration injury to the brain
unrestricted head movement that leads to shear, tensile and compressive forces on the brain
Coup/Contrecoup (front and back injuries)
what forces are associated with higher incidences of concussions?
higher forces from both linear acceleration (100G) and rotation acceleration (>5500 m/sec)
is force alone predictive of concussions?
NO!!! - small force could produce devastating injuries
what factor of the impact may help predict the s/s of SRC?
the location of the impact
what are s/s of frontal impact for SRC?
irritability, inappropriate tearfulness
what are s/s of parietal impact for SRC?
HA, Nausea
what are s/s of occipital impact for SRC?
dizziness, disequilibrium, visual sx’s
what are s/s of top of head impacts for SRC?
more likely to cause LOC (than front or side impacts)
what are the 3 high risk mechanisms of SRC?
double hit, trauma with rotational forces, second hit
what is secondary injury mechanism of SRC?
injury that happens immediately but clinical s/s take mins or hours to manifest
it’s a NEUROCHEMICAL CASCADE
what is the pathophysiology of the second injury?
it’s a NEUROCHEMICAL CASCADE
Hyper-acute ionic flux of K+ and Ca+ -> crazy release of excitatory neurotransmitters -> acute hyperglycolysis -> inflammation
what does the neurochemical cascade of the second injury mechanism cause?
causes transient and prolonged neurologic deficits (HA, dizziness) that characterize concussions
what makes the dx of SRC?
any new neurologic sx the develops following sports-related trauma
what are the HALLMARK sx’s of SRC?
confusion, amnesia, HA
concussions are ___ injuries
evolving injuries (may evolve over min or hrs)
what are the 4 categories of sx’s of concussions?
(1) physical
(2) cognitive
(3) emotional
(4) sleep
what are the physical sx’s of concussion?
HA, dizziness, visual problems, N/V, balance problems
what are the cognitive sx’s of concussion?
confusion, blank stare, disorientation, amnesia of events right before (retrograde) or after (anterograde) head injury
what are emotional sx’s of concussion?
irritability, sadness, more emotional, nervousness
what are sleep-related sx’s of concussion?
drowsiness, sleeping too much, insomnia
why are pediatric concussions so bad?
b/c peds brain is still developing, so when suffer concussion it can arrest some of the brain development
what are 4 modifying factors that tend to prolong children’s recovery after a concussion?
(1) ADHD
(2) mood d/o’s
(3) sleep disturbances
(4) learning disabilities
SCAT 5 used for what ages?
13+
what is the immediate assessment for the SCAT-5?
- red flags
- observable signs
- memory assessment with Maddocks questions
- GCS
- cervical spine assessment
what is the cognitive screening of the SCAT 5?
orientation to date, time, month, year
immediate memory - list of words and repeat
what is the concentration screening of the SCAT 5?
digits backwards, months in reverse order
what’s the neuro exam of the SCAT 5?
- read aloud and follow instructions
- full ROM of neck pain-free
- look side-topside w/out double vision
- finger to nose
- tandem gait
- Modified Balance Error Scoring System (mBESS)
what is one of the bigger predictors of concussions?
vestibular sx’s (balance)
if have any recorded BESS errors, what does that mean about the player?
that they can’t return to the sport
what are the recorded error of BESS?
- hands lifted off iliac crests
- opening of eyes
- step, stumble or fall
- hip moving into 30 degrees of abduction
- remaining out of testing position >5 seconds
what are indications for emergency department eval for concussion?
- prolonged LOC (>30sec)
- concern for cervical spine injury
- high-impact or high-risk mechanism for intracranial bleed (ex: bat to the temple)
- exam suggesting skull fx
- post trauma seizure
- deteriorating condition
what is the management of a concussion in the ER?
-neuro exam w/retesting q30min
-observe for 4 hours
-manage sx’s
(HA - APAP/NSAIDs, Nausea - anti-emetics)
what meds do you NOT want to use to manage sx’s of concussion?
opioids, benzo’s, ALCOHOL - any cognitive altering meds
what is the Glascow Coma Scale (GCS) used to measure?
the severity of neurologic injury in concussion pts or mTBI
what is the mainstay of rapid assessment in acute head injury?
GCS
what is the scoring for the GCS?
3-15 immediately after injury
3 = really bad; 15 = really good
when should the GCS improve to score of 15 after concussion?
w/in 2hrs
what are the indications to get CT for concussion? do it with or w/out contrast?
LOC, abnormal neuro findings, deteriorating condition
do w/out contrast b/c looking for bleed
when should an athlete with a suspected concussion NEVER return to play?
an athlete with a suspected concussion should NEVER return to play the SAME DAY
what should be avoided if have concussion? for how long should they be avoided?
any recreational activities that may lead to a second head injury or that raise the HR
video games, loud music, activities that require concentration/focus
usually avoid for 24-48 hrs after injury
what should the pt with concussion be doing until have no sx’s?
resting
usually asx’s from concussion after how many days?
7 days
how long should someone with concussion be observed for?
6-8 hrs
what is post-concussion syndrome?
common sequelae of TBI
it’s when people go past the 7-10 days of usual recovery period and have more persistent sx’s
what is the only sx that was studied for tx for post-concussion syndrome? what tx can you use for this sx?
Headaches
Use:
- amitriptyline
- dihydroergotamine and metoclopramide
- occipital blocks
- propranolol
- indomethacin
what is second impact syndrome? mortality rate?
death or devastating neurological injury attributed to massive brain swelling in athletes who sustain a second head injury before full recovery from the first
up to 50% mortality
what is imPACT testing?
Immediate Post-Concussion Assessment and Cognitive Testing
sophisticated test of cognitive abilities
imPACT testing helps healthcare professionals track recovery of what after a concussion?
track recovery of cognitive processes after concussion
baseline imPACt testing recommended every ___ years
baseline test recommended every 2 years
what does imPACT test assess after suspected concussion?
after a suspected concussion, use imPACT test to assess potential damage or changes caused by a concussion
what does the imPACT testing measure?
attention spain, working memory, reaction time
what is return-to-learn? kids may return to school with what adjustments?
when athlete returns to school after concussion
may return to school with academic adjustments:
-30-45 min of concentration on a task, decreased day length and course load
when are students allowed to return-to-play after a concussion?
only if they can tolerate a full day of school w/out sx’s
what are the 4 requirements to begin return-to-play?
(1) successful return to school
(2) sx free and off meds
(3) normal neuro exam
(4) back to baseline balance and cognitive performance measures
how many levels are there in the return-to-play protocol?
5 levels
(1) no restrictions
(2) in red - can’t hit the guy in red shirt
(3) agility
(4) run
(5) bike
when can athletes progress to the next level in the return-to-play protocol?
when they are sx-free during and after exertion at an activity level
how long should athletes remain at each stage of return-to-play?
no less than 24hrs
what’s the minimum days that should pass before athlete returns to full competition?
5 days
when do you return athlete to the previous level of symptom-free exertion in return-to-play?
if return of sx’s at current level
can PAs clear athletes to return to play in MA?
YES!!!
what is chronic traumatic encephalopathy?
permanent changes in mood, behavior, cognition, somatic sx’s and in severe cases Parkinson type sx’s and dementia
chronic traumatic encephalopathy occurs in patients with multiple ___
concussions
what is the ONLY way chronic traumatic encephalopathy can be diagnosed?
post-mortum
what pathology is seen post-mortum with chronic traumatic encephalopathy?
extensive hyperphosphorylated tau build-up in neurons
chronic traumatic encephalopathy seen in what sport?
NFL
what is the look up line?
Hockey’s warning track
Decreases injuries along the boards
Warns players to keep their heads up when going into the boards
where do subdural hematomas form in the brain?
b/w the dura and the arachnoid membranes
what are subdural hematomas caused by?
tearing of bridging veins that drain from the surface of the brain to the dural sinuses
what type of bleeding occurs in subdural hematomas?
venous bleeding
what is the most common type of intracranial mass lesion?
subdural hematoma
when does an acute subdural hematoma present? subacute? chronic?
acute SDH presents 1-2 days after trauma
subacute SDH presents 3-14 days after trauma
chronic SDH presents >15 days
what is the imaging method of choice for subdural hematoma?
head CT
what shape does subdural hematoma look like on head CT?
crescent shaped
if can’t see a bleed on a CT, what imaging do you do to look for a possible smaller bleed?
brain MRI
what’s the tx for subdural hematoma and also epidural hematoma? tx for small bleeds?
surgery - burr hole or craniotomy
small bleed can be treated non-operatively
what is the most common cause of subdural hematoma?
trauma - MVC, falls, assaults (low threshold for assaults)
presentation of subdural hematoma acute onset? what about chronic SDH?
LOC or coma for acute onset
insidious onset with chronic SDH - headaches, dizziness, cognitive impairment, seizures
what 7 factors is the decision to operate on a subdural hematoma dependent upon?
(1) GCS
(2) Head CT findings - clot thickness, mass effect
(3) Neurologic exam, including pupillary signs (focal neurologic findings)
(4) Clinical stability or deterioration over time
(5) Acuity of SDH
(6) Presence of comorbidities
(7) Age
where in the brain does an epidural hematoma occur?
space b/w the dura and the skull
most common cause of epidural hematoma?
trauma = M/C cause
spontaneous known to happen -> d/t epidural abscess, infection, cancer
most bleeds in epidural hematoma come from what arteries?
meningeal arteries
epidural hematoma due to what forces?
shearing and rotational forces and blows to the side of the head
what side of the head is the bleed found on for epidural hematoma?
same side as direct blow
75-95% of epidural hematomas are present in ____ fractures
skull fractures (on same side of the blow)
what’s the presentation for epidural hematomas?
patients are usually lucid and talking to you at first, followed by rapid deterioration -> sudden unconsciousness
what is the head imaging of choice for epidural hematoma? what shape is on the imaging?
Head CT -> shows biconvex shape
what is C/I in epidural hematoma?
LP
surgical tx for epidural hematoma is dependent on?
acuity, size of hematoma >30cm or mls regardless of GSC
acute EDH w/a GCS <9 and pupillary abnormalities
reversal of coagulation with unactivated prothrombin complex concentrates PCC
what type of bleeding occurs in epidural hematoma?
arterial bleeding
