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Geriatrics/Neuro > Concussions and Bleeds > Flashcards

Concussions and Bleeds Flashcards

1
Q

concussion more common in what gender?

A

males

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2
Q

according to Zurich Consensus, SRC may be caused by what?

A

either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head

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3
Q

SRC typically results in the rapid onset of ___ that resolves ___

A

SRC typically results in the rapid onset of short-lived impairment of neurological fxn that resolves spontaneously

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4
Q

what changes may SRC result in?

A

neuropathological changes

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5
Q

what type of injury is SRC? what type of injury is it NOT?

A

functional injury, NOT a structural injury -> can’t see it on MRI/CT

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6
Q

does SRC involve LOC?

A

Most of the time SRC does NOT result in LOC

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7
Q

the signs/sx’s of SRC must not be explained by ___

A

drugs, alcohol, meds, etc.

ANYTHING ELSE

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8
Q

what type of dx is SRC?

A

a clinical dx

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9
Q

what is the most well established sideline evaluation for SRC? how long does it take to do?

A

SCAT 5

takes 10min or more to go thru

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10
Q

dx of SRC is what type of a decision?

A

a medical decision - no one else can make the dx

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11
Q

is there evidence for brain rest for >24-48hrs post acute phase for SRC?

A

NO!!! - do not need brain rest >24-48 hrs post-acute phase for SRC

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12
Q

what are persistent sx’s defined as in time for SRC in adults and children?

A

> 10-14 days in adults and >4 weeks in children

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13
Q

what interventions for persistent SRC sx’s?

A

psychological, vestibular, and cervical rehab

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14
Q

what is the strongest and most consistent predictor of slower recovery for SRC?

A

the initial severity of the person’s sx on the first day or first few days

-more severe = long/slower recovery

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15
Q

what are risk factors for SRC?

A

dehydration (spinal fluid low, so less cushion)

fatigue/sleep deprivation

malnutrition

concurrent illness

illicit drug use

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16
Q

what is primary injury mechanism of SRC?

A

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)

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17
Q

what forces are associated with higher incidences of concussions?

A

higher forces from both linear acceleration (100G) and rotation acceleration (>5500 m/sec)

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18
Q

is force alone predictive of concussions?

A

NO!!! - small force could produce devastating injuries

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19
Q

what factor of the impact may help predict the s/s of SRC?

A

the location of the impact

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20
Q

what are s/s of frontal impact for SRC?

A

irritability, inappropriate tearfulness

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21
Q

what are s/s of parietal impact for SRC?

A

HA, Nausea

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22
Q

what are s/s of occipital impact for SRC?

A

dizziness, disequilibrium, visual sx’s

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23
Q

what are s/s of top of head impacts for SRC?

A

more likely to cause LOC (than front or side impacts)

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24
Q

what are the 3 high risk mechanisms of SRC?

A

double hit, trauma with rotational forces, second hit

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25
Q

what is secondary injury mechanism of SRC?

A

injury that happens immediately but clinical s/s take mins or hours to manifest

it’s a NEUROCHEMICAL CASCADE

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26
Q

what is the pathophysiology of the second injury?

A

it’s a NEUROCHEMICAL CASCADE

Hyper-acute ionic flux of K+ and Ca+ -> crazy release of excitatory neurotransmitters -> acute hyperglycolysis -> inflammation

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27
Q

what does the neurochemical cascade of the second injury mechanism cause?

A

causes transient and prolonged neurologic deficits (HA, dizziness) that characterize concussions

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28
Q

what makes the dx of SRC?

A

any new neurologic sx the develops following sports-related trauma

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29
Q

what are the HALLMARK sx’s of SRC?

A

confusion, amnesia, HA

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30
Q

concussions are ___ injuries

A

evolving injuries (may evolve over min or hrs)

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31
Q

what are the 4 categories of sx’s of concussions?

A

(1) physical
(2) cognitive
(3) emotional
(4) sleep

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32
Q

what are the physical sx’s of concussion?

A

HA, dizziness, visual problems, N/V, balance problems

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33
Q

what are the cognitive sx’s of concussion?

A

confusion, blank stare, disorientation, amnesia of events right before (retrograde) or after (anterograde) head injury

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34
Q

what are emotional sx’s of concussion?

A

irritability, sadness, more emotional, nervousness

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35
Q

what are sleep-related sx’s of concussion?

A

drowsiness, sleeping too much, insomnia

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36
Q

why are pediatric concussions so bad?

A

b/c peds brain is still developing, so when suffer concussion it can arrest some of the brain development

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37
Q

what are 4 modifying factors that tend to prolong children’s recovery after a concussion?

A

(1) ADHD
(2) mood d/o’s
(3) sleep disturbances
(4) learning disabilities

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38
Q

SCAT 5 used for what ages?

A

13+

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39
Q

what is the immediate assessment for the SCAT-5?

A
  • red flags
  • observable signs
  • memory assessment with Maddocks questions
  • GCS
  • cervical spine assessment
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40
Q

what is the cognitive screening of the SCAT 5?

A

orientation to date, time, month, year

immediate memory - list of words and repeat

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41
Q

what is the concentration screening of the SCAT 5?

A

digits backwards, months in reverse order

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42
Q

what’s the neuro exam of the SCAT 5?

A
  • 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)
43
Q

what is one of the bigger predictors of concussions?

A

vestibular sx’s (balance)

44
Q

if have any recorded BESS errors, what does that mean about the player?

A

that they can’t return to the sport

45
Q

what are the recorded error of BESS?

A
  • 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
46
Q

what are indications for emergency department eval for concussion?

A
  • 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
47
Q

what is the management of a concussion in the ER?

A

-neuro exam w/retesting q30min
-observe for 4 hours
-manage sx’s
(HA - APAP/NSAIDs, Nausea - anti-emetics)

48
Q

what meds do you NOT want to use to manage sx’s of concussion?

A

opioids, benzo’s, ALCOHOL - any cognitive altering meds

49
Q

what is the Glascow Coma Scale (GCS) used to measure?

A

the severity of neurologic injury in concussion pts or mTBI

50
Q

what is the mainstay of rapid assessment in acute head injury?

A

GCS

51
Q

what is the scoring for the GCS?

A

3-15 immediately after injury

3 = really bad; 15 = really good

52
Q

when should the GCS improve to score of 15 after concussion?

A

w/in 2hrs

53
Q

what are the indications to get CT for concussion? do it with or w/out contrast?

A

LOC, abnormal neuro findings, deteriorating condition

do w/out contrast b/c looking for bleed

54
Q

when should an athlete with a suspected concussion NEVER return to play?

A

an athlete with a suspected concussion should NEVER return to play the SAME DAY

55
Q

what should be avoided if have concussion? for how long should they be avoided?

A

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

56
Q

what should the pt with concussion be doing until have no sx’s?

A

resting

57
Q

usually asx’s from concussion after how many days?

A

7 days

58
Q

how long should someone with concussion be observed for?

A

6-8 hrs

59
Q

what is post-concussion syndrome?

A

common sequelae of TBI

it’s when people go past the 7-10 days of usual recovery period and have more persistent sx’s

60
Q

what is the only sx that was studied for tx for post-concussion syndrome? what tx can you use for this sx?

A

Headaches

Use:

  • amitriptyline
  • dihydroergotamine and metoclopramide
  • occipital blocks
  • propranolol
  • indomethacin
61
Q

what is second impact syndrome? mortality rate?

A

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

62
Q

what is imPACT testing?

A

Immediate Post-Concussion Assessment and Cognitive Testing

sophisticated test of cognitive abilities

63
Q

imPACT testing helps healthcare professionals track recovery of what after a concussion?

A

track recovery of cognitive processes after concussion

64
Q

baseline imPACt testing recommended every ___ years

A

baseline test recommended every 2 years

65
Q

what does imPACT test assess after suspected concussion?

A

after a suspected concussion, use imPACT test to assess potential damage or changes caused by a concussion

66
Q

what does the imPACT testing measure?

A

attention spain, working memory, reaction time

67
Q

what is return-to-learn? kids may return to school with what adjustments?

A

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

68
Q

when are students allowed to return-to-play after a concussion?

A

only if they can tolerate a full day of school w/out sx’s

69
Q

what are the 4 requirements to begin return-to-play?

A

(1) successful return to school
(2) sx free and off meds
(3) normal neuro exam
(4) back to baseline balance and cognitive performance measures

70
Q

how many levels are there in the return-to-play protocol?

A

5 levels

(1) no restrictions
(2) in red - can’t hit the guy in red shirt
(3) agility
(4) run
(5) bike

71
Q

when can athletes progress to the next level in the return-to-play protocol?

A

when they are sx-free during and after exertion at an activity level

72
Q

how long should athletes remain at each stage of return-to-play?

A

no less than 24hrs

73
Q

what’s the minimum days that should pass before athlete returns to full competition?

A

5 days

74
Q

when do you return athlete to the previous level of symptom-free exertion in return-to-play?

A

if return of sx’s at current level

75
Q

can PAs clear athletes to return to play in MA?

A

YES!!!

76
Q

what is chronic traumatic encephalopathy?

A

permanent changes in mood, behavior, cognition, somatic sx’s and in severe cases Parkinson type sx’s and dementia

77
Q

chronic traumatic encephalopathy occurs in patients with multiple ___

A

concussions

78
Q

what is the ONLY way chronic traumatic encephalopathy can be diagnosed?

A

post-mortum

79
Q

what pathology is seen post-mortum with chronic traumatic encephalopathy?

A

extensive hyperphosphorylated tau build-up in neurons

80
Q

chronic traumatic encephalopathy seen in what sport?

A

NFL

81
Q

what is the look up line?

A

Hockey’s warning track

Decreases injuries along the boards

Warns players to keep their heads up when going into the boards

82
Q

where do subdural hematomas form in the brain?

A

b/w the dura and the arachnoid membranes

83
Q

what are subdural hematomas caused by?

A

tearing of bridging veins that drain from the surface of the brain to the dural sinuses

84
Q

what type of bleeding occurs in subdural hematomas?

A

venous bleeding

85
Q

what is the most common type of intracranial mass lesion?

A

subdural hematoma

86
Q

when does an acute subdural hematoma present? subacute? chronic?

A

acute SDH presents 1-2 days after trauma

subacute SDH presents 3-14 days after trauma

chronic SDH presents >15 days

87
Q

what is the imaging method of choice for subdural hematoma?

A

head CT

88
Q

what shape does subdural hematoma look like on head CT?

A

crescent shaped

89
Q

if can’t see a bleed on a CT, what imaging do you do to look for a possible smaller bleed?

A

brain MRI

90
Q

what’s the tx for subdural hematoma and also epidural hematoma? tx for small bleeds?

A

surgery - burr hole or craniotomy

small bleed can be treated non-operatively

91
Q

what is the most common cause of subdural hematoma?

A

trauma - MVC, falls, assaults (low threshold for assaults)

92
Q

presentation of subdural hematoma acute onset? what about chronic SDH?

A

LOC or coma for acute onset

insidious onset with chronic SDH - headaches, dizziness, cognitive impairment, seizures

93
Q

what 7 factors is the decision to operate on a subdural hematoma dependent upon?

A

(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

94
Q

where in the brain does an epidural hematoma occur?

A

space b/w the dura and the skull

95
Q

most common cause of epidural hematoma?

A

trauma = M/C cause

spontaneous known to happen -> d/t epidural abscess, infection, cancer

96
Q

most bleeds in epidural hematoma come from what arteries?

A

meningeal arteries

97
Q

epidural hematoma due to what forces?

A

shearing and rotational forces and blows to the side of the head

98
Q

what side of the head is the bleed found on for epidural hematoma?

A

same side as direct blow

99
Q

75-95% of epidural hematomas are present in ____ fractures

A

skull fractures (on same side of the blow)

100
Q

what’s the presentation for epidural hematomas?

A

patients are usually lucid and talking to you at first, followed by rapid deterioration -> sudden unconsciousness

101
Q

what is the head imaging of choice for epidural hematoma? what shape is on the imaging?

A

Head CT -> shows biconvex shape

102
Q

what is C/I in epidural hematoma?

A

LP

103
Q

surgical tx for epidural hematoma is dependent on?

A

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

104
Q

what type of bleeding occurs in epidural hematoma?

A

arterial bleeding

Geriatrics/Neuro (11 decks)

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