sport concussion Flashcards
mild traumatic brain injury is a _ axonal injury and what word can describe it
diffuse, neuro metabolic storm, energy crisis
difference between diffuse and focal TBI
DIFFUSE type refers to an injury where there has been a widespread disruption of neurological function caused by shearing of neuronal connections. (ie: concussion!)
❑FOCAL type refers to injuries that are more localized (linear acceleration) and potentially life threatening (red flags) caused by increased intracranial pressure
from bleeding (epidural or subdural) or swelling (edema
difference with major TBI and minor TBI
Major TBI (focal injury) -canbecatastrophic
- lesions visible on imaging
- bleeds, increased intra-cranial pressure, etc.
Minor TBI or mTBI (diffuse injury) * debilitating
- not visible with traditional diagnostic imaging - m a y mask signs of more serious injury
direct MOI of TBI
primary impact to the head
indirect MOI of TBI
contrecoup secondary impact
Force applied to other parts of the to the body causing rapid acceleration/deceleration of the brain in the skull.
T/F both direct (coup) or indirect (contrecoup) can lead to either a minor or a major head injury
T
Sometimes the presence of concussion signs makes it difficult to determine _
whether a more serious focal injury exists or will develop.
Depending on the area of the brain that is injured, it can result in a wide range of deficits.
These include changes in
personality, loss of speech, inability to comprehend speech, motor impairment, attention and/or memory deficits to name a few.
Epidural bleeds usually presents initially with _ symptom
concussion-like
Important to remove from play and monitor (within field of vision) especially during first 20-30 minutes post injury.
which one between epidural or subdural bleed tend to develop more slowly
subdural bleed
which type of bleed are most likely to be missed and what do you need to do
subdural, Important to monitor athlete (within field of vision) Especially first 4-6 hours post injury. Must also monitor (close by) first
48-72 hours for any changes or signs.
what is second impact syndrome
Occurs when athlete not fully recovered from initial concussion (within last few weeks) and then receives another one.
Results in a rapid development of cerebral edema leading to brainstem herniation. Most frequently occurs in adolescents and young adults
major update of SCAT 6
Eliminationoft h e5-wordlistinfavorofa 10-wordversion
*Modifying instructions t o the symptoms scale
* AddingatimecomponenttoMonthsinReverse
* Introducinga noptionaldualt a s kTandemGaitmeasure
* Creatinganewsequenceofincreasingcomplexityfortheadministrationof posturalcontrolmeasures
* RevisedReturn-to-SportandReturn-to-Learnprogressions * Enhancedinstructionsandresourcesforclinicians
if concussion sign are evident do you necessary need to perform scat6
no
At a minimum, get GSC done after 10 minutes of rest. Remove, Observe, Rest (
SCAT6 is useful immediately after injury in and utility appears to decrease significantly after _
SCAT6 is useful immediately after injury in differentiating concussed from non-concussed. Utility appears to decrease significantly 3-5 days after injury”.
Immediate Assessment/Neuro Screen:
- Box :1 Red Flags and Step 1: Observable Signs
- Step 2: Glasgow Coma Scale
- Step :3 Cervical Spine Assessment
- Step 4: Coordination &Ocular/Motor Screen
- Step :5Memory Assessment Maddocks Questions
concussion off-field assessment
Step :1 Athlete Background
Step :2Symptom Evaluation
Step :3 Cognitive Screening
Step 4: Coordination and Balance Examination
Step :5Delayed Recall Step 6: Decisio
shen do take resting HR post concussion
10min after
T/F Non-scored Glasgow Coma Scale is performed during determination of LOC in the primary survey.
T
SCAT6 Components performed on-field as a screening tool to help determine
Recognize / Remove / Respond”
where can’t you evoke pain if suspect spinal
above clavicle
if no response at all after pain stimuli what is their Glasgow scale
3/15
secondary assessment on minor TBI include
SAMPLE, full body scan, vitals, GCS baseline score Detail of secondary assessment is symptom dependant Determine if concussion signs present: somatic, cognitive or emotional changes/impairment?
what is pupil normal diameter in bright light
2-4mm
usually asses what with perla
acuity, reflexe, field
how do you test visual acuity and what does it test
Check acuity of one eye at a time
with and without vision aids. Near and far vision
Visual acuity testing examines the integrity of the optic nerves (CN2) and the optic pathways, including the visual cortex.
how do you test pupillary reflex
Hand place vertically to block non-tested eye. Use penlight to test. Asymmetry between the pupils is a key to abnormalities
what is direct and indirect reflex of eyes
Direct reflex- same eye constricts ▪ Indirectreflex-oppositeconstricts
(consensual reflex)
how do you test visual field
VISUAL FIELD -Ask athlete to look directly at you.
Wiggle one of your fingers in each of four quadrants
Ask to identify which finger is moving
Check visual attention by moving both fingers at same time
eye movement are controller by which nerve
CN, III, IV, VI
how do you test extra ocular movement
Ask the athlete to follow a finger or pen with the eyes.
This tests cranial nerves 3 (oculomotor), 4 (trochlear), and 6 (abducens).
CN3 mediates medial deviation and all other directions of movement not coordinated by CN4 and CN6.
CN4 innervates the superior oblique muscle and mediates medial downward gaze.
CN6 innervates the lateral rectus and mediates lateral gaze.
Observing convergence of the eyes as an object is moved closer indicates function of the
medial rectus muscle and CN3 innervation
utilize what to fully assess all direction of gaze
H pattern
how do you perform smooth pursuit
Athlete is kneeling or seated in front of you, Ask to keep head still during testing.
Draw two large joining “H” in front of them using your finger (extending 1.5 feet from center point)
Ask them to follow your finger with their eyes, note capability and quality of movements.
Ask if this causes double vision, and if so when is it worse.
how do you test saccadic eye movement
Look back and forth between two objects with eyes (without moving head) Test separate horizontal and vertically.
Face the athlete, have a pen in each hand. Hold out both hands in front of you about 30 cm apart from side to side, and about
30 cm from the athlete.
Ask athlete to look from one hand to the other. Look at quality,capability of
the movements, symptoms provoked. Repeat in vertical plane as well.
symptoms of abducen nerve damage
affect eye will tend to be deviated inward because of the unopposed action of the medial rectus muscle
cannot move eyeball laterally beyond midpoint
how do you test facial nerve
Crease up forehead Close eyes and keep (raise eyebrows) closed against resistance
Show their teeth
Puff out their cheeks
T/F If the athlete is conscious, alert, and has no red flags indicating serious head injury or need for spinal motion restriction, the athlete can make their own way off the field, and the assessment may continue on the sideline.
t
if a concussion is suspected, the athlete should be removed from play -> do you need to do a full scat
no
if concussion is not evident do we need to do a scat or child scat6
yes to determine possible presence of concussion
how long the athlete must be within field of vision after a suspect concussion
30 min
when do need to complete a GSC
at time of injury (10 min rest), 2-3 hours, 24 hours, 48 hours, and 72 hours post injury.
The athlete should not be left alone during the initial
4h post injury
Regardless of the assessment tool chosen, it should include the following criteria:
History and observation (note MOI) *Orientation and memory
*Level of responsiveness
*Signs and symptoms
*Cognitive function *Cranial nerve function *Balance *Coordination
upper extremity myotome
C1-2 cervical flexion
C3 lat cervical flexion
C4 shoulder shrug
C5 shoulder abduction
C6 elbow flex,wrist ext
C7 elbow ext,wrist flex
C8 ulnar dev , thumb ext,finger flex & abd
king device test screen for
saccade
attention
concntratino
speech/language
K-D test is compose of what
There is a practice card and 3 test cards
* Athletes are asked to read out loud the numbers from left to right as quickly as possible without errors.
* The time taken for each card as well as number of errors is recorded and summed to give the total K-D score.
* The test usually takes les than 2 minutes to complete
* Need to have a baseline to be an effective tool
what is sideline-dropstick test
the tester drop the stick without warning and the person being tested catches it as quickly as he can, the place where the stick is grab, then the tester how fast the patient react
sideline drop-stick test has how many practice trial and test and mesure where
- TEST NON-DOMINANT
- 3 PRACTICE TRIALS
- 5 TEST DROPS
- MEASURE TO NEAREST .5 cm
can an athlete with a suspected concussion can RTP the same day
no
In some concussion cases, symptoms may take up to _ days to develop and / or evolve. Therefore, therapists should remain in contact with their injured athlete.
5
Athlete in sports with high incidence of concussion should have a follow-up care evaluation (SCOAT6 with a physician / allied health care professional with concussion management skills after hours.
72h
dults should be in a “relative” rest period for first * hours, whereas they can do ADL that cause no exacerbation of symptoms.
24
children may need up to _ day of relative rest
5-7
PHYSICIAN REFERRAL (post-concussion symptoms)
A referral to a physician (versed in concussion management) is required for all concussions whose symptoms are not improving within _ days*. (Children may take longer: up to _days)
10-14 days
28 days
Typical red flags indicating need for an urgent care referral:
Unconsciousness / prolonged loss of consciousness
* Altered or decreasing level of consciousness
* Decreased neurological function
* Decreased or irregularity in pulse
* Unequal / dilated / unreactive pupils
* Mental status changes such as lethargy, non-arousal,
confusion, agitation
* Seizure activity, lucid interval
* Convulsions
* Repeated vomiting (adult: 2 or more times, child: 3 or more times) * Severe or increasing headache
* Visual changes
* Slurred speech
* Any signs/symptoms of injuries such as suspected spinal, skull fracture or cranial bleeding.
after how many time of repeated vomiting do we need urgent care referral
adult: 2 or +
child (less than 13yrs): 3 or +
t is important to provide the person monitoring the person a completed copy of
scat6 and GSC
who are most susceptible for persistent symptom
Females with multiple concussions
Symptoms: cervical pain, dizziness, vestibular problems
❑ 13-17 yrs old with ADD/ ADHD
Symptoms: stress, anxiety, sleep problem, depression
❑ Migraine sufferers
Symptoms: increased symptom intensity, frequency in first 7 days post
Those with multiple, severe, and co-morbidities best referred to an MD sooner than later for further investigation and referrals.
T/F.Although initially the injury seems mild and there was no need for transportation to the hospital, the symptoms should be monitored closely as they may worsen with time.
t
CT head rule high risk for neurological intervention
- GCS score < 12 at 2hr after injury
- suspected open or depressed skull fracture
- any sign of basal skull fracture
- vomiting >= 2 episode
- age >= 65 yrs
CT head rule medium risk for brain injury on CT
- amnesia before impact >= 30min
- dangereux mechanism
exemple of basal skull fracture
hemotympanum, racoon eye, CSF, battle sign
example of dangerous mechanism for CT head rule
pedestrian struck by vehicle
occupant ejected from motor vehicule
fall from elevation = 3 feet or 5 stair
CT hear rule not applicable if
non-trauma case
GSC <13
age <16
Coumadin or bleeding disorder
obvious open skull fracture
strong indication of CT scan if
GCS <15 at 2hours post injury. #1
* Deterioration in GCS.
* Focal neurological deficit.
* Clinical suspicion fo skul fracture #2
* Vomiting (especially fi recurrent) #3
* Known coagulopathy robleeding disorder #4
* Age >65 years. #5 * Seizure #6
* Prolonged loss of consciousness 5>( mins).
* Persistent post traumatic amnesia (A-WPTAS <18/18 at 4hrs post injury) #7
= Persistent abnormal alertness * Persistent severe headache.
/ behaviour /cognition #8
relative indication for CT scan if
Large scalp haematoma or laceration #9 * Multi-system trauma. #10
* Dangerous mechanism. #1
* Known neurosurgery /neurological impairment. #12
* Delayed presentation or representation. 31#
in most uncomplicated mild head injury patients clinical symptoms start ot imorove be _hours post iniurv and are returning to normal by _hours oost iniurv.
2h, 4h
no indication for CT scan if all of
GCS 51ta2hourspostinjury.
* No focal neurological deficit.
* No cnilcial suspicion of skul fracture.
* No vomiting
* No known coagulopathy or bleeding disorder.
* Age <65 years.
* No seizure
* Brief loss fo consciousness
(«5 mins).
* Brief post traumatic amnesia
<(30 mins)
* No s e v e r e h e a d a c h e .
* No al r g e s c a l p h a e m a t o m a
r o l a c e r a t i o n
* Isolated head injury
* No dangerous mechanism.
* No known neurosurgery / neurological impairment.
* No delayed presentation o r representation
mild acute clinical symptom such as _ are not associated with increase risk of intracranial injury
lethargy, nausea, dizziness, mild headache, mild behaviour change, change amnesia for event and mild disoriented
As cognitive rest is important, the practice of keeping awake or waking up the individual the first night (is/is not) longer advised
is not
However, the parent or designated guardian should check in on the individual after they are asleep.
suggested monitoring the first night may involve quickly observing the person while they are sleeping to take note of
abnormal breathing patterns, excessive snoring, posturing, or distress signs. This is checked ideally 2-4 hours after they went to bed. If unsure of person’s condition, they may wake them to ensure they respond and have not deteriorated to a condition where they need emergency care
checking on the concussed person once they fall a sleep can be done when and what do you look
This can be done 2 and 4 hours after the individual has gone to bed. At this point the parent/guardian can also note if the individual is not sleeping. If there is any doubt regarding their condition, he/she should be woken up to ensure that they can be awakened, that there is no amnesia or any increase in symptoms requiring an urgent intervention.
General rules in management usually involve waking the individual up only if
they had experienced a LOC, prolonged period of amnesia, or if they are still experiencing significant symptoms.
The four most common patterns of post-traumatic headaches are:
- Tension types (including cervicogenic component)
- Migraine
- Combined migraine and tension-type
- Cognitive fatigue
Vomiting after a head injury may have different implications depending on the situation.
CHILDREN:(<13 yrs. old) Persistent vomiting ≥ or more times is a more reliable indicator.
ADULTS: Persistent vomiting ≥ or more times would be suspect in absence of migraine/motion sickness history.
3, 2
t/F. Some people with family or personal history of migraines or motion sickness may be more prone to vomiting after a head injury and may not be indicative of head injury severity.
T
T/F.Persistent vomiting may be more of an indicator than a single occurrence post trauma. Approximately 10-15% of children vomit after a mild traumatic brain injury.
T
can you give medication in the acute phase of concussion
no
who can dispense medication on a concussed athlete
It is recommended that only clinicians with experience with concussion management should be dispensing medication. RTP decision while still on medication should be considered cautiously.
All individuals with any signs or symptoms of an acute concussion are removed from play for usually a minimum of _ week for an adult or _ weeks for a child/adolescent/ young adult and must follow acceptable current age-appropriate RTP guidelines.
1 , 2+
The determination of the safest initial rest period duration for individuals ≤ years of age remains one of the biggest challenges due to the lack of consensus. It is best to err on the side of caution and encourage a longer rest period for this age group.
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