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Neurology > Sports-related concussion (SRC) > Flashcards

Sports-related concussion (SRC) Flashcards

Pathophysiology, clinical features, assessment, management, return to play guidelines

1
Q

Other term for Concussion

A

Mild traumatic brain injury (MTBI)

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2
Q

Concussion definition

A

Complex pathophysiologic process affecting the brain induced by traumatic biomechanical forces secondary to direct or indirect forces to the head

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3
Q

What causes a concussion

A

Blow or jolt to the head (or face/neck with forces transmitted to the head) that causes disruption of brain function, which is usually associated with normal structural neuroimaging findings (CT, MRI)

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4
Q

Natural course of concussion (typical)

A 
Rapid onset (sometimes gradual: min --> hr)
Short duration
Spontaneous resolution, sequential (but sometimes recovery is prolonged)
LOC in about 10% of cases
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5
Q

Concussion pathophysiology

A 
"RACPAM"
Release of excitatory neurotransmitters
Altered cerebral blood flow
Changes in glucose metabolism
Production: Lactic acid, Free radicals
Axonal injury
Mitochondrial dysf
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6
Q

Concussion symptoms

A

(Alphabetical order)
Amnesia, Confusion, Diff concentrating/completing tasks
Dizziness/lightheadedness, Emotional lability
Fatigue, Feeling sluggish/foggy/groggy
Headache, Irritability, LOC (10%)
Nausea, Noise sensitivity, Poor cognitive performance
Sleep disturbances, Slow reaction time
Visual dist: light sensitivity, blurry/double vision

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7
Q

Concussion physical findings

A

LOC, motionless, memory impairment, blank/vacant look, finger-to-nose test, tandem gait

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8
Q

When to suspect

A

Suspect w/ abnormalities in 1 or + of these domains:

  1. Clinical symptoms
  2. Neurobehavioral symptoms
  3. Physical findings
  4. Cognitive impairment
  5. Sleep/wake disturbances
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9
Q

What to do with a suspicious case

A

Remove PT from activity and have him/her assessed ASAP by a physician or other licensed healthcare provider (nurse, NP, etc)

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10
Q

Concussion assessment

A

A. Sideline A (5 steps): 1. Red flags, 2, observable signs,
3. Memory ass/Maddocks questions, 4. GCS, 5. C spine ass
B. Office/off-field (5 steps): 1. Background, 2. Symptoms,
3. Cognitive screening, 4. Neurologic screening,
5. Delayed recall

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11
Q

Tools for sideline assessment

A
  1. Sport concussion assessment tool-5th edition (SCAT5):
    Well recognized, done by trained health professional, can add video review if available, 2 versions (< and > 12 y). NOT useful after 3-5 d > injury, for rapid ass but not diagnostic of Head Injury
  2. Concussion recognition tool-5th edition (CRT5): For coaches and nonlicensed personnel
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12
Q

Red flags (8)

A
  1. Neck pain (cons C Spine injury), 2. Double vision, 3. Numbness/weakness of extremity (cons C spine SCI), 4. Severe/worsening HA (cons intracranial bleed), 5. Seizure, 6. LOC/decreased consciousness (cons intracranial bleed), 7. Vomiting (cons incr ICP), 8. Restless/agitated/combative (cons incr ICP or bleeding)
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13
Q

Observable signs (5)

A

Motionless, balance/gait abn, confusion/disorientation, blank/vacant look, Facial injury after head trauma

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14
Q

Memory ass/maddocks questions

A

On SCAT5

*Standard orientation questions: time/place/person –> unreliable in athletic competition

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15
Q

GCS

A

To assess consciousness level in response to predetermined stimuli

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16
Q

C spine ass

A

Ask Pt if no pain when resting –> No pain –> Perform FROM and check if pain + check if limbs and sensation are normal

17
Q

Where do you do office/off-field ass?

A

Distraction free area: Medical office, locker room

Pt in resting state, resting HR

18
Q

Background

A

Hx: prior concussions or head injuries, prior concussion Tx, previous recovery time
Prior Hx HA, learning disability, depression, anxiety or other mental health problems
Medications

19
Q

Symptoms

A

Pt given a symptom form, reads it aloud and scores them on a severity scale

20
Q

Cognitive screening

A

Athlete complete tasks related to orientation and immediate memory
To assess concentration:
Athlete repeats series of numbers read backward to him/her
Athlete names months of the year in reverse order

21
Q

Neurologic screening

A

Complete neurologic exam: cranial nerves, sensation, reflexes, cerebellar testing, finger-to-nose, rapid alternating hand, heel-to-shin, Romberg test, balance tests: stand on 1 leg, tandem gait

22
Q

Delayed recall

A

Repeat as many words as possible at least 5 min after the immediate recall task

23
Q

Should athlete return to play even if no symptoms?

A

Athlete should not return to play on the same day of SRC, even if Pt does not have any symptoms!
Should rest until symptom free
Should gradually increase activity and cognitive levels up to a degree that does not increase symptoms

24
Q

What is the main concern if there is immediate return?

A

Second-impact syndrome:
Cerebral blood flow dysregulation –> rapid cerebral vascular congestion –> cerebral swelling –> death
Can occur in the first 1-2 wk after initial concussion

25
Q

Return-to-play phases?

A

0-1-2-3-4-5 (AAP and 2016 concussion guidelines)

26
Q

Phase 0

A

Baseline: Physical/cognitive rest with no symptoms for at least 24 h
Goal: Gradual reintroduction of school/work activities

27
Q

Phase 1

A

Increase HR: x 5-10 min w/ mild activity: walking, light jogging, exercise bike
Goal: Increase HR

28
Q

Phase 2

A

Moderate exercise: limited body/head movement –> brief running/skating, noncontact sports-specific movements, no weightlifting, no heading the ball
Goal: Increase HR

29
Q

Phase 3

A

Noncontact exercise/training drills: to increase intensity but avoid contact –> more intense sprints, heavy conditioning, weight training, non contact sport-specific drills
Goal: Exercise, coordination, increase intensity

30
Q

Phase 4

A

Practice: Reintegrate into full-contact practice
Goal: restore confidence and assess functional skills

31
Q

Phase 5

A

Play: Return to competition
Goal: 100% game play

32
Q

What to do when seeing Pt at office for follow up?

A

Perform or repeat SCAT5 to see is there is improvement or worsening of symptoms

33
Q

Return to learn points

A
  • Should take place before return to play
  • Cognitive rest recommended (avoid cognitive stressors: video games, school work, texting and TV, which can worsen symptoms)
  • Limit cognitive activity to the point where it begins to reproduce or worsen symptoms
  • Out of school if symptoms prevent concentration for up to 30 min –> If able to concentrate for 30 min OK –> home tutoring or in-school instruction
34
Q

2016 concussion guidelines x return-to-learn initially

A

24-48 of rest –> gradual increase in cognitive activity to a degree where it cannot reproduce/exacerbate symptoms

35
Q

2016 concussion guidelines x return-to-learn stages

A

4-stage approach
Stage 1: Typical daily activities at home that do not increase symptoms. Start: 5-10 min and gradually build up
Stage 2: Homework, reading assignments and other cognitive activities outside of school
Stage 3: Return to school part time, partial days, or with extended breaks while there
Stage 4: Return to school full time w/ normal activities until having a full day without symptoms

36
Q

Academic adjustments at school for Pt w/ concussion*

A 
Shortened days
30 min of instructions w/ a 15 min break
Provide class notes, tutoring
Decrease course expectations, decrease exposure to classes that exacerbate symptoms
No computer work
Untimed tests and quizzes
Lunch in a quiet place
*Discontinue them after full recovery, usually within 4 wk
37
Q

How do return-to-play phases progress?

A

Every 24 H as long as there are no symptoms
If they occur, Pt is returned to previous phase (eg 2–>1)
Monitor symptoms on each phase
Symptoms mean Pt needs additional rest
If no symptoms x 24 h, start at the step where he/she was experiencing them (eg 2 from above)
Athletes progress differently
Younger ones usually take longer than older adolescents

38
Q

When to refer?

A

When symptoms persist for > 1 month –> healthcare professional expert in concussion management

Neurology (3 decks)

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