TBI and Concussion Flashcards
Define TBI
- Caused by bump, blow, or jolt to head or penetrating head injury
- Disrupts normal brain function
- Severity may be mild to severe
- Includes concussion
A. Mild TBI, usually occurring after a blow to the head
How is TBI classified?
- Severity
- Mechanism of injury
A. Penetrating Injury
B. Closed Injury
What can a TBI lead to?
- Alterations in cerebral blood flow
2. Increased ICP due to swelling
How is a concussion diagnosed?
- Concussion is a clinical diagnosis
2. 90% of concussions occur w/o LOC
What is the usual GCS for pts with a concussion?
ED pts w/minor head injury & GCS of 15
6-8% have an intracranial abnormality
What is the GCS for a mild TBI?
13 to 15
What is the GCS for a moderate TBI?
9-12
What is the GCS for a severe TBI?
3-8
What the common sxs of concussions in athletes?
- Headache or “pressure” in head
- N/V
- Balance problems or dizziness
- Double or blurry vision
- Sensitivity to light
- Sensitivity to noise
- Feeling sluggish, hazy, foggy, or groggy
- Concentration or memory problems
- Confusion
- Does not “feel right” or is “feeling down”
What are the common signs of a concussion observed by a coach?
- Appearsdazedorstunned
- Isconfusedabout assignmentor position
- Forgetsan instruction
- Is unsureofgame,score,oropponent 5. Movesclumsily
- Answersquestionsslowly
- Loss ofconsciousness(even briefly)
- Showsmood, behavior,orpersonalitychanges
- Can’trecalleventspriorto hit or fall
- Can’trecalleventsafterhitor fall
How is an athlete with a concussion managed?
- Remove athlete from play immediately
A. March 2013 new AAN guidelines
B. Ensure that the athlete is evaluated by a health care professional experienced in evaluating for concussion
C. Keep the athlete out of play the day of the injury & until a health care professional (experienced in evaluating for concussion) releases them to return to play
What are the sxs, immediate treatment and follow-up of a grade 1 concussion?
- Transient confusion; no LOC; concussive sxs
What are the sxs, immediate treatment and follow-up of a grade 2 concussion?
- Transient confusion; no LOC; concussive sxs > 15 min
- Removal from contest w/out return that day
- See return to play progression plan
What are the sxs, immediate treatment and follow-up of a grade 3 concussion?
- Any LOC
- Removal from contest & ED evaluation
- See return to play progression plan
True/false: a concussed athlete can return to play in the same day
Athlete should NEVER return to practice or game same day as injury
True/false: Upon discharge from the ED, follow-up appt w/ PCP is necessary
True
What is the return to play progression?
- Light aerobic exercise- Step 1
- Moderate exercise- Step 2
- Noncontact exercise- Step 3
- Resume practice- Step 4
- Return to play – Step 5
What is included in Light aerobic exercise- Step 1 for return to play progression?
- Exercise time 5-10 minutes
- Exercise bike, walk or light jog
- NO weightlifting, jumping, or hard running
What is included in moderate exercise- Step 2 for return to play progression?
Reduced amount of activity when compared w/ normal routine
What is included in noncontact exercise- Step 3 for return to play progression?
- More intensity but no contact
2. Running, high-intensity stationary bike, regular weightlifting routine
How can concussions be prevented?
- Sport-specific helmets
- Bicycle helmets
A. 140,000 children treated each year in ED in US for TBI sustained while riding bicycles
When does post-concussion syndrome occur?
- Persistent sx’s following injury
- Most occur w/in 7-10 days & resolve w/in 3 months, can persist ≥ 1 year
- Risk of post-concussion syndrome not assoc. w/severity of initial injury
How many pts experience post concussive syndrome?
Occurs in 5-8% of concussion pts
How are post-concussion syndrome pts managed?
- Refer to Neurologist
- Avoid athletics while sx’s persist
- Risk of depression
- 504 Plan for students
What are the common sxs for post-concussion syndrome?
- Headache
- Dizziness
- Sleep problems
- Psychological symptoms such as depressed mood, irritability, & anxiety
- Cognitive problems involving memory, concentration, & thinking
What are the criteria for the severity of a TBI using post-traumatic amnesia guidelines?
- Mild: less than 1 day,
- Moderate: greater then 1 day, but less than 7 days
- Severe: greater than 7 days
What are the criteria for the severity of a TBI using LOC guidelines?
- Mild: 0-30 min
- Mod: > 30 min, but less than 24 hrs
- Severe: greater than 24 hrs
What is included in mild TBI?
- Head injury
- Cortical contusions d/t coup & contrecoup injuries
- Hallmark of concussion:
A. Confusion & amnesia w/ or w/o LOC - Post-traumatic seizure
What is included in pt management for those with a mild TBI?
- ABC’s
A. Oximetry
B. Hypotension (MAP 45 mmHg (Hypercapnea/Hypercarbia) = ↑ Mortality & Morbidity
What is included in the HEENT assessment of a pt with a mild TBI?
- Palpate for step down injury of skull, hematoma, lacs
- R/O basilar skull Fx
A. Battle sign (mastoid)
B. Hemotympanum
C. Raccoon’s eyes (periorbital)
D. CSF leak
E. Hearing loss
What is included in the Neuro assessment of a pt with a mild TBI?
- MMSE
2. Complete neuro assessment
What is included in the CV, lungs, abd, spine, and ext assessment of a pt with a mild TBI?
Assess for trauma
How is a pt with a head trauma injury approached?
- Any pt w/blunt force injury to head should be suspected of having a C-spine injury until proven otherwise
- Intoxication frequently accompanies head trauma
A. Obtain BAC & toxicology screen
B. “DON’T” Tx - Accompanying systemic injuries may produce vascular collapse or resp. compromise requiring immediate attention
- If combative
A. Assess O2, accucheck, BP, pain, THEN OK to sedate/give analgesic
B. Narcotic or Benzodiazepine
What radiographs are needed for a minor concussive injury?
- CT scan not usually ordered for minor concussive injury
2. More liberal ordering for children or elderly
What is the treatment for minor concussive injury?
- All pts w/TBI: 100% O2 by high-flow NRB mask
2. Observe in ED for several hours
When should a pt with a minor concussive injury be hospitalized?
Persistent N/V, severe HA
When should an intracranial hemorrhage be considered in a concussion pt?
- Elderly (must get CT if taking anti-coags)
- Amnesia > 30 min
- Seizure
- 2 or more episodes vomiting
What can cause intracranial hemorrhage?
- Neurological deterioration after mild TBI is highly suggestive of an evolving intracranial hematoma
- Intracerebral, subdural, epidural
- Usually 2° to tear in intracranial artery or vein
What are the sxs for a moderate concussive injury?
Persistent confusion, behavioral changes, lethargy, extreme dizziness, hemiparesis
How is moderate TBI pt managed?
Admit 24 hr for medical observation & interventions as needed
What imaging is needed for a moderate TBI pt?
- CT Brain w/o contrast
A. Cerebral Contusion
B. Subdural hematoma
What are the sxs of a severe concussive injury?
- Comatose patients
2. Cushing’s Response or signs of neuro deterioration
How is severe concussive injury pt managed?
1. Cushing’s Response or signs of neuro deterioration A. Give Mannitol ( 0.25-1.0 g/kg IV bolus) to lower ICP B. Maintain serum osmolality Intubation 3. GCS 8 or less: A. Intubate B. Start seizure prophylaxis -Phenytoin (Dilantin) in adults -Carbamazepine (Tegretol) in adults -Phenobarbital in children 4. Stabilize & admit to ICU
What images are needed for a severe TBI pt?
- Cervical X-rays
- CT scan w/o contrast
A. Epidural hematoma
B. Subdural hematoma
C. Intracerebral hemorrhage
What operative managment may be necessary for a severe TBI?
- Hematomas or bleed require prompt decompressive surgery
- Post-op
A. Maintain appropriate ICP
B. Treat hypoxia, hyperthermia, hypercarbia
C. +/- Prophylactic anti-convulsants
What are the sxs of a mild concussive injury?
- HA
- Dizziness
- Faintness
- N/V
- Difficulty w/ concentration
- Blurred vision
- Brief period of amnesia
What are the leading causes of TBI?
Falls
