Concussion Flashcards
(40 cards)
Mild Traumatic brain injury (TBI)
S/SX
Confusion
Amnesia
Sometimes loss of consciousness
Headache
Dizziness
Nausea/vomiting
Mild TBI
Neurologic assessment
- History with as much detail as possible
Include before and after recollections - Mental status exam
Short term memory
Attention and concentration - Neurologic exam
Cranial nerve exam
Limb strength and reflexes
Coordination and Gait
Pathophysiology of TBI
Axon stretch due to injury
Excitatory neurotransmitters released
K+ efflux and Ca++ influx
This leads to metabolic changes
Hyperglycolysis
Lactate accumulation
Mitocondrial dysfunction/oxidative phosphorylation
Increased energy need/decreased energy production
Globally:
Axonal swelling
Apptosis
Decreased cerebral blood flow
Inflammation
Concussion Recovery Rate
Brain Metabolism
30 days
Concussive Symptoms
15 days
Ion Imbalance
4 days
Second Impact Syndrome
Diffuse cerebral swelling in setting of second concussion
Rare, but can be fatal
May be due to disorder of cerebral autoregulation that causes
Cerebrovascular congestion
Cerebral edema
Increased intracranial pressure
Careful consideration for “return to play”
Post Concussion Syndrome
General
Common sequela of TBI
30-80% of patient with mild/moderate TBI will experience some type of symptom
Female and increased age are risk factors
Post Concussive Syndrome
S/Sx
Headaches
Tension
Migraine
Other
TMJ, occipital neuralgia, trigeminal nerve injury
Dizziness
Lightheadedness, vertigo
Sleep Disturbances
Insomnia usually
Psychological and cognitive symptoms (50% of patients)
Personality change, irritability, anxiety, depression
SKull fracture
most common fracture and causes
Most fractured-> parietal bone, followed by the temporal, occipital, and frontal bones.
Most common fracture-> linear, followed by depressed and basilar skull fractures.
Each year, approximately 2.8 million people suffer head injuries in the US alone.
Most common causes-> Falls, assaults, motor vehicle collisions, penetrating missiles
skull fracture
After injury
-You should assume a skull fracture exists in a any patient who has sustained a significant head injury or other major trauma.
-High kinetic injury is needed to cause injury
-Important to maintain immobilization of the cervical and thoracic spine
-A dressing held in place by a circumferential head bandage
is often not sufficient
skull fracture
patient arrives to the ER..
Identify and stabilize life threatening injuries
Protect and stabilize airway
Note: bleeding wounds from skull fractures can be profuse. Use Direct pressure for approximately 15 minutes as initial treatment
After stabilization, assess for: altered mental status, focal neurologic deficits, scalp lacerations, bony step-off of the skull, or periorbital or retroauricular ecchymosis.
Do NOT probe scalp wounds…
skull fracture
Dx
Non-contrasted CT is the imaging study of choice
There is a specialized study but not much research on it
If there is evidence suggestive of basilar fracture, reasonable to obtain CT angiography to assess for vascular injury
There is little evidence supporting use of CTA for skull fracture. Chat with radiologist to determine next best steps.
MRI is useful if evaluating vascular or ligament injury BUT CT is main choice
No benefit with skull x-rays
If that is the only option depending on practice location, 2 views should be performed
Negative plain radiographs in low risk situation (minor mechanism of injury, normal neuro eval) are reassuring however, they cannot completely rule out injury
skull fracture
don’t miss on Dx
You may need to keep looking.. Per Up to Date 5-15% of patients with skull fracture also suffer fracture of cervical spine.
Essential to perform careful assessment for concurrent injuries
In addition to imaging, may need to consider tox screen if altered mental status
Types of skull frcatures
Linear
Depressed
Basilar
Linear skull frcature
General
A single fracture that often extends through the entire thickness of the skull
Location: most often involving the temporoparietal, frontal, and occipital regions
Fortunately, the majority of linear skull fractures have minimal or no clinical significance
linear skull fracture
There is always a catch…..
If the linear fracture crosses the middle meningeal groove in temporal bone or major venous dural sinuses- could cause significant extra axial bleeding (beneath the skull but outside the brain parenchyma.
linear skull fracture
Presentation
Presentation- if simple and closed- usually no neurologic symptoms.
There may be swelling over fracture site
A minority who develop ICH can have depressed mental status, headache, vomiting, cranial nerve deficit
Depressed Skull Fracture
general
Occur when trauma drives a segment of skull below the level of the adjacent skull
Ex: direct trauma from a bat or a club
Often involve injury to the brain parenchyma
Increased risk of CNS infection, seizures, and death if not early ID and managed appropriately
Mortality is high among patients with depressed fractures with a significant decline in mental status
Closed or Open - majority are open, assume any depressed fracture is open until proven otherwise
depressed skull fracture
Presentation
They can present with report of loss of consciousness
CAREFULLY palpate but this is often limited due to swelling
Bone fragments can easily lacerate adjacent structures such as the dura mater —-which can lead to CNS infection
DO NOT blindly probe wound itself
Basilar skull fracture
general
Involve at least one of the 5 bones that make up the skull base
Cribiform plate of ethmoid bone, orbital plate of the frontal bone, petrous and squamous portion of the temporal bone, and sphenoid and occipital bones.
Most commonly occur through temporal bone, so high risk for extra-axial (outside of the brain but beneath the skull) hematomas
The temporal bone is relatively weak and is right by the middle meningeal artery and vein
basilar skull fractures
Clinical signs
Periorbital ecchymosis– Racoon eyes
Retroauricular ecchymosis (mastoid)- Battle’s sign
These appear 1-3 days later than initial injury
Otorrhea- CSF leak from ear
Rhinorrhea- CSF leak from nose
20% of patients display this. Within hours or up to several days after trauma
Hemotympanum- blood behind the tympanic membrane
Common
Generally appears within hours of injury
Neurologic presentation depends on degree of brain tissue and cranial nerve injury
If close to brainstem, N/V due to vestibular centers
Oculomotor deficits from injury to CN III,IV, or VI as may facial nerve palsies or hearing loss due to injury of CN VII and VIII.
basilar skull fracture
CSF leak
CSF leak occurred in approximately 11-45% of these fractures as noted prior
Most traumatic CSF leaks resolve spontaneously within 7 days but in rare cases, can persist for as long as several months.
lab to check if CSF- Beta 2 transferrin
Elevated skull fracture
Uncommon
Occur when the fracture fragment is elevated above the underlying skull
Impact usually tangential rather than perpendicular
Tangential skull fracutres- gun shot wounds- hemorrhage likely to be noted
Often affect frontal skull
Limited literature but associated with significant intracranial injury
Penetrating skull fracture
Result of gun shot, stab wounds, and blast injuries
Significant brain injury and hemorrhage
Emergent neurosurgical consult
