Concussions

Question 1

Severe: GCS <9

Moderate: GCS 9-12

Mild: GCS 13-15

Used to classify what?

Answer 1

Traumatic Brain Injuries

Question 2

Almost 2 million TBI US/yearly

75-95% fall into ____ category

Highest mortality for severe in young (15-24) and old (over 65)

Answer 2

“mild”

Question 3

• Young people
• Low income
• Unmarried
• Athletes (contact sports)
• Soldiers
• Members of ethnic minorities
• Residents of inner cities
• Men (3:1)
• Hx of substance abuse
• Suffered previous

At greatest risk for what?

Answer 3

TBI

Question 4

MVC/MVA (leading cause in general population)

Falls

Occupational accidents

Recreational accidents

Assaults/violance (war)

Sports

ALOCHOL (increases all the above)

Common causes of _____?

Answer 4

TBI

Question 5

15 point scale used to rate mental status and function—used to rate severity of brain injury and predict outcome

Based on eye opening, verbal responses and motor control

15 is the highest score

3 is the lowest score

Should be performed at triage and repeatedly during evaluation

Any decrease in score is a danger sign

Answer 5

Glasgow Coma Scale (GCS)

Question 6

Best eye response for TBI

How many grades are there?

Answer 6

4

Question 7

1. No eye opening
2. Eye opening in response to pain (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital pressure and/or sternal rub may be used—with caution)
3. Eye opening to speech. 1.. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)
4. Eyes opening spontaneously

Answer 7

Best eye response for TBI

Question 8

1. No verbal response
2. Incomprehensible sounds. (Moaning but no words.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Answer 8

Best verbal response for TBI

Question 9

best verbal response for TBI

How many grades?

Answer 9

5

Question 10

Best motor response for TBI

How many grades?

Answer 10

6

Question 11

1. No motor response
2. Extension to pain (decerebrate response)
3. Abnormal flexion to pain (decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied; pulls part of body away when nailbed pinched)
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands. (The patient does simple things as asked.)

Answer 11

Best motor response

Question 12

3 types of tissue deformation: Compression, Tensile, Shear

Mechanical injury to neurons & axons

Direct & indirect

Coup & Countercoup

Acceleration & deceleration

Seen in what?

Answer 12

Primary injury with TBI

Question 13

Tissue compression

Answer 13

Compression

Question 14

Tissue stretching

Answer 14

Tensile

Question 15

Tissue distortion when tissue slides over tissue

Answer 15

Shear

Question 16

Occurs in minutes, hours, days AFTER the inital insult

Microscopic/cellular: intracellular swelling, electrolyte imbalances (Na, K, Cl, Ca, Mg), inflammatory response (increased cytokines), Cytoxic edema, disruption of axonal neurofilament organization

More severe: cerebral arterial dilation, intracranial hemorrhage, cerebral edema, ischemia/hypoxia. increased intracranial pressure

What type of TBI injury?

Answer 16

Secondary injury

Question 17

Can be obtained in seconds on nursing not/triage form:

Age

MOI (mech. of injury)

CC

Vitals

GCS

PMH

Rx

Answer 17

patient evaluation

Question 18

Focused on head/neuro, but don’t forget C-spine!

Answer 18

PE of patient evaluation

Question 19

Can patient have skull fractures, scalp lacerations, scalp hematomas WITHOUT brain injury?

Answer 19

YES!

but be highly suspicious for underlying brain injury (serial exams, maybe admit for observation)

Question 20

Battle’s sign

Racoon eyes

CSF rhinorrhea or otorrhea

hemotympanum

Classic signs for what?

Answer 20

Basilar skull fracture

Question 21

No HA

No Vomitting

Age under 60

No intoxication

No deficits in STM

No physical evidence of trauma about clavicles

No seizure

No anticoags

likely or not likely to hve signficant intracranial injury?

Answer 21

NOT likely

Question 22

Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces

Answer 22

Concussion

Question 23

What does everyone with possible TBI get?

Answer 23

non-contast head CT

Question 24

May be caused by direct blow to the head, face, neck, or elsewhere on body with ‘impulse’ force transmitted to head

Results in graded set of clinical syndromes that may or may not involve loss of consciousness

Typically associated with grossly normal structural neuroimaging studies

Answer 24

Concussion

Question 25

Rapid onset of short-lived impairment of neurologic function that resolves spontaneously May result in neuropathological changes , but actue clinical sx largely reflect functional disturbance rather than structural injury

Answer 25

Concussion

Question 26

Vacant stare (befuddled facial expression) Delayed verbal expression (slower to answer or follow instructions) Inability to focus attention (easily distracted and unable to follow through w/ normal activites) Disorientation (wallking in wrong direction, unaware of time, date, place) Slurred/incoherent speech (making disjointed or incomprehensive statements) Gross observable incoordination (stumbling, inability to walk tandem/straight line) Emotionality out of proportion to circumstances (appearing distraught, crying for no apparent reason) Memory deficits (exhibited by patient repeatedly asking the same question that has already been answered or inability to memorize and return three of three words and three of three objects for five minutes) Any period of loss of consciousness (coma, unresponsiveness to stimuli) Signs of someone with what?

Answer 26

Concussion

Question 27

Some surverys have found that more than \_\_\_% of individuals with past concussion did not recognize it as such

Answer 27

80%

Question 28

Diffuse cerebral swelling --\> ICP Rare but fatal Hypothesis: disordered cerebral autoregulation Controversal

Answer 28

Second impact syndrome

Question 29

No loss of consciousness Post-traumatic amnesia or other signs lasting less than 30 mins Management: Athlete may return to play is asymptomatic for 1 week What grade of cantu guidelines for concussion?

Answer 29

Grade 1

Question 30

Loss of consciousness for less than 1 min **OR** Post-traumatic amnesia or other sx for more than 30 mins, less than 24 hours Management: Athlete may return to play in 2 weeks if asx at rest and on exertion for 7 days What cantu guidelines grade for concussion?

Answer 30

Grade 2

Question 31

Loss of consciousness for longer than 1 min **OR** Post-traumatic amnesia or other sx for longer than 24 hours Management: Athlete may return to play in one month if asx at rest and on exertion for 7 days What canti guideline grade for concussion?

Answer 31

Grade 3

Question 32

No activity and rest until asx Light aerobic exercise Sport-specific training Non-contact drills Full-contract drills Game play

Answer 32

Stepwise return to play

Question 33

Observation in ED Most discharged home If GCS\<15, abnormal head CT, seizures, abnormal bleeding --\> may need to admit Sleeping - no clear recommendations. One recommendation: awaken pt every 2 hours the first night and avoid strenuous activity for 24 hours and return with ANY concerning sx Tx for what?

Answer 33

Concussion

Question 34

Within first week after injury Occurs in less than 5% 1/4 occur in 1st hour, 1/2 occur in 24 hours Increases risk of post-traumatic epilepsy to 25%

Answer 34

Early post-traumatic seizures

Question 35

Within 5 years of traumatic event 50% within first year 80% within first 2 years

Answer 35

Post-traumatic epilepsy

Question 36

May be caused by multiple factors: Rupture of perilymphatic fluid Displacement of otiliths Direct injury to cochlear/vestibular structures More resistant to tx but usually resolves

Answer 36

Post-traumatic vertigo

Question 37

Anosmia and hyposmia Diplopia Trigeminal/occipital neuralgia Other complications of what?

Answer 37

Concussion

Question 38

May occur even with most mild TBI (30-80%) Occurs within days to weeks after inital concussion

Answer 38

Post-concussion syndrome

Question 39

Sx: HA, dizziness, vertigo, memory problems, difficulty with concentrating, sleeping problems, restlessness, irritability, apathy, depression, or anxiety May last for weeks More common in patients with pre-existing psychiatric dx (depression/anxiety) and in women

Answer 39

Post-concussion syndrome

Question 40

Tailored to patient Try to avoid narcotic pain medications Antidepressants/anxiolytics Counseling/Cognitive behavioral therapy Reassurance Donepezil (Aricept) Most get better in 3 mon-year Tx for what?

Answer 40

PCS

Question 41

Dementia Pugilistica Chronic traumatic encephalopathy cerebral atrophy plaques, neurofibrillary tangles, tau proteins (similar to Alzheimers)

Answer 41

Cognitive deficits from repeated TBI