Concussions

Question 1

Concussion - Definition

Answer 1

Clinical syndrome characterized by an immediate and transient impairment of normal neurological function

Brain injury defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces

Question 2

Concussion facts

Answer 2

Functional disturbance rather than a structural disturbance
Majority resolve in 7-10 days
Caused by direct or indirect forces - over 100 G-forces in football impacts
Typically rapid onset, but some s/s may take a few hours to develop
Typically s/s do not significantly worsen over time and new ones to do not appear
Clinical neurological signs typically are not present
A concussion will not show on dx imaging

Question 3

Clinical domains of a concussion

Answer 3

Physical signs
Behavior changes
Cognitive impairment
Sleep disturbance

Question 4

Physical signs of concussion

Answer 4

Loss of consciousness
Loss of balance
Vomiting
Visual
Ha

Question 5

Behavior changes associated with concussion

Answer 5

Irritability
Aggression
Sadness

Question 6

Cognitive impairment associated with concussion

Answer 6

Delayed reaction
Lack of concentration
Amnesia

Question 7

DDX

Answer 7

Concussion
Diffuse axonal injury
Vascular rupture
Fx - laceration of brain

Question 8

Concussion dx

Answer 8

Dx of exclusion - need to r/o more serious pathology

R/o non-trauma and other trauma related conditions

Question 9

R/o non-trauma related causes

Answer 9

Stroke
Tumor
Meningitis
Aneurysm
Heat stroke
DM conditions

Question 10

R/o other trauma related conditions (direct or indirect)

Answer 10

Cranial fx
Intracranial hemorrhaging (increased intracranial pressure)
- subdural hematoma
- epidural hematoma
- intra-cerebral hematoma

Question 11

Concussion - dx and managment (in a nutshell)

Answer 11

1. Primary survey? CABs
2. Hx
3. Observation
4. Palpation?
5. Special Testing
   - r/o s/s of increased ICP
   - symptomatic baseline testing

Question 12

Concussion - hx

Answer 12

When did injury occur?
MOI
PMH of injury (frequency, duration, etc)
Basic s/s check

Question 13

Concussion - observation

Answer 13

Behavior
Thought process
Movement quality

Question 14

Concussion - Palpation

Answer 14

Fx?

Question 15

Special tests

Answer 15

R/o increased intracranial pressure

Baseline concussion assessment

Question 16

Increased intracranial pressure

Answer 16

S/s of increased intracranial pressure (red flags)
Pathological reflex present
- decorticate /decerebrate rigidity
- Babinski's sign
Increased DTR (hypereflexia)
Hypertonicity (spasticity and rigidity)
Decreased/absent superficial reflexes
CN dysfunction
S/s progressively worsening
Blurring of optic disc and hemorrhaging of retina
Increased BP and PP
Slow irregular pulse
Prolonged loss of consciousness
Seizure
Overall deterioration
GCS <15

Question 17

GCS Categories

Answer 17

Eye Opening response
Best verbal response
Best motor response

Question 18

GCS - eye opening responses

Answer 18

Spontaneously - 4
To speech - 3
To pain - 2
No response - 1

Question 19

GCS - Best verbal response

Answer 19

Oriented to time place & person - 5
Confused - 4
Inappropriate words - 3
Incomprehensible sounds - 2
No response - 1

Question 20

GCS - Best motor response

Answer 20

Obeys commands - 6
Moves to localized pain - 5
Flexion withdrawal from pain - 4
Abnormal flexion (decorticate) - 3
Abnormal extension from pain (decerebrate) - 2
No response - 1

Question 21

GCS Scoring

Answer 21

Best response - 15
Comatose client = 8
Totally unresponsive - 3

Question 22

CN Testing

Answer 22

Vision
Visual fields
Eye tracking
Facial sensation
Muscles of facial expression
Muscles of mastication
Hearing / balance
Swallowing
Upper trap / SCM strength
Tongue protrusion
Pupil reflexes

Question 23

Symptomatic Baseline Testing - Tests available

Answer 23

ImPACT
SAC
SCAT 5
CogSTate
ANAM
CogSport

Question 24

ImPACT

Answer 24

Immediate Post-concussion assessment and cognitive testing

Question 25

SAC

Answer 25

Standardized assessment of concussion

Question 26

SCAT

Answer 26

``` Sport concussion assessment tool Free Easy to administer Developed by leading experts Portions are valid/reliable ```

Question 27

ANAM

Answer 27

Automated neuropsychologial assessment metrics

Question 28

When to do symptomatic baseline testing

Answer 28

Pre-season baseline testing | Symptomatic baseline testing - not for dx, but for managment

Question 29

Managment

Answer 29

Cornerstone is cognitive and physical rest | Graduated return to activity when s/s reside

Question 30

Graduated return to sport

Answer 30

``` No activity until s/s free for 24-48h Light aerobic exercise Sport specific skills Non-contact raining drills Full contact drills Return to full, unrestricted play 24h for each stage if not return of s/s ```

Question 31

Return to learn

Answer 31

Gradual return to learning activities | Rest from cognitive strain

Question 32

VOMS

Answer 32

Vestibular Ocular Motor System Testing & tx Provocation of s/s Helps with dysfunction between eyes & ears

Question 33

Concussion management modifiers

Answer 33

``` Age Seizure d/o Depression Extended LOC Significant amnesia Duration of s/s ```

Question 34

Prevention

Answer 34

Equipment of little benefit in most sports Rule enforcement and rule changes Common sense

Question 35

Grading

Answer 35

Not a concern with newer guidelines

Question 36

Second impact syndrome

Answer 36

``` Patho Loss of auto-regulation of blood and CSF Rapid increased ICP and brain herniation Brain stem failure in 2-5 minutes Rare and difficult to determine incidence rate ```

Question 37

Chronic Traumatic Encephalopathy (CTE

Answer 37

Patho Atrophy of the brain Neuronal loss Protein build-up