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Clin Med III Unit 3 > Concussions > Flashcards

Concussions Flashcards

(53 cards)

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1
Q

What is the definition of a concussion?

A

A traumatically induced alteration in mental status that may or may not involve loss of consciousness

Also considered a mild TBI

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2
Q

Concussions are considered to be a _______ injury rather than a ______ injury.

A

Functional

Structural

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3
Q

The term concussion is interchangeable with _____

A

Mild TBI

People just don’t like being told they have a brain injury

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4
Q

What is the gender ratio for concussions?

A

M:F ratio ~ 2:1

Mostly b/c boys are stupid and do dumb shit

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5
Q

Examples of common precipitating events for mild TBIs

A

MVAs, contact sports, accidental falls, occupational hazards

75-95% of these injuries are considered “mild”

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6
Q

What are the requirements for a head injury to be considered a “mild” TBI?

A

GCS > 13

No acute cranial or intracranial pathology (NO STRUCTURAL INJURY)

Non-focal neurological exam

No post-traumatic seizures

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7
Q

Which patients must be closely managed for TBIs?

A

Those on anticoagulants - at higher risk for acute and delayed bleeding

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8
Q

Things you DON’T WANT TO MISS when working up a mild TBI

A

Intracranial hemorrhages (need neurosurg consult, surgical intervention, ICP lowering tx)

Focal neuro findings (intracranial, spinal, or occult peripheral injuries)

Anticoagulated patients (higher risk for acute/delayed bleeding)

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9
Q

What is the key to diagnosing a mild TBI?

A

Keeping the DDx broad

Act immediately on ABC issues and call for help

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10
Q

What is the mechanism of injury in mild TBIs?

A

Direct contact, acceleration/deceleration or “coup countrecoup”

Trauma causes cortical contusion, atonal inflammation, neurotransmitter signal disruption (basically a “brain bruise”)

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11
Q

Do you need imaging studies for mild TBIs?

A

Not usually

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12
Q

Presentation/Sx of Mild TBI

A

Hx of witnessed or suspected head trauma

Acute Sx:
\+/- TRANSIENT LOC
Retrograde/anterograde amnesia
Slow speech
Confusion
Repetitive questions
H/A
Dizziness
Decreased focus and attention
Emotional volatility
Sleep disturbance
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13
Q

W/o history, it is easy to mistake sx of mild TBI for other conditions such as…

A

EtOH intoxication

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14
Q

What are some signs of clinical deterioration in a patient with a TBI?

A

Decreasing mental status, seizures, vitals

“Lucid phase” followed by decreased mental status (associated with ICH, specifically epidural hematoma)

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15
Q

Precipitating sx of worsening condition following TBI

A

Chest pain, dyspepsia, syncopal episode, seizure like sx, severe sudden onset H/A, pleuritic chest pain

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16
Q

Concerning PMH items when working up a TBI

A 
Anticoagulation
DM
Syncopal or cardiac Dx
Seizure hx
Bleeding or platelet disorders
Elderly pt
Young pt
Osteoporosis
Dementia
New meds

Prior Hx of TBI

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17
Q

Concerning answers in SH when working up a TBI

A

Lives alone***
Homeless
Hx of or concurrent substance abuse

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18
Q

To constitute a mild TBI, physical exam findings should be…

A

Generally benign

Improving memory and psych deficits over time
Non-focal neuro exam
No SSx of basilar skull fracture or palpable cranial defect
“Cleared” C-spine

Do head to toe exam to r/o other injury

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19
Q

Concerning PE findings following TBI

A 
Battle sign
Raccoon eyes
CSF leaking from nose
Hemanotympani
Unequal pupils
Cervical spinal injury
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20
Q

How is a mild TBI diagnosed?

A

CLINICALLY

No specific test or imaging

Several scoring scales but have limited utility/not validated
• Sport Concussion Assessment Tool 5th ed. (SCAT5)
•Standardized Assessment of Concussion (SAC)

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21
Q

Any diagnostic tests you order for TBI are to…

A

R/o other illness, complicating factors, or to facilitate management of the patient’s condition

Ex:
Labs prior to hospital admission
CT to rule out structural injury

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22
Q

In general, mild TBI patients need close monitoring for ______

Study These Flashcards
A

24 hours

To make sure their condition doesn’t deteriorate

23
Q

Outpatient treatment of a mild TBI requires…

Study These Flashcards
A

Reliable adult to monitor patient

Discharge with careful, well-explained return precautions

24
Q

Factors that favor inpatient admission of a mild TBI patient

Study These Flashcards
A 
Unstable home situation 
No reliable caregiver
Significant comorbidities
GCS <15
\+ CT findings
\+ post-traumatic seizure
Intractable vomiting
Focal neuro findings
Anticoagulant use
25
How long should a mild TBI patient be on cognitive rest?
Generally 2-5 days rest and light activity at home Gradual return to cognitive activity, school, or work If patient can tolerate 30-45 min of focus (ie homework) w/o Sx they can trial return to school/work Implement more rest, reduce activity intensity if return of Sx
26
When should a patient with a mild TBI return to physical activity?sports
Can be difficult to implement b/c of non-compliant patient population Return should be graduated May use standardized protocol such as Return to Play
27
What are the steps in Return to Play protocol
1. No activity (Recovery) 2. Light Aerobic Exercise (Increase HR) 3. Sport Specific Exercise (Add movement) 4. Non-Contact Training Drills (Inc Exercise, Coordination, Attention) 5. Full Contact Practice For each step, if Sx free for 24 hours, step up to next step; if not, step down to previous step until Sx free
28
Pharmaceutical treatment for Mild TBI
Symptomatic: APAP, ibuprofen, melatonin
29
What do you do to follow up with a mild TBI
Patients should follow up with PCP w/in 7 days Regular f/u until asymptomatic important for athletes and peds
30
Indications for further f/u or specialty referral following mild TBI
Minimal improvement after 10 days Multiple TBIs, particularly with cumulative neuropsychiatric SSx Clinical deterioration
31
What is the prognosis for mild TBIs?
With full recovery, mild TBI typically benign May be associated with short and long term sequelae (inc M&M with recurrent TBI, associations with epilepsy, sleep disturbance, mood/behavior disorders, vertiginous disorders) Secondary and chronic syndromes: • Postconcussive Syndrome (PCS) • Second Impact Syndrome • Chronic Traumatic Encephalopathy
32
Common sequelae of mild TBI that includes HA, dizziness, mental fog, mild cognitive impairment, neurobehavioral changes, usually worst in first 7-10 days but can last up to 30-90
Post concussive syndrome (PCS)
33
More severe sx of PCS are correlated with...
Repeat injuries w/o full recovery Increased age F>M
34
What is the treatment for PCS?
Generally supportive • Tailored to address pt’s specific sx • Rx: analgesics, sleep aids, anti-depressants • Non-Rx: Patient Ed!, modified work/school schedule, psychiatric counseling MRI sometimes considered to r/o missed injury or etiology
35
Rare but potentially catastrophic consequence of suffereing a second concussion prior to full recovery from a prior TBI
Second Impact Syndrome
36
Pathophysiology of second impact syndrome
Cerebral autoregulation from initial injury leads to uncontrolled increase in ICP —> cerebral edema in context of second injury —> ischemic changes
37
Why is removal from play so important if there is any suspicion of TBI?
Risk of second impact syndrome (—> death)
38
Treatment for second impact syndrome
Non-specific Recognize signs of and treat elevated ICP Neurology, neurosurg consult
39
Constellation of symptoms and pathology findings seen with repeated head trauma (subconcussive blows and TBIs)
Chronic Traumatic Encephalopathy Hallmark is cumulative but often delayed and/or poorly recognized
40
SSx of CTE
Cognitive impairment, aggression, psychotic disorders, SI, HI, anxiety, depression, Parkinsonism, ALS, dementia, speech and gait disorders
41
110 of 111 brains of deceased NFL players had signs of ...
CTE (chronic traumatic encephalopathy) NFL plays estimated to have 3x the risk of neurodegenerative disease vs general pop
42
Pathophysiology of CTE
Pathologically distinct dysregulation of tau proteins (structural CNS proteins) Damaged, dysfunctional, immunoreactive proteins —> inflammation and further dysregulation of CNS
43
How is CTE diagnosed?
Can only be definitively diagnosed POST MORTEM (+) MRI findings but not sensitive/specific May be expected clinically based on Hx/presentation
44
Treatment for CTE
B/c definitive Dx not practically possible, current tx are symptomatic and non-specific Current research is all about PREVENTION
45
Anticoagulation with oral meds (Warfarin, others) increases the risk of ______ after head trauma
Intracranial bleed
46
All patients with head trauma who are on an oral anticoagulant should have...
A stat head CT regardless of LOC or other red flags
47
Intracranial bleed following TBI in patients on oral anticoagulants typically presents ________ after the initial injury
6-24 hours (but really, pretty quickly) That’s why we would observe an old man who hit his head and is on warfarin for 6 hours in the ED before considering D/C
48
Who else can you talk to besides the patient/family to get a better Hx?
EMS and nursing staff - they know what’s up
49
What is Cushing Reflex
Triad of HYPERtension, BRADYcardia, and IRRegular breathing Occurs due to increased ICP —> brainstem herniation/compression
50
When is the Cushing reflex most often seen?
In terminal phases of acute head injury Indicates very poor prognosis with death often occurring within minutes
51
How do you deal with Cushing Reflex?
Emergency ICP lowering interventions Emergent neurosurg consult
52
What is a main cause of AMS that can quickly lead to demise and you DON’T WANT TO MISS
Hypoglycemia ALWAYS do a finger stick blood glucose (seriously, it takes like 30 sec)
53
Why are c-collars controversial?
Takes patient out of position of comfort Can’t examine neck Can interfere with important interventions (ie intubation) Little data to show they prevent injury But we use them anyway 🤷‍♀️

Clin Med III Unit 3 (5 decks)

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