Neuro chapter 11 Concussion Flashcards
1
Q
Concussion
Description
A
A complex pathophysiological process affecting the brain, induced by bio-mechanical forces: a brain injury.
2
Q
Description part 2
A
- Concussion typically causes a rapid onset of short-lived neurological impairment; this impairment usually resolves spontaneously. In some cases, symptoms and signs evolve over hours.
- Concussion may cause loss of consciousness
- Resolution of clinical and cognitive symptoms typically follows a sequential course.
3
Q
Concussion
Etiology
A
- Concussion results from a direct blow to the head, face, neck, or other body part that transmits an impulsive force to the head.
- Concussions can be mild, moderate or severe.
4
Q
Concussion
Incidence
A
- about 500,000 ED visits per year are for traumatic brain injury (TBI) in children 0-14 years old
- Adults 75 years or older have the highest rate of TBI-related hospitalization and death
- Significant causes: falls (40.5%), unintentional blunt trauma (15%), motor vehicle accidents (14%), and assault (10%).
5
Q
Concussion
Risk Factors
A
- Conditions or actions leading to falls, unintentional blunt trauma, motor vehicle accidents, assault
6
Q
Assessment Findings
Mild Traumatic Brain Injury
A
- period of observed or self-reported LOC lasting < 30 minutes.
~ Confusion and blunted affect.
~ Delayed responses and emotional changes.
~ Pain / dizziness / headache.
~ Change in sleep patterns
~ Visual disturbances include: seeing stars, blurry vision, double vision
~ amnesia: pretraumatic (retrograde) and post-traumatic (antegrade) amnesia.
7
Q
Assessment findings
Severe Traumatic Brain Injury
A
- period of observed LOS lasting > 30 minutes.
- post-traumatic amnesia lasting > 24 hours.
- penetrating craniocerebral injury
- signs of increased ICP:
~ Persistent vomiting
~ worsening headache
~ increasing disorientation
~ changing LOC - Inability to think clearly, difficulty remembering, trouble concentrating, feeling slow
- Irritability, sadness
- Sleeping more or less than usual, trouble falling asleep
8
Q
Physical Findings
A
- Injury/fracture involving the head, neck, facial bones, jaw or nose.
- persistent rhinorrhea or otorrhea (clear) might indicate possible skull fracture
- abnormalities in visual field exam, visual field, EOM, pupillary reflexes, saccades, smooth pursuit movements, vergence movements, and vestibulo-ocular movements.
- changes in strength and/or sensation in upper or lower extremities
- difficulty in coordinating and balance (finger-nose-finger test; slow, purposeful movements to complete task)
9
Q
Concussion
Differential Diagnosis
A
- Post-traumatic stress disorder (PTSD)
- Depression
- Headache syndromes
10
Q
Concussion
Diagnostic Studies
A
- Neurocognitive computer testing (IMPACT, SCAT3)
- Acute concussion evaluation (ACE) tool for ED and office
- CT scan (if meets criteria): not necessary with every concussion, with LOC and one of the following:
~ Headache
~ vomiting
~ age > 60 years
~ drug or alcohol intoxication
~ deficits in short-term memory
~ physical evidence of trauma above the clavicle
~ Post-traumatic seizure
~ GCS score < 15
~ Focal neurologic deficit
~ Coagulopathy
11
Q
Concussion
Prevention
A
- Promote use of helmets with sports, play activities (all ages)
- use of seatbelts, proper child restraints
- Emphasis on returning to play/activities after a concussion; evaluation by healthcare provider
- Implement safety measures to prevent falls in the home (older adults).
12
Q
Concussion
Nonpharmacologic management
A
- mainstay of concussion care is physical and cognitive rest
- evaluate for good sleep hygiene:
~ eliminate bedroom distractions that can affect sleep
~ limit intake of caffeine, alcohol, and nicotine - avoid excessive stress
- patient education regarding concussion, treatment options, etc.
13
Q
Concussion
Pharmacologic management
A
- focused on symptom management of sleep, somatic (headache), emotional, and cognitive.
- insomnia (short-term): consider melatonin, tricyclic antidepressants; avoid benzodiazepines due to negative effects on arousal and cognition
- tylenol and/or NSAIDs for headache (if ineffective, consider agents used to treat migraines, pain syndromes, tension-type headaches)
- drug therapy should target specific emotional symptoms (depression = SSRI, anxiety = buspirone)
- Amantadine may enhance cognitive processing
- Methylphenidate or other stimulants can be used to enhance attention, concentration, and processing speed, but should be used with caution.
14
Q
Concussion pharm therapy
A
Sleep
- nonbenzodiazepine, benzodiazepine receptor agonists
Somatic (headache)
- analgesics
- NSAIDs
- antiseizure
Emotional
- SSRI
- Nonbenzodiazepine anxiolytics
Cognitive processing
- antiviral
- central nervous system stimulants
15
Q
Sleep
Nonbenzo, benzo receptor agonists
Zolpidem (Ambien)
A
- caution with pregnancy re: teratogencitity
- may use during breastfeeding limited data about effect on milk production
- give > 7 hours before planned awakening, on empty stomach
- caution with concomitant CNS depressant, alcohol, or drug abuse history, respiratory or hepatic impairment, older age or debilitated state, change in smoking habits
- common adverse reactions: headache, drowsiness, dizziness, lethargy, drugged feeling
- serious reactions: complex sleep-related behavior, impaired mental alertness
16
Q
Sleep
Eszopiclone (Lunesta)
A
- caution with pregnancy
- for sleep onset issues, maximum 2mg/day for older adults
- avoid high-fat meal prior to administration
- taper dose gradually for prolonged use
17
Q
Sleep
Zaleplon (Sonata)
A
- caution with pregnancy
- contraindication: sensitivity
- for sleep onset issues, maximum 10mg/day for older adults
- avoid high-fat meal prior to administration
- taper dose gradually for prolonged use
18
Q
Somatic
Analgesics
Acetaminophen (Tylenol)
A
- metabolized in liver, excretion in urine 5-10% unchanged, with half-life 2-4 hours.
- drug of choice during pregnancy, no known fetal risk.
- maximum 3gram daily
- adjust dosing for renal impairment: CrCl 10-50, give every 6 hours for 325mg doses; CrCl < 10, given every 6 hours…
- educate patients that tylenol is found in many OTC products.
19
Q
Somatic
NSAIDs
Ibuprofen (Advil, Motrin)
A
- CAUTION IN FIRST TRIMESTER AND AVOID USE AFTER 30 WEEKS DUE TO INCREASED RISK OF FETAL HARM.
- maximum 2400mg daily
- contraindicated ASA triad
- caution with cardiac disease
- monitor Cr with severe renal disease and blood pressure
20
Q
Somatic
NSAIDs
Naproxen, Naproxen Sodium (Aleve)
A
- caution in first trimester and avoid use after 30 weeks due to increased risk of fetal harm.
- maximum 1100mg daily for OTC
- maximum 1375mg daily for prescription
- contraindicated ASA triad
- caution with cardiac disease
- avoid CrCl < 30
21
Q
Somatic
Antiseizure
Gabapentin (Neurontin)
A
- caution advised during pregnancy
- maximum 3600mg daily; taper dose > 7 days to D/C
- monitor Cr at baseline; signs and symptoms of depression, behavior changes, suicidality
22
Q
Somatic
Antiseizure
Topiramate
A
- risk of teratogenicity with prevalence of clet palate and low birth weight
- monitor Cr at baseline; signs and symptoms of depression, behavior changes, suicidality
23
Q
Emotional
SSRI
Sertraline (Zoloft)
Escitalopram (Lexapro)
A
- caution advised in pregnancy, especially in third trimester; risk of neonatal serotonin syndrome if withdrawn
- monitor for s/s of suicidality, clinical worsening, unusual behavior changes, especially during initial treatment or after dose change
- DO NOT USE IN CHILDREN
- Taper off gradually
- max dose 200mg/day
- escitalopram max 20mg/day
24
Q
Emotional
Nonbenzo Anxiolytics
Hydroxyzine (atarax)
A
- caution advised in pregnancy, low risk but limited human data.
- adjust dosing for CrCl < 50; decrease dose by 50%
25
Emotional
Nonbenzo Anxiolytics
Buspirone (BuSpar)
- may use during pregnancy; no known harm based on limited human data
- maximum 60mg daily for adults and children
- note: adjustments needed for renal or hepatic disease
26
Cognitive processing
Antiviral
Amantadine
- caution during pregnancy; no human data
- lactation: avoid use; possible decrease in milk production
- monitor Cr at baseline; decrease dose for renal impairment
- childrens dose should not exceed adults dose.
27
Cognitive Processing
Central Nervous System Stimulant
Methylphenidate (Aptensio XR, various generics)
- caution during pregnancy, no human data
- baseline cardiac evaluation in patient with risk factors; BP, HR at baseline, after dose increase, then periodically; height, weight in pediatric patients at baseline, then periodically; consider CBC with differentials, platelet count annually if prolonged treatment.
28
Concussion
| Pregnancy / Lactation considerations
- all nonbenzo hypnotics should be used with caution
- sertraline is drug of choice with lactation
- encourage patients to enroll in National Pregnancy Registry for Antidepressants
29
Concussion
| Consultation / Referral
- Refer immediately to ED for any signs of intracranial hemorrhage
- Refer to concussion specialist for ongoing symptom management
30
Concussion
| Follow-up
- Indicated until without sleep, headache or cognitive functioning symptoms
- serial neurocognitive computer testing and symptom report by the patient helps assess progress
31
Concussion
| Expected Course
- overall, progress is dictated by multiple factors: severity of concussion, age, overall health prior to injury, comorbid conditions (history of headache, ADHD, depression)
- residual headaches and sleep issues are common.
- Recovery can take weeks to months and is different for each person.
- Gradual return to daily activities.
32
Concussion
| Possible Complications
- Post-traumatic seizures
- agitation
GI and GU complications
