Concussions Flashcards Preview

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Flashcards in Concussions Deck (41)
1

Severe: GCS <9

Moderate: GCS 9-12

Mild: GCS 13-15

Used to classify what?

Traumatic Brain Injuries 

2

Almost 2 million TBI US/yearly 

75-95% fall into ____ category

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

"mild" 

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?

 

TBI 

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 _____?

TBI 

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

Glasgow Coma Scale (GCS)

6

Best eye response for TBI

How many grades are there?

4

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 

Best eye response for TBI 

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.) 

Best verbal response for TBI 

9

best verbal response for TBI

How many grades?

5

10

Best motor response for TBI

How many grades?

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.) 

Best motor response 

12

3 types of tissue deformation: Compression, Tensile, Shear

Mechanical injury to neurons & axons

Direct & indirect

Coup & Countercoup

Acceleration & deceleration

Seen in what?

Primary injury with TBI 

13

Tissue compression

 

Compression 

14

Tissue stretching

Tensile 

15

Tissue distortion when tissue slides over tissue 

Shear 

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?

Secondary injury 

17

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

Age

MOI (mech. of injury)

CC

Vitals

GCS

PMH

Rx

 

patient evaluation 

18

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

 

PE of patient evaluation

19

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

YES!

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

20

Battle's sign

Racoon eyes

CSF rhinorrhea or otorrhea

hemotympanum

Classic signs for what?

Basilar skull fracture 

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?

NOT likely 

22

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

Concussion

23

What does everyone with possible TBI get?

non-contast head CT

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 

Concussion 

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 

Concussion 

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?

Concussion 

27

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

80%

28

Diffuse cerebral swelling --> ICP 

Rare but fatal

Hypothesis: disordered cerebral autoregulation

Controversal 

Second impact syndrome 

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?

Grade 1 

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?

Grade 2 

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?

Grade 3 

32

No activity and rest until asx

Light aerobic exercise 

Sport-specific training

Non-contact drills

Full-contract drills 

Game play

 

Stepwise return to play 

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?

Concussion 

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%

 

Early post-traumatic seizures 

35

Within 5 years of traumatic event

50% within first year

80% within first 2 years 

Post-traumatic epilepsy 

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

Post-traumatic vertigo

37

Anosmia and hyposmia

Diplopia

Trigeminal/occipital neuralgia

Other complications of what?

Concussion 

38

May occur even with most mild TBI (30-80%)

Occurs within days to weeks after inital concussion

 

Post-concussion syndrome 

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 

Post-concussion syndrome 

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?

PCS 

41

Dementia Pugilistica

Chronic traumatic encephalopathy

cerebral atrophy

plaques, neurofibrillary tangles, tau proteins (similar to Alzheimers)

 

Cognitive deficits from repeated TBI