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Concussions & Head Injuries

Topic updated on 05/23/16 4:30pm
Introduction
Anatomy
  • Layers of the spinal cord include the 
    • dura mater (outside)
      • epidural hematoma 
      • subdural hematoma
    • arachnoid (middle)
      • subarachnoid hematoma
    • pia mater (inside)
Classification
  •   American Academy of Neurology (AAN) guidelines
Grade
Definition
Grade I No loss of consciousness and symptoms of confusion last less than 15 minutes
Grade II No loss of consciousness and symptoms of confusion last greater than 15 minutes
Grade IIIa Brief loss of consciousness (measured in seconds)
Grade IIIb
Brief loss of consciousness (measured in minutes) 
 
Presentation
  • Symptoms
    • headache and dizziness most common symptoms
    • amnesia (memory loss)
Imaging
  • CT
    • usually normal
    • rule out intracranial hemorrhage
      • subdural hematoma most common
      • epidural, subarachnoid, intracerebral bleeds also possible
      • CT required if patient is unconscious for greater than 5 minutes
Evaluation
  • Standard Assessment of Concussion Test (SAC) 
    • orientation, memory, concentration, exertional delayed recall
  • Immediate Post-Concussion Assessment and Cognitive Testing battery (ImPACT) 
    • a computer-based test that assess the users attention, memory, and processing speed
    • comparison is made to baseline scores or historical controls
    • useful tool in guiding treatment and return to play decisions
  • Memory testing
    • antegrade and retrograde must be tested
  • Balance error scoring system (BESS)
Treatment
  • Nonoperatve
    • same day return to play is NOT indicated in patients diagnosed with concussion  
    • graduated return to play
      • indications
        • any athlete <18 years of age
        • elite athletes of any age without team physicians experienced in concussion management
      • technique (see table below)
        • each step should take 24 hours, so an athlete should take one week to proceed through the full protocol and return to play 
    • return to play contraindicated until further evaluation  
      • indications
        • LOC
        • prior Grade 1 concussion in same season
        • symptoms > 15 minutes
        • positive exertional stress test
        • amnesia
        • postconcussion syndrome
  • Prevention
    • includes enforcing proper head gear
    • minimizing premature return to play
Graduated Return to Play Protocol
Rehabilitation Stage Exercise at each stage of rehabilitation Objective of each stage
1. No activity Complete physical and mental rest
Recovery
2. Light aerobic exercises Walking, swimming, or stationary cycling to maintain HR at <70% of maximum.  No resistance training
Increase heart rate
3. Sport-specific exercise No head impact activities
Add motion
4. Non-contact training drills More complex training drills and may begin resistance training
Exercise, coordination, and improved cognition
5. Full contact practice Normal training activities
Restore confidence, assess functional skills
6. Return to play Normal game play
 
 
Complications
  • Second impact syndrome
    • second minor blow to head before initial symptoms resolve
    • due to loss of autoregulation of the brain's blood supply
    • 50% mortality rate
    • affects adolescent males
  • Epidural bleeding
    • commonly have a lucid period before neurologic decline
    • neurosurgical decompression and seizure prophylaxis indicated
  • Cumulative effects
    • cumulative effects of repeated concussions is controversial
  • Postconcussion syndrome
    • headache, confusion
    • RTP contraindicated

 

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Qbank (7 Questions)

TAG
(SBQ07.20) Which of the following is the most common injury sustained as the result of a non-helmeted rider falling off a horse? Topic Review Topic

1. Cervical neck strain
2. Subdural hematoma
3. Proximal humerus fracture
4. Lumbar spine fracture
5. Tibia fracture

PREFERRED RESPONSE ▶
TAG
(OBQ12.60) In which of the following situations is it appropriate to allow the athlete to return to play on the same day?

Topic Review Topic

1. 15-year-old American Football player develops a headache with no further symptoms after being tackled to the ground and parents sign a waiver giving permission for him to play
2. 21-year-old baseball player collides with another player while sliding head-first into second base and has five minutes of right upper extremity pain, paresthesias, and deltoid weakness
3. 23-year-old college soccer player sustains a hit to the head from a long kick with 15 seconds loss of consciousness
4. 16-year-old American Football player who strikes a player head-first can't remember the last play he was injured on but parents agree to sign consent for him to play
5. 18-year-old African American baseball player is hit in the head with a 95 mph fastball with immediate nausea and diplopia, but normal neuropsychologic testing

PREFERRED RESPONSE ▶
TAG
(OBQ11.124) Which of the following is a computer-based neurocognitive test that assesses the users attention, memory, and processing speed? Topic Review Topic

1. Immediate Post-Concussion Assessment and Cognitive Testing battery (ImPACT)
2. Standardized Assessment of Concussion (SAC)
3. Sport Concussion Assessment Tool (SCAT)
4. Sport Concussion Assessment Tool II (SCAT-2)
5. Safe Concussion Outcome Recovery & Education (SCORE)

PREFERRED RESPONSE ▶
TAG
(OBQ04.254) An athlete who sustains a head injury should be removed from competition for each of the following findings EXCEPT: Topic Review Topic

1. Symptoms lasting more than 15 minutes
2. Recurrence of symptoms with exertion
3. Amnesia
4. History of prior concussion
5. Low baseline neuropsychological testing

PREFERRED RESPONSE ▶
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