Concussion

1. See Also
   1. Head Trauma
   2. Mild Traumatic Brain Injury
2. Definition: Concussion
   1. Acute trauma-induced mental function alteration
   2. Duration under 24 hours
   3. Loss of consciousness may be present
3. Pathophysiology: Second Impact Syndrome
   1. Repeated Concussions over short period of time
   2. Results in progressive cerebral edema
4. Epidemiology: Incidence Concussion in football per year
   1. High School athletes: 20%
   2. College athletes: 10%
5. Risk Factors
   1. Contact Sports Participation
      1. Football
      2. Ice Hockey
      3. Soccer
      4. Boxing
      5. Lacrosse
      6. Wrestling
      7. Basketball
   2. Non-Contact Sports Participation
      1. Gymnastics
      2. Skiing
      3. Sledding
      4. Ice Skating
      5. Inline Skating
      6. Horseback riding
6. Symptoms
   1. See Concussion Symptom Checklist
   2. Headache (most common)
   3. Dizziness
   4. Nausea or Vomiting
   5. Slurred speech
   6. Imbalance or Incoordination
      1. Typically lasts 3-5 days after Concussion
   7. Loss of consciousness
      1. Present in 10% of Concussions
7. Signs
   1. Amnesia
   2. Disorientation
   3. Confusion
      1. Vacant stare
      2. Disorientation
      3. Delayed answers to questions
      4. Poor concentration
      5. Inattention
8. Signs: Red Flags for severe Head Injury
   1. Mental status changes
      1. Loss if consciousness for more than 60 seconds
      2. Somnolence or confusion
      3. Disorientation
      4. Language or speech deficit
      5. Memory deficit
   2. Eye findings (Brainstem dysfunction)
      1. Visual disturbance
      2. Pupils unequal, fixed or dilated
      3. Extraocular Movements abnormal
   3. Deep Tendon Reflexes (Upper motor neuron dysfunction)
      1. Hyperreflexia
      2. Babinski Reflex present
   4. Muscle Strength
      1. See Motor Exam
      2. Decreased muscle tone or weakness (especially asymmetric)
      3. Involuntary movements (consider basal ganglia or cerebellar injury)
   5. Sensory deficit
      1. See Sensory Exam
      2. Numbness or abnormal sensation (consider dermatomal pattern for spinal root deficit)
   6. Incoordination or Balance problem (Cerebellar dysfunction)
      1. Rhomberg sign positive
      2. Ataxic gait
      3. Postural instability (e.g. abnormal Balance Error Scoring System)
      4. Finger-to-Nose Test
9. Grading
   1. See Concussion Grading
10. Evaluation: Stabilization
    1. See Management of Mild Head Injury
    2. See Primary Survey
    3. See Secondary Trauma Survey
    4. See Head Injury
    5. See Cervical Spine Injury
11. Evaluation: Sideline
    1. Sport Concussion Assessment Tool ( SCAT2)
       1. http://www.cces.ca/en/files-116
       2. Comprehensive - includes all other tests listed below
    2. Concussion Symptom Checklist (22 points)
    3. Glasgow Coma Scale (15 points)
    4. Maddocks Score (5 points)
    5. Balance Error Scoring System (30 points)
    6. Finger-to-Nose Test (1 point)
    7. Standard Assessment of Concussion (30 points total)
12. Imaging
    1. See Head Injury CT Indications in Concussion
13. Management: General Guidelines
    1. See Mild Head Injury Home Management
    2. See Return to Play after Concussion
    3. See Cognitive Deficit following Concussion
    4. See Postconcussion Syndrome
14. Patient Instructions: Criteria for immediate follow-up
    1. See Head Injury Precautions
15. Complications
    1. Cumulative neuropsychologic deficits
       1. See Cognitive Deficit following Concussion
    2. Cerebral edema
    3. Second Impact Syndrome
       1. Occurs only in children and adolescents
       2. Rapid cerebral edema with no effective treatment (does not respond to manitol)
       3. Mortality approaches 50%
    4. Intracranial bleeding
    5. Postconcussion Syndrome
16. References
    1. (1997) Neurology 48:581-5
    2. (1999) Pediatrics 104:1407-15
    3. Cantu (1986) Phys Sportsmed 14(10):75-83
    4. Kushner (2001) Am Fam Physician 64:1007-14
    5. Whiteside (2006) Am Fam Physician 74(8):1357-62
    6. Scorza (2012) Am Fam Physician 85(2): 123-32
    7. Putukian (2011) Clin Sports Med 30(1): 49-61
    8. Patel (1010) Pediatr Clin North Am 57(3): 649-70
    9. Hunt (2010) Clin Sports Med 29(1): 5-17