Emergency Medicine Book

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Concussion

Aka: Concussion, Concussion in Sports, Brain Concussion, Concussion Red Flags
  1. See Also
    1. Head Trauma
    2. Mild Traumatic Brain Injury
    3. Return to Play after Concussion
    4. Concussion Grading
    5. Postconcussion Syndrome
    6. Cognitive Deficit following Concussion
  2. Definition: Concussion
    1. Mildest form of minor Traumatic Brain Injury
    2. Acute Trauma-induced mental function alteration
    3. Transient loss of consciousness variably present (10% overall, 40% of Emergency Department evaluations)
  3. Epidemiology
    1. Incidence: 1 in 220 children annually (30-50% sports related, esp. football and soccer)
  4. Pathophysiology
    1. Concussion results in acute Neuron injury (esp. axonal Stretching and shearing)
      1. Leads to extracellular release of ions (esp. Potassium) and neurotransmitters (esp. glutamate)
    2. Increased energy demands (esp. ATP) to correct ion disruption (e.g. Sodium-Potassium ATP Pump)
      1. Yet decreased blood flow to injured tissue results in energy delivery deficit
    3. Metabolic derangements resolve over the course of weeks (corresponding to symptom improvement)
      1. Recovery may approach 7 weeks (or longer in younger children)
      2. In some cases, especially in young children, effects may persist longterm
  5. Risk Factors
    1. Active duty military deployed to combat regions
      1. Traumatic Brain Injury affected 15% U.S. troups involved in Iraq and Afghanistan
    2. Non-Sports related injury
      1. Falls (38%)
      2. Vehicle-related injuries (31%)
      3. Non-accidental Trauma (11%)
    3. Contact Sports Participation
      1. Football
        1. Most common cause of sports-related Concussion in U.S.
        2. Concussion in 20% of high school and 10% of college athletes each year
      2. Ice Hockey
      3. Soccer
        1. Second most common cause of Concussion in U.S. (especially in female athletes)
      4. Boxing
      5. Lacrosse
      6. Wrestling
      7. Basketball
      8. Softball
    4. Non-Contact Sports Participation
      1. Bicycling
      2. Playground-related injuries
      3. Gymnastics
      4. Skiing
      5. Sledding
      6. Ice Skating
      7. Inline Skating
      8. Horseback riding
  6. Symptoms
    1. See Concussion Symptom Checklist
    2. Headache (75%, most common)
    3. Blurred vision (75%)
    4. Dizziness (60%)
    5. Nausea or Vomiting (54%)
    6. Double Vision (11%)
    7. Noise sensitivity or light sensitivity (4%)
    8. Slurred speech
    9. Imbalance or Incoordination
      1. Typically lasts 3-5 days after Concussion
    10. 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
      6. Decreased verbal learning and memory
  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: Acute clinical
    1. See Head Injury
    2. Systematic evaluation (unless isolated Minor Head Injury)
      1. See Trauma Evaluation (includes Primary Survey)
      2. See Secondary Trauma Evaluation
    3. Neurologic evaluation
      1. See Emergency Neurologic Exam
      2. Glasgow Coma Scale (GCS)
      3. Complete Neurologic Exam
      4. Oculomotor testing
        1. Sensitive for minor Concussion
        2. Observe for Nystagmus, saccades, CN IV palsy, Anisocoria
    4. Assess for significant head and neck injuries
      1. Intracranial Hemorrhage (Epidural Hemorrhage, Subdural Hemorrhage)
      2. Skull Fracture
      3. Scalp Laceration with active bleeding (control bleeding as part of Primary Survey)
      4. Cervical Spine Injury (or Pediatric Cervical Spine Injury)
  11. Evaluation: Sideline or in sports medicine evaluation
    1. Sport Concussion Assessment Tool ( SCAT3)
      1. Comprehensive - includes all other tests listed below
      2. Age 13 years old and older (SCAT3)
        1. http://bjsm.bmj.com/content/47/5/259.full.pdf
      3. Age younger than 13 years old (Child-SCAT3)
        1. http://bjsm.bmj.com/content/47/5/263.full.pdf
    2. Tools included in SCAT3
      1. Concussion Symptom Checklist (22 points)
      2. Glasgow Coma Scale (15 points)
      3. Maddocks Score (5 points)
      4. Balance Error Scoring System (30 points)
      5. Finger-to-Nose Test (1 point)
      6. Standard Assessment of Concussion (30 points total)
    3. Other tools
      1. Computer based Neuropsychological Testing (e.g. ImPACT)
      2. Postconcussive Symptom Scale
        1. http://www.hawaiiconcussion.com/pdf/post-concussion-symptom-scale.aspx
  12. Imaging
    1. Head imaging indications
      1. See Head Injury CT Indications in Adults
      2. See Head Injury CT Indications in Children
    2. C-Spine imaging indications
      1. See Cervical Spine Imaging in Acute Traumatic Injury
      2. See NEXUS Criteria
  13. Management
    1. Acute evaluation and management should follow Head Injury protocol
    2. See Head Injury
    3. See Management of Mild Head Injury
    4. See Cervical Spine Injury
    5. See Pediatric Cervical Spine Injury
  14. Management: Disposition
    1. See Mild Head Injury Home Management
      1. Includes Head Injury Precautions (criteria for immediate follow-up)
    2. See Return to Play after Concussion
      1. Includes graduated (stepped) return to play protocol
    3. See Cognitive Deficit following Concussion
    4. See Postconcussion Syndrome
    5. Follow-up with medical provider
      1. Consider Concussion clinic (sports medicine) follow-up
  15. Course
    1. Symptoms may evolve or worsen over the first few days after Concussion
    2. Symptoms may persist for weeks to months
    3. Common Symptoms typically resolve by 1 week in most cases
      1. Headache (most common)
      2. Dizziness
      3. Sleep disturbance (daytime Somnolence, difficulty initiating and maintaining sleep)
    4. Cognitive Symptoms typically resolve by 2-4 weeks in most cases
      1. Impaired attention and memory
      2. Difficult Executive Function (e.g. organization, planning, reasoning)
    5. Prolonged course in a sizeable majority
      1. Anticipate resolution by 3 months (even in prolonged cases)
        1. In rare cases, symptoms persist years
      2. Postconcussion Syndrome (lasting 3 months)
        1. Identified on neurocognitive testing in up to 30% of children at 3 months
        2. Overall, more sensitive testing suggests >38% develop Postconcussion Syndrome
  16. Complications
    1. Postconcussion Syndrome
    2. Recurrent Head Injury (especially if next Head Injury before recovery from the last)
      1. Second Impact Syndrome
      2. Cumulative neuropsychologic deficits
        1. See Cognitive Deficit following Concussion
      3. Chronic Traumatic encephalopathy
    3. Serious acute and subacute complications
      1. Cerebral edema
      2. Intracranial bleeding (Epidural Hematoma, Subdural Hematoma)
  17. Prevention
    1. Mouth guards prevent dental injury but not Concussion
  18. References
    1. (1997) Neurology 48:581-5 [PubMed]
    2. (1999) Pediatrics 104:1407-15 [PubMed]
    3. Cantu (1986) Phys Sportsmed 14(10):75-83 [PubMed]
    4. Hunt (2010) Clin Sports Med 29(1): 5-17 [PubMed]
    5. Kushner (2001) Am Fam Physician 64:1007-14 [PubMed]
    6. McCrory (2012) Br J Sports Med 47(5): 250-8 [PubMed]
    7. Putukian (2011) Clin Sports Med 30(1): 49-61 [PubMed]
    8. Patel (1010) Pediatr Clin North Am 57(3): 649-70 [PubMed]
    9. Scorza (2012) Am Fam Physician 85(2): 123-32 [PubMed]
    10. Whiteside (2006) Am Fam Physician 74(8):1357-62 [PubMed]

Brain Concussion (C0006107)

Definition (MEDLINEPLUS)

A concussion is a type of brain injury. It's the most minor form. Technically, a concussion is a short loss of normal brain function in response to a head injury. But people often use it to describe any minor injury to the head or brain.

Concussions are a common type of sports injury. You can also have one if you suffer a blow to the head or hit your head after a fall.

Symptoms of a concussion may not start right away; they may start days or weeks after the injury. Symptoms may include a headache or neck pain. You may also have nausea, ringing in your ears, dizziness, or tiredness. You may feel dazed or not your normal self for several days or weeks after the injury. Consult your health care professional if any of your symptoms get worse, or if you have more serious symptoms such as

  • Seizures
  • Trouble walking or sleeping
  • Weakness, numbness, or decreased coordination
  • Repeated vomiting or nausea
  • Confusion
  • Slurred speech

Doctors use a neurologic exam and imaging tests to diagnose a concussion. Most people recover fully after a concussion, but it can take some time. Rest is very important after a concussion because it helps the brain to heal.

Centers for Disease Control and Prevention

Definition (MSHCZE) Náhlá porucha mozkových funkcí vyvolaná úrazem a provázená různě dlouhým bezvědomím (od zlomků sekundy po hodiny). Následují obvykle bolesti hlavy, vegetativní poruchy (nevolnost, zvracení). Pacient si nevzpomíná na události těsně předcházející úrazu (retrográdní amnézie). Není přítomen zřetelný neurologický deficit. Prognóza je většinou dobrá a stav se upraví, i když určité obtíže např. bolesti hlavy mohou přetrvávat i měsíce. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) A violent jar or shock, or the condition which results from such an injury.
Definition (NCI_FDA) A violent jar or shock, or the condition which results from such an injury.
Definition (MSH) A nonspecific term used to describe transient alterations or loss of consciousness following closed head injuries. The duration of UNCONSCIOUSNESS generally lasts a few seconds, but may persist for several hours. Concussions may be classified as mild, intermediate, and severe. Prolonged periods of unconsciousness (often defined as greater than 6 hours in duration) may be referred to as post-traumatic coma (COMA, POST-HEAD INJURY). (From Rowland, Merritt's Textbook of Neurology, 9th ed, p418)
Concepts Injury or Poisoning (T037)
MSH D001924
ICD9 850.9, 850
ICD10 S06.0, S06.00, S06.0X9, S06.0X
SnomedCT 157321003, 209832007, 81371004, 110030002
LNC LA7422-4
English Brain Concussions, Concussion, Brain, Concussion, unspecified, concussion (diagnosis), concussion, Cerebral Concussion, Cerebral Concussions, Concussion, Cerebral, Commotio Cerebri, Brain Concussion [Disease/Finding], Concussive injury, brain concussion, cerebral concussion, commotio, concussion disorder, brain concussions, concussions, Concussion NOS, Brain Concussion, Concussion NOS (disorder), concussion injury of brain (diagnosis), Brain--Concussion, CONCUSSION, Concussion, Commotio cerebri, Cerebral concussion, Brain concussion, Commotio, Concussion (disorder), Concussion injury of brain (disorder), Concussion injury of brain, brain; blast, brain; commotio, brain; concussion, cerebral; concussion, cerebri; commotio, commotio cerebri, commotio; brain, concussion; brain, concussion; cerebral, Concussion (Brain), Injury;concussion;head
Italian Concussione, Concussione non specificata, Commotio cerebri, Commozione cerebrale
Dutch commotio cerebri, hersenschudding, niet-gespecificeerd, cerebraal; concussie, cerebri; commotie, commotie; hersenen, concussie; cerebraal, concussie; hersenen, hersenen; commotie, hersenen; concussie drukgolf, hersenen; concussie, hersenschudding, Hersenschudding, Commotio cerebri
French Commotion , non précisée, Commotion de l'encéphale, Commotion cérébrale, Commotion encéphalique, Commotion
German Gehirnerschuetterung, unspezifisch, Gehirnerschuetterung, Commotio cerebri, Gehirnerschütterung
Portuguese Concussão NE, Comoção cerebral, Concussão Encefálica, Concussão Cerebral, Comoção Cerebral, Comoção Encefálica, Concussão
Spanish Conmoción no especificada, Conmoción cerebral, Conmoción Encefálica, Conmoción Cerebral, conmoción (trastorno), conmoción(trastorno), conmoción, SAI (trastorno), conmoción, SAI, Concusión Cerebral, Concusión Encefálica, concusión cerebral (trastorno), concusión cerebral, concusión, conmoción cerebral (trastorno), conmoción cerebral, conmoción, lesión cerebral por concusión, Conmoción
Japanese 脳振盪、詳細不明, ノウシントウ, ノウシントウショウサイフメイ, 脳振とう, 脳振とう症, 脳振盪, 脳振盪症, 脳震とう, 脳震盪
Swedish Hjärnskakning
Finnish Aivotärähdys
Russian MOZGA GOLOVNOGO SOTRIASENIE, МОЗГА ГОЛОВНОГО СОТРЯСЕНИЕ
Czech Otřes mozku, blíže neurčený, Komoce mozková, Otřes mozku, otřes mozku, komoce mozku, mozek - komoce, commotio cerebri
Korean 뇌진탕
Croatian POTRES MOZGA
Polish Wstrząśnienie mózgu
Hungarian Commotio, nem meghatározott, Commotio cerebri, Commotio
Norwegian Hjernerystelse, Commotio cerebri
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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