by THE CASE: 20-something year old male comes into the dept with bruising and swelling to his face. Pt states he was jumped yesterday and had followed up at a CITYMD but refused transfer to the ED for further imaging. Today he has come to the ED because his face is swollen and he is in pain with a slight headache. On physical exam, Pt had good ROM of his neck w/o pain, conjunctival hemorrhages bilaterally without any corneal abrasions under wood’s lamp, a little slow in answering questions. CT of face showing no acute fractures just gross edema, and no abnormalities on CT of brain.
There is clearly some concussion component going on here, what should we do to provide the best care in these patients?
Concussion: Mild Traumatic Brain Injury
Definition: Pt with GCS 14-15 with neurologic dysfunction that varies without gross lesions (MRI and CT are usually negative in these patients) after injury to the head [direct external contact forces OR brain bumped against
intracranial surfaces (MVC, roller coaster)].
Neurologic dysfunctions include: difficulty with memory, attention, concentration, reaction times, calculations
Physical symptoms include: headaches, dizziness, insomnia, fatigue, n/v, blurred vision, unsteady gait Will also include Behavioral changes such as: irritability, depression, sleep disturbances, anxiety, helplessness, loss of initiative
Pathophysiology: Can result in brain cortical contusions (brain bruises) with injury to the axons of the nerve (remember these are the parts of our nerves that send information), repeated injuries mean increased axonal swelling.
Flavors of Concussion:
1. Simple Concussion: resolution of symptoms within 7-10 days
2. Complex Concussion: symptoms worse with exertion, persistent symptoms or cognitive impairment
Why This is Important : Repeated traumatic brain injuries and concussions lead to a condition known as
Chronic Traumatic Encephalopathy which is a break down and loss of mass over a period of years to decades in addition to accumulation of tau protein (which we see in Alzheimer’s) and effects function of the neurons. In addition, there are numerous sequela of concussions that I will spend more time discussing in next week’s Scaries.
**according to EM:RAP’s review on concussions, it is not a requirement to have any LOC in order to have a concussion
Is our neuro exam enough? Using your favored clinical decision rules on whether or not to get the
head/cervical spine CT. Next, assess probable concussion using tools such as the Westmead post-traumatic amnesia scale (shown to have positive findings with more detailed neuropsych testing) or the Sport Concussion Assessment Tool- SCAT5 (not well validated but used by many in sports med for concussion assessment–attached as pdf). Realistically, if we do the Westmead in the ED, it’s good enough for us to determine if they have some component of concussion.
**ADMIT** any patient with GCS <15, seizure activity present, anticoagulation/bleeding disorders, or no responsible individual to observe them and potential worsening symptoms the next 24-48 hrs.
How to educate the concussed patient that you dispo home
#Golden Rule: abstain from any strenuous physical or cognitive activity for a minimum of 24 hrs and DO NOT resume
activities until acute concussive symptoms have resolved.
Suspend use of alcohol, recreational drugs, and anticoagulants
Cognitive rest including: no use of cell phones, TV, no reading, no homework…basically sit in a room and watch the paint dry or look outside the window
STRICT follow-up with primary care provider in 2 days for follow up assessment
Return to play for Athletes:
Step-wise approach of increasing physical activity that does not worsen symptoms, advancing gradually as long as concussion symptoms do not occur
Step 1: Return to regular activities (going to work/school)
Step 2: Light aerobic activity, about 5-10 minutes of walking, avoid weight lifting
Step 3: Moderate aerobic activity, increase heart rate with jogging, lighter weight lifting
Step 4: Heavy, non-contact activity including sprinting, regular weight lifting routine
Step 5: Practice & Full contact where pt has mostly controlled environment for contact sport Step 6: Competition
Encourage non-athletes to engage in physical activity (any intensity level) after the first 48 hours as it has been show to lower rates of persistent symptoms compared to those who had no activity
Lastly, spend the time educating the patient on precautions of when to return to the ED.
- inability to wake patient
- severe or worsening headaches confusion or somnolence seizures, unsteadiness in gait difficulties with vision
- vomiting, fever, stiff neck
- urinary or bowel incontinence
- weakness or numbness in any part of the body
Stay tuned for Part 2 next week
Happy Sunday Night Football!
References: https://wikem.org/wiki/Mild_traumatic_brain_injury
https://www.emrap.org/episode/emrapspecial/emrapspecial https://oemac.org/wp-content/uploads/2018/09/David-Elias-Diagnostic-and-Treatment-Challenges-in-mTBI-Concussion.pdf http://www.emdocs.net/concussion-in-sports-sideline-and-emergency-department-evaluation-and-management/ https://www.cdc.gov/headsup/basics/return_to_sports.html http://www.apta.org/PTinMotion/News/2017/1/5/ConcussionActivity/
