Concussions

Question 1

Concussions are also known as?

Answer 1

mild traumatic brain injury

Question 2

1. What kind of trauma are concussions due to? 3
2. Due to what kind of pathology?
3. How do most resolve?
4. Full recovery in how long?

Answer 2

1.

• direct blow,
• countercoup, or
• rotational/acceleration injury

2. Due to changes in brain physiology rather than structural changes
3. 80–90% resolve in a short period (7–10 days)
4. Most HS athletes fully recovered in 14-21 days

Question 3

Define the following:

1. Coup?
2. Countercoup?
3. Rotational?
4. Can it happen without trauma?

Answer 3

1. Coup- direct blow – skull driven into brain
2. Countercoup- brain driven into far skull
3. Rotational-features of both
4. yes, deceleration injury

Question 4

What do concussions impair?
3

What will CT, MRI and EEG show?

Answer 4

1. Glucose metabolism
2. Cerebral blood flow
3. Axonal Function

structural changes are rare (normal imaging)

Question 5

Diagnosis of concussion?

5

Answer 5

1. history,
2. signs and symptoms,
3. exam findings, 4. neurocognitive testing,
4. balance testing

Question 6

Loss of consciousness seen in only 10%

Presence of ________ more predictive of symptoms and neurocognitive deficits than loss of consciousness.

Answer 6

amnesia

Question 7

Cognitive symptoms of concussion?

6

Answer 7

1. Feeling ‘dinged, foggy, or dazed’ – not ‘with it’
2. Inability to focus attention – easily distracted
3. Cognitive slowing, confusion, amnesia
4. Memory dysfunction: disorientation
   - —-Repeatedly asking the same question
5. Inappropriate emotionality: sadness, irritability, anger
6. Fatigue

Question 8

Physical Symptoms of concussion?

8

Answer 8

1. Double vision,
2. seeing stars,
3. light sensitivity
4. Headaches,
5. ringing in the ears,
6. nausea
7. Balance problems and dizziness
8. Difficulty falling asleep or sleeping less than usual

Question 9

Physical Signs of concussion?

8

Answer 9

1. Vacant stare
2. Poor coordination or unsteady gait
3. Slow to answer questions or follow commands
4. Poor concentration
5. Slurred or incoherent speech
6. Behavior or personality changes
7. Diminished ability or reckless playing behavior
8. Loss of consciousness or seizure

Question 10

How should we test mental staus? 3

Answer 10

1. Orientation
2. Concentration
3. Memory

Question 11

1. How should we test orientation? 4
2. How should we test concentration? 2
3. How should we test memory? 2

Answer 11

1. • time,
   • place,
   • person,
   • situation
2. • subtraction
   • months backwards
3. • details of contest
   • recent newsworthy events

Question 12

How should we test for gait and balance?

3

Answer 12

1. Have patient walk away and back - look for imbalance
2. Tandem gait: heel-toe on a straight line
3. Romberg: feet together and close eyes positive if they lose their balance

Question 13

Signs Demanding Emergency Action

6

Answer 13

1. Increasing headache, nausea, vomiting
2. Progressive impairment of consciousness
3. Gradual rise in blood pressure
4. Diminution of the pulse rate
5. Blown pupil
6. Disorientation

Question 14

Head injury referral: Emergent?

6

Answer 14

1. Suspicion for hematoma
2. C-spine injury
3. Worsening LOC
4. Focal motor weakness
5. Transient quadriparesis
6. Seizure

Question 15

Head injury referral: General?

5

Answer 15

1. Persistent headache > 7 days
2. Post concussion syndrome lasting > 2 wks
3. Abnormal neuropsych testing
4. History of multiple high grade concussions
5. Clinical judgment

Question 16

Concussion Can Mimic Other Disorders such as?

6

Answer 16

1. Substance Abuse/Dependency
2. Intermittent Explosive Disorder
3. Suicidal Ideation/Tendencies
4. Depression
5. Mood Disorder
6. Impulse Control

Question 17

Severe Head injuries that can be associated with concussion?

5

Answer 17

1. Focal Neurologic Deficit
2. Increased Intracranial Pressure
3. Skull Fracture
4. Hematoma
5. Spinal Cord Injury

Question 18

What are the clinical features of increased intracranial pressure?
4

Answer 18

1. Headache,
2. vomiting,
3. papilledema,
4. brain stem herniation

Question 19

Onfield evaluation?

3

Answer 19

1. ABCs always come first
2. Any loss of consciousness, treat as cervical spine injury
3. Any signs of neurologic deficits, immediate transfer to ER

Question 20

Any loss of consciousness, treat as cervical spine injury. So what do we do? 2

Answer 20

1. C-spine precautions

2. immobilization

Question 21

Sideline evaluations?

3

Answer 21

1. Signs, symptoms
2. Mental status
3. Gait assessment & balance

Question 22

What are the problems with sideline evaluation?

4

Answer 22

1. Players/coaches/parents know consequences of concussion – no play
2. Can happen on all plays, injury may not be seen
3. Concussions don’t only happen on big hits
4. Dx difficult if athlete doesn’t report and changes are not noted

Question 23

Post Game Evaluation

4

Answer 23

1. Can determine if additional testing needed- emergent or not
2. Should include take home instructions
3. Coordinate the care and follow-up of the injured athlete
4. Discuss status of athlete with parents, ATs, coaching staff

Question 24

Indications for Transfer to Emergency Department

5

Answer 24

1. Loss of consciousness
2. Possible cervical spine injury or skull fracture
3. High risk for intra-cranial bleed
4. Post-traumatic seizure
5. Acute worsening of mental status

Question 25

Treatment of Mild Concussions | 5

Answer 25

1. While symptomatic – rest, fluids, and good nutrition 2. Physical rest – sleep is good (no training, playing, exercise) 3. Cognitive rest (no TV, video games, texting, studying) 4. Avoid NSAIDs first 48 hours 5. Avoid recreational activities that have risk for head injury

Question 26

Why should we avoid NSAIDS in the first 48 hours?

Answer 26

Increases the risk of bleeding | better to take acetometaphin

Question 27

Describe the rule of 3s for concussions.

Answer 27

1 concussion: out of game/full practice for several days 2 concussions: out for the season 3 concussions: out of the sport

Question 28

Progression for Return | 6

Answer 28

1. Recurrence of symptoms at any point, drop back 2. Aerobic exercise – light walking, biking 3. Sport-specific activities without opponent - ---Dribbling, shooting, throwing, kicking 4. Non-contact drills 5. Full-contact drills 6. Return to Game Play

Question 29

1. What is second impact syndrome? 2. Occurs following what? 3. Occurs before what?

Answer 29

1. Second impact to the brain during the vulnerable metabolic cascade – sudden, severe swelling 2. Occurs following a head injury/concussion 3. Occurs prior to healing of initial injury

Question 30

Why is this second impact syndrome serious and dangerous? | 2

Answer 30

1. May be a minor/ incidental injury BUT | 2. Can lead to worsening mental status and death

Question 31

Prevention of concussions? | 7

Answer 31

1. Cannot condition the brain – can strengthen the neck muscles 2. Rule changes if there is a clear cut cause – spearing in football 3. Protective equipment may lead to more risky behavior 4. Promote fair play and respect and develop team awareness 5. Teach players to play under control, how to fall, how to protect selves 6. Helmets do decrease risk of skull fracture and intracranial hemorrhage 7. Mouth guards decrease risk of dental and oral trauma

Question 32

ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) 8

Answer 32

1. Computer based neurophysiologic testing 2. Records players symptoms 3. Scores verbal & visual memory, processing speed, reaction time 4. Need baseline testing every two years (SD2 – freshmen, juniors) 5. Administered by trained personnel – usually ATs 6. Random variation of forms to inhibit learning the test 7. Athletes can game the test 8. Time & dollar costs are high

Question 33

SCAT2: Sport Concussion Assessment Tool 2 Standardized test to measure what? 4

Answer 33

1. symptoms, 2. verbal 3. motor 4. cognitive

Question 34

SAC: Standardized Assessment of Concussion | 6

Answer 34

1. Orientation 2. Immediate memory 3. Concentration 4. Exertional maneuvers 5. Delayed recall 6. Neurologic screening

Question 35

Consequences of Repetitive Injury: After suffering one concussion what are they at risk for? 5

Answer 35

1. Athletes 3 – 6 times more likely to have a second one 2. Second impact syndrome 3. Don’t recover as quickly or fully from another concussion 4. Additional concussions tend to be more severe 5. 4 – 7 times more likely to get knocked unconscious

Question 36

Consequences of Repetitive Injury: What are they more likely to recover? 4

Answer 36

1. Post concussive syndrome 2. Headaches and sleep disorders 3. Depression and dementia 4. Chronic traumatic encephalopathy

Question 37

Post Concussive Syndrome | 8

Answer 37

1. Chronic cognitive and behavioral symptoms following injury 2. Headaches, 3. fatigue, 4. sleep difficulties, 5. concentration issues, 6. emotional problems, 7. dizziness 8. Beware of depression

Question 38

Treatment of post concussion syndrome?

Answer 38

physical and cognitive rest

Question 39

What is Chronic Traumatic Encephalopathy? How can you diagnosis it? 2

Answer 39

1. A progressive degenerative disease found in individuals who have been subjected to multiple concussions and other forms of head injury 1. Can only be diagnosed posthumously via autopsy 2. Characteristic streaks of a protein called tau found on the brain (DARK)

Question 40

What is CTE linked to? | 8

Answer 40

Linked to 1. memory loss, 2. confusion, 3. impaired judgment, 4. paranoia, 5. impulse control problems, 6. aggression, 7. depression 8. progressive dementia

Question 41

What are the key provisions in Dylan Steiger's Law? 3

Answer 41

1. Educate coaches, athletes, parents on dangers of concussions 2. May not play with signs, symptoms, or behaviors of a concussion 3. Must get medical clearance before returning to play/practice

Question 42

Concussive effects are cumulative.....

Answer 42

!!!!