Mild traumatic brain injury: Difference between revisions

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==Background==
==Background==
  [[File:Mild TBI.JPG|400px]]
  [[File:Mild TBI.JPG|400px]]
*Concussion (mild TBI) is defined as GCS 14-15 with associated signs or symptoms after a blunt force or acceleration-deceleration [[head injury]]
*Concussion (mild TBI)  
**GCS 14-15
**Neurologic dysfunction that varies without gross lesions (ie patients have trouble with memory, attention, and executive functioning
**Occurs after a blunt force or acceleration-deceleration [[head injury]]
**Likely secondary to metabolic insult ie low oxygen state, ion changes
**Structural imaging on MRI or CT might not indicate any injury
**Often evidence on microscopic level of injury with histology
**Important to not expose the already injured brain to repeated insults which is why there are usually worsening symptoms after a repeat concussion
 
*Types
*Types
**Simple concussion
**Simple concussion
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***Symptoms with exertion
***Symptoms with exertion


==Evaluation==
==Clinical Signs and Symptoms==
*Any alteration in the mental state at the time of event or subsequent to the event
**Symptoms may be delayed by days-weeks
*Most consistent abnormality is subtle impairments in cognitive function
*Most consistent abnormality is subtle impairments in cognitive function
**Attention, concentration, memory, processing speed, reaction time
**Attention, concentration, amnesia, memory, processing speed, reaction time, calculation, executive function
*Physical signs/symptoms
*Physical signs/symptoms
**[[Headache]], dizziness, insomnia, fatigue, uneven gait, nausea/[[vomiting]], blurred vision, [[seizure]]
**[[Headache]], dizziness, insomnia, fatigue, uneven gait, nausea/[[vomiting]], blurred vision, [[seizure]]
*Behavioral changes
*Behavioral changes
**Irritability, depression, anxiety, sleep disturbances, problems related to school/work
**Irritability, depression, anxiety, sleep disturbances, problems related to school/work, emotional lability, loss of initiative, loneliness and helplessness
 
 
 
==Evaluation==
*No reliable test that can confirm diagnosis of concussion
*Clinical Signs and Symptoms may occur immediately or be delayed by days-weeks
*Important to document full examination and should do gait and congnition testing
**Mini Mental State Exam
**Standardized Assessment for Concussion
***Takes 10-15 mins to administer often not performed in ED


==Differential Diagnosis==
==Differential Diagnosis==
{{Intracranial hemorrhage DDX}}
{{Intracranial hemorrhage DDX}}
==Evaluation==
*Based on history and clinical evaluation


==Management==
==Management==
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==Disposition==
==Disposition==
*Upon discharge from the ER all patients with a diagnosis of concussion should receive educational materials on activities to avoid and symptoms to anticipate during recovery as those who received it have better long-term outcomesials<ref>Ronsford J, et al. Impact of early intervention on outcome after mild traumatic head in adults. 2002</ref>
*Given good follow up instructions detailing a graded return-to-activity program and symptoms to anticipate during recovery <ref>Ronsford J, et al. Impact of early intervention on outcome after mild traumatic head in adults. 2002</ref>
*Discharge patient to care of responsible individual
*Patients might not understand discharge instructions so repeat them to the individual taking care of the patient
*Recommend strict rest for 1-2 days with gradual introduction back to regular activity<ref>Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015; 2(135):213-223.</ref>
*Recommend strict rest for 1-2 days with gradual introduction back to regular activity<ref>Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015; 2(135):213-223.</ref>
*Physical activity at any level (light aerobic, moderate, full) within first 7 days compared with no activity associated with lower rates of persistent symptoms at 28 days (29% vs. 40%)<ref>Grool AM et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514.</ref>
*Physical activity at any level (light aerobic, moderate, full) within first 7 days compared with no activity associated with lower rates of persistent symptoms at 28 days (29% vs. 40%)<ref>Grool AM et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514.</ref>
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==Prognosis==
==Prognosis==
*At 3 mo after injury <30% are symptomatic
*At 3 mo after injury 20-40% are symptomatic
**with treatment for the most common symptoms of headache, difficulty concentrating and short-term memory difficulties being rest and in some circumstances NSAIDS.
*At 1 yr after injury 15% are symptomatic
*At 1 yr after injury 15% are symptomatic
==Post Concussive Syndrome==
*Most common symptoms
**Headache
**Dizziness
**Decreased concentration
**Memory problems
**Sleep Disturbance
**Irritability
**Fatigue
**Visual disturbances
**Judgment problems
**Depression
**Anxiety
*Cluster of symptoms becomes chronic ie for 6 weeks
*Diagnosed w/
**Neuropsychological testing
**Symptom checklist
*Treated with symptom management
**Appropriate referral to TBI clinic or Neuropsychologist


==See Also==
==See Also==

Revision as of 21:03, 7 July 2017

Background

Mild TBI.JPG
  • Concussion (mild TBI)
    • GCS 14-15
    • Neurologic dysfunction that varies without gross lesions (ie patients have trouble with memory, attention, and executive functioning
    • Occurs after a blunt force or acceleration-deceleration head injury
    • Likely secondary to metabolic insult ie low oxygen state, ion changes
    • Structural imaging on MRI or CT might not indicate any injury
    • Often evidence on microscopic level of injury with histology
    • Important to not expose the already injured brain to repeated insults which is why there are usually worsening symptoms after a repeat concussion
  • Types
    • Simple concussion
      • Gradual resolution of symptoms within 7-10d
    • Complex concussion
      • Persisting symptoms or cognitive impairment
      • Symptoms with exertion

Clinical Signs and Symptoms

  • Most consistent abnormality is subtle impairments in cognitive function
    • Attention, concentration, amnesia, memory, processing speed, reaction time, calculation, executive function
  • Physical signs/symptoms
  • Behavioral changes
    • Irritability, depression, anxiety, sleep disturbances, problems related to school/work, emotional lability, loss of initiative, loneliness and helplessness


Evaluation

  • No reliable test that can confirm diagnosis of concussion
  • Clinical Signs and Symptoms may occur immediately or be delayed by days-weeks
  • Important to document full examination and should do gait and congnition testing
    • Mini Mental State Exam
    • Standardized Assessment for Concussion
      • Takes 10-15 mins to administer often not performed in ED

Differential Diagnosis

Intracranial Hemorrhage Types

Management

  • Simple
    • Limitations on playing and training while symptomatic
    • Follow up with primary care provider
  • Complex
    • Refer to sports medicine or concussion specialist

Disposition

  • Given good follow up instructions detailing a graded return-to-activity program and symptoms to anticipate during recovery [1]
  • Discharge patient to care of responsible individual
  • Patients might not understand discharge instructions so repeat them to the individual taking care of the patient
  • Recommend strict rest for 1-2 days with gradual introduction back to regular activity[2]
  • Physical activity at any level (light aerobic, moderate, full) within first 7 days compared with no activity associated with lower rates of persistent symptoms at 28 days (29% vs. 40%)[3]
    • Multicohort study - 2400 children, aged 5-18, in the emergency department
    • Still recommend strict rest for first 24-48 hours

Prognosis

  • At 3 mo after injury 20-40% are symptomatic
    • with treatment for the most common symptoms of headache, difficulty concentrating and short-term memory difficulties being rest and in some circumstances NSAIDS.
  • At 1 yr after injury 15% are symptomatic

Post Concussive Syndrome

  • Most common symptoms
    • Headache
    • Dizziness
    • Decreased concentration
    • Memory problems
    • Sleep Disturbance
    • Irritability
    • Fatigue
    • Visual disturbances
    • Judgment problems
    • Depression
    • Anxiety
  • Cluster of symptoms becomes chronic ie for 6 weeks
  • Diagnosed w/
    • Neuropsychological testing
    • Symptom checklist
  • Treated with symptom management
    • Appropriate referral to TBI clinic or Neuropsychologist

See Also

References

  1. ↑ Ronsford J, et al. Impact of early intervention on outcome after mild traumatic head in adults. 2002
  2. ↑ Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015; 2(135):213-223.
  3. ↑ Grool AM et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514.
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