Mild traumatic brain injury
Revision as of 17:50, 21 November 2017 by Rossdonaldson1 (talk | contribs) (→Post Concussive Syndrome)
Background
- 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
Pathophysiology
- Predominantly metabolic insult
- Mitochondrial dysfunction
- shifts in calcium and sodium balances
- Ultimately leads to damage to axonal integrity and axonal transport
- Microscopic structural injury is often unidentifiable on CT or MRI
Clinical Features
- 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
Differential Diagnosis
Intracranial Hemorrhage Types
- Intra-axial
- Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
- Traumatic intracerebral hemorrhage
- Extra-axial
- Epidural hemorrhage
- Subdural hemorrhage
- Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)
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
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
See also post-concussive syndrome
- 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
See Also
References
- ↑ Ronsford J, et al. Impact of early intervention on outcome after mild traumatic head in adults. 2002
- ↑ 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.
- ↑ 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.