Concussion

Concussion

Neha Raukar, MD and Anand Swaminathan, MD

• Definition
  • Concussion is a complex pathophysiologic process induced by traumatic biomechanical forces caused either by a direct blow to the head, face, or neck with an impulsive force translated to the brain.
  • This results in the rapid onset of short-lived neurologic impairment that spontaneously resolves and is due to functional disturbance rather than a structural injury.

PEARLS

• Only 10% of concussions involve a loss of consciousness.
• Immediate Symptoms
  • Somatic
    • Headaches
    • Vomiting
    • Visual disturbances
    • Balance disturbances
  • Cognitive
    • Difficulty concentrating
  • Emotional
    • Increased emotionality
    • Sadness
  • Sleep
    • Increased or decreased sleep

PITFALLS

• Concussion is a clinical diagnosis without a diagnostic test available at this time. It can be difficult to make a full assessment in the acute setting and we can’t always make the diagnosis immediately, as symptoms may only manifest later on with exertion or concentration.
• We cannot predict the duration or severity of concussion symptoms based on presentation.
• We should not “clear for return to activity” based on initial assessment.
• Risk factors for prolonged symptoms:
  • Age (kids are at higher risk)
  • History of prior concussions
  • Sex (women tend to have longer recovery)
  • Comorbidities (migraines, ADHD, sleep disorders, anxiety, or depression)
• Emergency Evaluation (at sporting event or in ED)
  • Primary Question: Does the patient have an intracranial hemorrhage or cervical spine injury?
  • Next, perform a concussion assessment:
    • Sports Concussion Assessment Tool-5 (SCAT-5) is a validated tool:
      • https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf
    • Assessment tools are comprehensive and may be better utilized in follow up.
• Neuroimaging
  • Imaging is used to rule in/rule out intracranial hemorrhage or cervical spine injury in cases where there is clinical concern.
  • It has no utility in the diagnosis of concussion (ie, normal imaging does not rule out concussion).
• Management
  • Protect the brain from future injury (ie, hold from sports activities).
  • Provide an environment for the brain to heal.
    • Stress will evoke and prolong symptoms.
    • Activity should be guided/restricted by patient’s symptoms.
  • Follow up
    • Start with a primary care physician or pediatrician.
    • Ideally, a neurologist or concussion specialist should be involved.
  • Long-term sequelae are still unclear and a subject of ongoing research.

Related Segments

EM:RAP 2016 Special Report: Concussion

ROP 2019 October Abstract 6: Early Subthreshold Aerobic Exercise for Sport-Related Concussion

EM:RAP 2019 June Pediatric Pearls: Pediatric Mild Traumatic Brain Injury

CorePendium: Traumatic Brain Injury (major and minor)