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					       Concussion




        Michael A. Bernstein, M.D.
Chairman, Department of Emergency Medicine
     RWJ University Hospital at Rahway
               865 Stone St
        Rahway, New Jersey 07065
             Tel 732-680-7912
       What is a Concussion?
• Traumatic Brain Injury
  – Head injury due to contact or
    acceleration/deceleration forces

     • Direct blow to the head, face, neck or other body parts with a
       consequential force transmitted to the head


• Medically defined as:

  – A complex pathophysiological process affecting the
    brain, induced by traumatic biomechanical forces.
                          Presentation
• Rapid onset of transient neurologic dysfunction with spontaneous
  resolution

          • Functional rather than Structural disturbance
          • +/- LOC
          • Grossly normal neuroimaging
•   Confusion and Amnesia

          • immediately or minutes to hours later
          • repetitive questions

•   Headache
•   Dizziness
•   Vertigo
•   Imbalance
•   Lack of awareness of surroundings
•   Nausea and Vomiting
            Other Symptoms
•   Vacant stare
•   Delayed verbal expression
•   Inability to focus
•   Disorientation
•   Slurred or incoherent speech
•   Incoordination
•   Emotion out of proportion
•   Memory Deficits
            Incidence and Etiology
•   Approximately 1.4 million reported incidents of TBI / year in the U.S.

•   Men : Women 2-2.8:1

•   Approximately ½ of all reported cases between 15-34 years of age

•   Motor Vehicle Accidents (MVA) – 45%

•   Falls – 30%

•   Occupational Accidents – 10%

•   Recreational Accidents – 10%

•   Assaults – 5%
     Motor Vehicle Accidents
• 45% of reported cases
• Seatbelts
• Airbags
                  Falls
• 30% of reported cases
• More common in the elderly but if you do
  not have your balance….
     Occupational Accidents
• 10% of reported cases
      Recreational Accidents
• 10% of reported cases
               Assaults
• 5% of reported cases
             Contact Sports
•   Football
•   Ice Hockey
•   Soccer
•   Boxing
•   Rugby
           Other Sports
• Gymnastics
• Swimming/Diving
• Ice Skating
                Football
• Approximately 10-20% of players sustain
  some form of traumatic brain injury
         Medical Evaluation
• Standardized Assessment of Concussion
  (SAC)



  – Sideline evaluation of head trauma
             Modified Westmead Post-
             Traumatic Amnesia Scale
                     (WPTAS)
•   What is your name?
•   What is the name of this place?
•   Why are you here?
•   What month are we in?
•   What year are we in?
•   In what town/suburb are you in?
•   How old are you?
•   What is your date of birth?
•   What time of day is it? (morning, afternoon, evening)
•   Three pictures are presented for subsequent recall

• An incorrect response to any one question is considered a positive
  test for cognitive impairment after head injury.
   Medical Evaluation (cont’d)
• To image or not to image?

  – Prolonged symptoms?

    • Persistent nausea or vomiting

    • Persistent abnormal neurological exam
       Canadian CT Head Rules
• GCS <15 two hours after injury

• Suspected open or depressed skull fracture

• Any sign of basilar skull fracture
    – Hemotympanum, raccoon eyes, Battle's sign or oto- or rhinorrhea

• Two or more episodes of vomiting

• 65 years of age or older

• Amnesia before impact of 30 or more minutes

• Dangerous mechanism (pedestrian struck by motor vehicle,
  occupant ejected from motor vehicle, fall from ≥3 feet or ≥5 stairs)
      Glasgow Coma Scale (GCS)
•   Best eye response

     –   1. No eye opening
     –   2. Eye opening in response to pain.
     –   3. Eye opening to speech.
     –   4. Eyes opening spontaneously

•   Best verbal response

     –   1. No verbal response
     –   2. Incomprehensible sounds.
     –   3. Inappropriate words.
     –   4. Confused.
     –   5. Oriented.

•   Best motor response

     –   1. No motor response
     –   2. Abnormal Extension to pain
     –   3. Abnormal flexion to pain
     –   4. Withdrawal to pain
     –   5. Localizes to pain.
     –   6. Obeys commands.
            Neuroimaging
• CT Scan
  Picture of machine
  Picture of images

• MRI
  Picture of machine
  Picture of images
                                Complications
•   Intracranial hemorrhage
     –   Subdural, Epidural, Intracerebral
           •   Lucid Interval

•   Second Impact Syndrome
     –   Swelling after a 2nd Concussion

•   Post-concussion Syndrome
     –   Headache, dizziness, cognitive impairment
     –   Days to weeks

•   Post-traumatic Headaches
     –   Days to weeks

•   Post-traumatic Epilepsy
     –   Seizures - < 5 % of generally moderate TBI

•   Post-traumatic Vertigo
     –   Days to weeks
            Return to Play
• Cantu Guidelines

• Colorado Guidelines


  – (+) Symptoms – Remove from Game


  – Symptoms > 15 minutes – Remove for 1 week
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