Michael A. Bernstein, M.D.
Chairman, Department of Emergency Medicine
RWJ University Hospital at Rahway
865 Stone St
Rahway, New Jersey 07065
What is a Concussion?
• Traumatic Brain Injury
– Head injury due to contact or
• 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.
• Rapid onset of transient neurologic dysfunction with spontaneous
• Functional rather than Structural disturbance
• +/- LOC
• Grossly normal neuroimaging
• Confusion and Amnesia
• immediately or minutes to hours later
• repetitive questions
• Lack of awareness of surroundings
• Nausea and Vomiting
• Vacant stare
• Delayed verbal expression
• Inability to focus
• Slurred or incoherent speech
• 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
• 30% of reported cases
• More common in the elderly but if you do
not have your balance….
• 10% of reported cases
• 10% of reported cases
• 5% of reported cases
• Ice Hockey
• Ice Skating
• Approximately 10-20% of players sustain
some form of traumatic brain injury
• Standardized Assessment of Concussion
– Sideline evaluation of head trauma
Modified Westmead Post-
Traumatic Amnesia Scale
• 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.
• CT Scan
Picture of machine
Picture of images
Picture of machine
Picture of images
• 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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