Concussion/mTBI
Mild TBI (mTBI)
Mild TBI (mTBI)
- Head injury due to contact and/or acceleration/deceleration forces
- Mild : GCS 13 to 15, measured at approximately 30 minutes after the injury
Concussion
Concussion
- The immediate and transient symptoms of mTBI, not explained by drug/alcohol/medication or other injuries (C-spine, peripheral vestibular dysfunction, psychological medical conditions)
- Somatic (headache)
- Physical signs (loss of consciousness, amnesia, neurological deficit)
- Balance impairment (gait unsteadiness)
- Behavioral changes (irritability, emotional lability)
- Cognitive impairment (slowed reaction times, feeling ‘in a fog’, difficulty concentrating)
- Sleep/wake disturbance (somnolence, drowsiness)
- Initial assessment and follow-up progression of symptoms with SCAT 5 or Child SCAT 5
Imaging
Imaging
- Consider imaging any patient with neuro deficit, seizure, or bleed risk (anticoagulated)
CT Head Rules in >16yo, Head CT not required if NONE of the following are present
CT Head Rules in >16yo, Head CT not required if NONE of the following are present
- Excludes: Age<16,
- High risk (neurosurgical intervention)
- GCS <15 two hours after injury
- Suspected open or depressed skull fracture
- Any sign of basilar skull fracture: hemotympanum, raccoon eyes (intraorbital bruising), Battle's sign (retroauricular bruising), or CSF leak, oto/rhinorrhea
- ≥ 2 episodes of vomiting
- Age ≥ 65
- Medium risk (normally require admission)
- Retrograde amnesia (past memories) to the event ≥ 30 minutes
- Dangerous mechanism (pedestrian struck by motor vehicle, ejected from motor vehicle, fall from ≥3 feet or ≥5 stairs)
- High risk (neurosurgical intervention)
- Note may consider CT (New Orleans or Nexus II rule) as well in:
- Anticoagulation
- Seizure
- Persistent anterograde amnesia (deficits in short-term memory)
- Visible trauma above the clavicles
- Drug or Alcohol Intoxication (may consider observing/deferring head CT)
- GCS 14 or altered mental status or palpable skull fracture or signs of basilar skull fracture
- <2yo
- Non-frontal (occipital/parietal/temporal) scalp hematoma
- History of LOC ≥ 5 seconds
- Severe mechanism (pedestrian or bicyclist without helmet struck by motor vehicle, fall ≥1m or ≥3 feet, head struck by high-impact object)
- Not acting normally
- >2yo
- History of LOC
- History of Vomiting (consider observation if no other indication = 0.2% risk of cTBI)
- In CATCH2, ≥ 4 episodes of vomiting was added
- Severe mechanism of injury (as above but fall ≥2m or ≥5 feet,
- Severe headache
Treatment
Treatment
- Treat cervical/vestibular symptoms
- Consider 1-2 days of complete rest (cognitive/physical rest) - may require temporary absence from school
- >14 days of non-contact, non-risk gradual progressive sub-symptom threshold activity
- Prolonged rest can prolong symptoms
- >24 hours for each step of the progression
- If any symptoms worsen, the athlete should go back to the previous step
- Repeated TBI can be life-threatening and lead to neuropsychological sequelae
- >14 days of non-contact, non-risk gradual progressive sub-symptom threshold activity
- Consider individualized aerobic exercise program for 20 minutes a day during the first week (may speed recovery)
- Exercise bike or treadmill at target heart rate 80% of the point of symptom exacerbation
Post-injury assessment within 48h
Post-injury assessment within 48h
- Neurological
- Cervical spine
- Vestibular exam
- Oculomotor exam
Risk for slower recovery
Risk for slower recovery
- Severity of initial symptoms
- History or development of migraine headaches
- Depression or other mental health problems
- Adolescence (girls>boys)
Persistent Post-Concussive Symptoms (PPCS)
Persistent Post-Concussive Symptoms (PPCS)
- >2w in adults
- >4w in children/adolescents
- Treatment
- Referral to concussion expert (sports medicine specialist, physiatrist or neurologist)
- Treat co-existing pathologies
- Limited evidence for rest
- Individualized sub-symptom threshold activity
- Physiotherapy/vestibular rehabilitation
References:
Patient Handout: INESSS
Patient Handout: INESSS