Concussion/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

• 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

• 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

• 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)

• 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)

PECARN, CATCH2, CHALICE for children, Head CT not required if NONE of the following are present

• 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

• 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 (even in the presence of mild and transient symptoms, ie <2 point increase in symptom severity score for <1h)

    • • 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

• 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

• Neurological

• Cervical  spine

• Vestibular exam

• Oculomotor exam

Risk for slower recovery

• Severity of initial symptoms

• History or development of migraine headaches

• Depression or other mental health problems

• Adolescence (girls>boys), and infants, and elderly

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