Concussion

AIS Guidelines

• Concussion guidelines - AIS

• Flowchart

  • Concussion Management Flow Chart - medical practitioners - on field - 10/10 - Useful

  • Concussion Management Flow Chart - emergency departments and medical clinics - off field - 10/10 - Useful

• SCAT6

  • SCAT6 – Sport Concussion Assessment Tool - Age > 13 years - 10/10 - Gold standard

  • ChildSCAT6 – Sport concussion Assessment Tool for children - Age <13 years - 10/10 - Gold standard

• Return to Sport

  • Return to Sport Protocol - children 18 years of age and under -

  • Return to Sport Protocol - adults over 18 years of age -

  • Return to Learn Care Plan - Letter for school for extra breaks or postponing exams / assignments post concussion

  • Key Points for Medical Practitioners

Resources

• Guidelines of Sports-Related concussion - AAFP - 7/10 - Useful

• Concussion + Michael Collins on Youtube - Petter Attia - 8/10 - Really interesting

• SCAT5 - BMJ - Outdated / now SCAT6

• Child SCAT5 - BMJ - Outdated / now SCAT6

• Head Injury Guidelines - RCH - 10/10 - Gold standard

Overview

• Concussion is complex pathophysiological process affecting the brain due to biomechanical forces

• Most concussions recover in 10 to 14 days

Mechanism

• Brain is an egg yolk in an egg shell

• Acceleration / deceleration = brain shifting in skull

• Membranes stretch

• Potassium leaks out of neuron

• Increased demand glucose / energy to force potassium back into neuron

• Calcium leaks into cells + vasoconstriction + decreased cerebral blood flow = decrease energy supply

• Concussion is mismatch of demand for energy versus supply

• Cells struggle to operate at normal levels

• Cells don’t die, just inefficient

• Different systems decompensate

Risk factors

• History of car sickness = less force causes injury

• Migraine history

• Strabismus

• Anxiety

• Females > Male (have 6 x greater incidence car sickness + migraine)

High severity of acute and subacute concussive symptoms

• a high number of concussive symptoms

• prolonged loss of consciousness (longer than one minute)

• post-concussive seizure

• previous history of concussion

• age of the athlete

• female sex

• history of depression, anxiety or migraine

Six types of concussion

• Cognitive Fatigue

• Vestibular - Central pathways

• Ocular - Ocular motor

• Migraine

• Anxiety

• Neck - Uncommon

Symptoms

• About 21 symptoms post concussion at the time of event

• Signs

  • LOC

  • Confusion

  • Balance

  • Vomitting

• Symptoms

  • Dizzy (Best predicts longer recovery from concussion = 6 x more predictive of longer recovery > 1 month. Maybe because players play through the injury.)

  • Foggy (2nd best predictor)

  • Detached

  • Light sens

  • Noise sens

  • Blurred vision

  • Nausea

  • Fatigue

  • Headache

  • Amnesia

• Study comparing those taken out of play immediately versus playing on

  • Taken out immediately = 18 days

  • Playing 15 minutes through event = 44 days

  • Every minute playing through injury might add 7 to 8 days to injury

Complications

• Impaired performance

• Acute progressive diffuse cerebral oedema

• Prolonged symptoms

• Depression

• CTE

Management

• Make a diagnosis

• Differentiate other pathologies

Concussion modifiers

• Symptoms - High number, longer duration, high severity

• Signs - Prolonged LOC > 1min, amnesia

• Sequelae - Prolonged concussive symptoms

• Temporal - Frequency, repeated concussions, timing of injuries

• Threshold - Repeated concussion with progressively less force

• Age - Child and adolescent

• Comorbid - Migraine, depression, mental health

• Medication - Psychoactive, anticoagulants

• Sports - High0risk activity, contact and collision sport

Diagnosis

• SCAT

Return to sport

• Any player with suspected or confirmed concussion is not to return to play that day

• Not allowed to return to play until complete recovery

• Comprehensive approach

  • Cognitive and physical rest

    • Physiological stress (Exercise, Flying, Altitude)

    • Cognitive loads (Work, Video games, Computer)

  • Monitoring post-concussive symptoms + signs

    • SCAT

  • Neuropyschiatric tests

    • Common deficits are reduced attention, ability to process information, slowed reaction time, impaired memory

  • Graduated return to activity with monitoring

Treatment for long-term post concussive symptoms

• Sleep hygiene

• Physical exercise

• Vestibular training

• Medications

  • SSRI, TCA