Brain Concussion (cont.)
What are the signs and symptoms of concussion?
The signs and symptoms of concussion may be obvious or subtle. Much of the
experience in caring for mild head injuries comes from the treatment of sports
injuries. Football, hockey, and soccer have high potential for head injury, and
player research has given insight into what symptoms may occur.
While dramatic, loss of consciousness or
seizure are not common in concussion
and do not predict severity. More common are mild
confusion and disorientation.
Symptoms tend not to be objective and may be hard to describe. As well, they may
be delayed for many hours after injury, and sometimes the initial injury may
have been forgotten or discounted.
Typical symptoms of concussion include:
Physical Signs
Since, by definition, concussion does not damage the structure of the brain,
the physical examination should be normal. More subtle findings may include:
- Slow to answer questions or follow directions
- Poor concentration
- Emotional lability (emotional changes or instability)
- Slurred speech
- Personality changes
How is concussion diagnosed?
Physical Examination and Testing
History and physical examination are crucial to making the diagnosis of
concussion.
Understanding the mechanism of injuries allows the healthcare provider to
decide if further radiologic testing is required. A normal neurologic
examination is somewhat reassuring that no major structural injuries to the
brain have occurred.
Glasgow Coma Score (GCS)
The GCS was developed to quickly assess a patient's neurologic status based
on speech, eye opening, and movement. The scale is used as part of the initial
evaluation of a patient. Since it "scores" the level of
coma, the GCS can be
used by healthcare providers with different skill levels to assess changes in
patient status.
| Glasgow Coma Scale
|
| Eye Opening |
|
| Spontaneous |
4 |
| To loud voice |
3 |
| To pain |
2 |
| None |
1 |
| |
| Verbal Response |
|
| Oriented |
5 |
| Confused, Disoriented |
4 |
| Inappropriate words |
3 |
| Incomprehensible words |
2 |
| None |
1 |
| |
| Motor Response |
|
| Obeys commands |
6 |
| Localizes pain |
5 |
| Withdraws from pain |
4 |
| Abnormal flexion posturing |
3 |
| Extensor posturing |
2 |
| None |
1 |
Computerized Tomography (CT scan)
Not everyone who has sustained a blow to the head needs a
CT scan. The
Canadian Head CT Rules were developed to minimize the number of brain scans that
were done with little chance of finding bleeding in the brain and requiring an
operation. There is no need for CT scanning if none of the following high or medium
risk criteria are met.
High risk for bleeding:
- Glasgow Coma Score <15 at two hours after injury
- Suspected open or depressed skull
fracture
- Any sign of basal skull fracture [blood behind the eardrum, "raccoon eyes" or
bruising around the eyes, cerebrospinal fluid leaking from the nose or ears,
or Battle's sign (bruising behind the ear)]
- More than two episodes of
vomiting
- Age > 65 years
Medium risk for bleeding:
- Amnesia before impact >30 minutes - This refers to loss of memory prior
to the trauma (retrograde amnesia).
- Amnesia can be retrograde (loss of memory of events prior to
the injury) and antegrade (where the person cannot remember
events that have occurred after he injury). Antegrade amnesia is common
and not an indicator of significant brain trauma. Retrograde amnesia of
more than 30 minutes is a risk for brain bleeding.
- Dangerous mechanism of injury (pedestrian struck by motor vehicle, occupant
ejected from motor vehicle, fall from height >3 feet or five stairs)
These indications are valid for those patients aged 2 to 65.
X-rays of the skull are not indicated in minor head trauma, since normal
x-rays do not correspond to a normal brain.
Since concussion is defined as a temporary change in brain function, it is
important to examine the patient on more than one occasion. Brain function may
or may not correlate with the resolution of symptoms. Neuropsychologic testing
can be used to assess brain function to decide when to allow a patient to return
to full activity.
Next: What is the treatment for concussion? »
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