cerebral concussion (mini case study)

8/19/2019 Cerebral Concussion (Mini Case Study)

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CEREBRAL CONCUSSION

Background

The most important consideration in any head injury is whether the brain is

injured. Even seemingly minor injury can cause significant brain damage secondary to

obstructed blood flow and decreased tissue perfusion. The brain cannot store oxygen or

glucose to any significant degree. Because the cerebral cells need an uninterrupted

blood supply to obtain these nutrients, irreversible brain damage and cell death occur if

the blood supply is interrupted for even a few minutes. Closed (blunt brain injury occurswhen the head accelerates and then rapidly decelerates or collides with another object

and brain tissue is damaged but there is no opening through the s!ull and dura. "pen

brain injury occurs when an object penetrates the s!ull, enters the brain, and damages

the soft brain tissue in its path (penetrating injury , or when blunt trauma to the head is

so severe that it opens the scalp, s!ull, and dura to expose the brain. #njuries to the

brain can be focal or diffuse. $ocal injuries include contusions and hematomas.

Concussions and diffuse axonal injuries are the major diffuse injuries.

Definition

% concussion after a head injury is a temporary loss of neurologic function with

no apparent structural damage to the brain. % concussion (also referred to as a mild

TB# may or may not produce a brief loss of consciousness. The mechanism of injury is

usually blunt trauma from an acceleration&deceleration force, a direct blow, or a blast

injury. #f brain tissue in the frontal lobe is affected, the patient may exhibit bi'arre



irrational behavior, whereas involvement of the temporal lobe can produce temporary

amnesia or disorientation.

There are three grades of concussion or mild TB# defined by the %merican

%cademy of eurology when the injury is sport related. % grade ) concussion has

symptoms of transient confusion, no loss of consciousness, and duration of mental

status abnormalities on examination that resolve in less than )* minutes. % grade +

concussion also has symptoms of transient confusion and no loss of consciousness, but

the concussion symptoms or mental status abnormalities on examination last more than

)* minutes. #n grade concussion, there is any loss of consciousness lasting fromseconds to minutes.

% mild TB# is often overloo!ed in the emergency department (E- because

diagnostic studies may show no apparent structural sign of injury. The duration of

mental status abnormalities is an indicator of the grade of the concussion. The patient is

discharged from the hospital or E- once he or she returns to baseline after the

concussion. onitoring includes observing the patient for a decrease level of

consciousness (/"C , worsening headache, di''iness, sei'ures, abnormal pupil

response, vomiting, irritability, slurred speech, and numbness or wea!ness in the arms

or legs. The occurrence of these symptoms is a red flag indicating the need for further

intervention. 0ecovery may appear complete, but long&term se1uelae are possible and

repeat injuries common. 2roblems at wor! and at home can result in interpersonal

relationship problems or the loss of employment. The family and patient are instructed

to follow up with the primary provider.



Causes

The brain has the consistency of gelatin. #t3s cushioned from everyday jolts and

bumps by cerebrospinal fluid inside the s!ull. % violent blow to the head and nec! or

upper body can cause the brain to slide bac! and forth forcefully against the inner walls

of the s!ull.

4udden acceleration or deceleration of the head, resulting from certain events such as a

car crash or being violently sha!en, also can cause brain injury.

These injuries affect brain function, usually for a brief period, resulting in signs and

symptoms of concussion. % brain injury of this sort may lead to bleeding in or around the brain, causing symptoms

such as prolonged drowsiness and confusion that may develop right away or later.

4uch bleeding in the brain can be fatal. That3s why anyone who experiences a brain

injury needs monitoring in the hours afterward and emergency care if symptoms

worsen.

Statistical Data

Prevalance of Traumatic Brain Injury:

5.+6 of population has an ac1uired brain injury in %ustralia )778 (%ustralia9s

:ealth +55;, %#:<

Prevalance Rate for Traumatic Brain Injury:

%pproximately ) in *55 or 5.+56 or *;;,555 people in =4%



Medical-Surgical Management

%ssessment and diagnosis of the extent of injury are accomplished by the initial

physical and neurological examinations. CT and 0# scans are the main neuroimaging



diagnostic tools and are useful in evaluating the brain structure. 2ositron emission

tomography (2ET is available in some trauma centers for assessing brain function. %

flow chart developed by the Brain Trauma $oundation (+55> for the initial management

of brain injury is presented below.

%ny patient with a head injury is presumed to have a cervical spine injury proven

otherwise. The patient is transported from the scene of the injury on a board with the

head and nec! maintained in alignment with the axis of the body. % cervical collar

should be applied and maintained until cervical spine x&rays have been obtained and

the absence of cervical spinal cord injury (4C# documented. %ll therapy is directed toward preserving brain homeostasis and preventing

secondary brain injury, which is injury to the brain that occurs after the original traumatic

event (Bader ? /ittlejohns, +5)5 . Common causes of secondary injury are cerebral

edema, hypotension, and respiratory depression that may lead to hypoxemia and

electrolyte imbalance. Treatments to prevent secondary injury include stabili'ation of

cardiovascular and respiratory function to maintain ade1uate cerebral perfusion, control

of hemorrhage and hypovolemia, and maintenance of optimal blood gas values.



Initial management

Severe headinjury GCS 8 or

Emergencydiagnosis ortherapeutic

EndotrachealintubationFluid resuscitationVentilation !aC" # $%mm&g'"(ygenationSedation) !harmacologic

)& erventilation

&erniation*+,eterioration*+

-esolution*CT scan

Sur ical lesion*

" eratin room.ntensive care

/onitor .C!

Treat intracranialhypertension



Diagnostics

% computed tomography (CT scan is used to diagnose a s!ull fracture. The ease

with which a diagnosis of s!ull fracture is made depends on the site of the fracture. #f a

fracture is found on CT scan, there is always the 1uestion of associated brain injury, and

magnetic resonance imaging ( 0# provides better resolution and clearer pictures of the

injured area (:ic!ey, +557 .

% blow to the head, nec! or upper body can cause a concussion, which may

include symptoms such as a headache, di''iness, nausea or loss of consciousness.

The doctor will evaluate the signs and symptoms, review medical history, and conduct aneurological examination. 4igns and symptoms of a concussion may not appear until

hours or days after the injury.

Tests the doctor may perform or recommend include@

1. Neurological examination %fter your doctor as!s detailed 1uestions about your injury, he or she may

perform a neurological examination. This evaluation includes chec!ing your@• Aision• :earing• 4trength and sensation• Balance• Coordination• 0eflexes• Cognitive testing

our doctor may conduct several tests to evaluate your thin!ing (cognitive

s!ills during a neurological examination. Testing may evaluate several factors,

including your@• emory• Concentration• %bility to recall information

2. Imaging tests



Brain imaging may be recommended for some people with symptoms

such as severe headaches, sei'ures, repeated vomiting or symptoms that are

becoming worse. Brain imaging may determine whether the injury is severe and

has caused bleeding or swelling in your s!ull. % cranial computeri'ed tomography (CT scan is the standard test to

assess the brain right after injury. % CT scan uses a series of &rays to obtain

cross&sectional images of your s!ull and brain.agnetic resonance imaging may be used to view bleeding in your brain

or to diagnose complications that may occur after a concussion. %n 0# uses powerful magnets and radio waves to produce detailed

images of your brain.

3. O servation

ou may need to be hospitali'ed overnight for observation after a

concussion.

#f your doctor agrees that you may be observed at home, someone shouldstay with you and chec! on you for at least +; hours to ensure your

symptoms aren3t worsening. our caregiver may need to awa!en you

regularly to ma!e sure you can awa!en normally.

cerebral concussion (mini case study)

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