-Patient meets criteria for a concussion.
–History & Physical, above.
–Post Concussion Symptom Scale completed.
-No red flags (no focal neurologic deficits, no anticoagulation use or coagulopathy, no evidence of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign) which would demand an immediate referral to the ED.
–Indications for neuroimaging reviewed. Not indicated at this time.
-Was appropriately removed from the game.
-No cervical spine injury. No serious traumatic brain injury.
-This patient doesn’t have risk factors for prolonged recovery.
Treatment
-Concussion Management reviewed with the patient.
–Complete Cognitive and physical rest until symptoms resolve without medication. Cognitive and physical rest are the cornerstones of initial management.
-Medication choices and interventions are the same for those without concussions.
-Coordinate w/ school to make the transition back to school smooth.
-Graded-return-to-play protocol. Once the patient’s symptoms have resolved without medication, the patient would be reevaluated and will start a graded return-to-play protocol.
-Counseling: Patient should not return to play until symptoms resolve to avoid the second impact syndrome which can occur if an athlete returns to play before full resolution of a concussion.
-F/u in 1 week
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Concussion Pearls and Links
- Never allow a same-day return to play; consider longer asymptomatic rest periods before initiating graded return-to-play protocol
- Complete physical rest means avoiding any physical activity that exacerbates symptoms.
- Cognitive rest means avoiding activities that require concentration or attention, such as schoolwork and electronics use.
Appropriate management of concussions can prevent long-term complications.
“In this scenario, the patient meets the criteria for a concussion, with headache, nausea, and imbalance following an injury. She was appropriately removed from the game. The next step in management is complete physical and cognitive rest until her symptoms resolve without medication (SOR C). Complete physical rest includes avoidance of any physical activity that exacerbates symptoms. Cognitive rest means avoidance of activities that require concentration or attention, such as schoolwork and electronics use.
Once the patient’s symptoms have resolved without medication, she should be reevaluated and can start a graded return-to-play protocol (SOR C). Reevaluation may include repeat neurocognitive testing and postural stability testing (SOR C). Both types of testing can be important in the evaluation but there is insufficient evidence that either affects outcomes.In the initial evaluation of concussion, imaging is not indicated in the absence of focal neurologic findings, loss of consciousness for more than 60 seconds, or evidence of skull fracture (SOR C). If imaging criteria are met, CT of the head is indicated. Plain films are not indicated in the evaluation. There is no evidence that protective gear reduces the incidence of concussion (SOR C). Even though some protective gear can prevent other types of injuries, it is not indicated for concussion prevention. Eliminating dangerous behaviors such as heading the ball in soccer can help, however.” ABFM critique.
References
http://www.aafp.org/afp/2016/1215/p1006.html
http://www.aafp.org/afp/2014/0401/p585.html
http://www.aafp.org/afp/2012/0115/p123.html