Cerebral Concussion
concussion
(kon-kush'on) [L. concussio, a shaking]concussion of brain
cerebral concussion
Traumatic brain injury.concussion of labyrinth
spinal concussion
Cerebral Concussion
| DRG Category: | 83 |
| Mean LOS: | 4.5 days |
| Description: | MEDICAL: Traumatic Stupor and Coma, Coma > 1 hour With CC |
| DRG Category: | 84 |
| Mean LOS: | 2.8 days |
| Description: | MEDICAL: Traumatic Stupor and Coma, Coma > 1 hour Without CC or Major CC |
| DRG Category: | 955 |
| Mean LOS: | 11.5 days |
| Description: | SURGICAL: Craniotomy for Multiple Significant Trauma |
The word concuss means “to shake violently.” Cerebral concussion is defined as a transient, temporary, neurogenic dysfunction caused by mechanical force to the brain. Cerebral concussions are the most common form of head injury. Concussions are classified as mild or classic on the basis of the degree of symptoms, particularly those of unconsciousness and memory loss. Mild concussion is a temporary neurological dysfunction without loss of consciousness or memory. Classic concussion includes temporary neurological dysfunction with unconsciousness and memory loss. Recovery from concussion usually takes minutes to hours. Most concussion patients recover fully within 48 hours, but subtle residual impairment may occur. New research findings indicate that for at least 4 months after a mild traumatic brain injury, the brain continues to display signs of damage even if patients have no symptoms. There is a growing awareness that athletes may not notice mild symptoms or may underreport concussions so that they can continue to play the sport. Repeat concussions are a significant issue for young athletes. Athletes with a history of one or more concussions have a greater risk for being diagnosed with another concussion than those without such a history. The first 10 days after a concussion presents the greatest risk for another concussion.
In rare cases, a secondary injury caused by cerebral hypoxia and ischemia can lead to cerebral edema and increased intracranial pressure (ICP). Some patients develop postconcussion syndrome (postinjury sequelae after a mild head injury). Symptoms may be experienced for several weeks and, in unusual circumstances, may last up to 1 year. In rare situations, patients who experience multiple concussions may suffer long-term brain damage. Complications of cerebral concussion include seizures or persistent vomiting. In rare instances, a concussion may lead to intracranial hemorrhage (subdural, parenchymal, or epidural).
Causes
The most widely accepted theory for concussion is that acceleration-deceleration forces cause the injury. Sudden and rapid acceleration of the head from a position of rest makes the head move in several directions. The brain, protected by cerebrospinal fluid (CSF) and cushioned by various brain attachments, moves more slowly than the skull. The lag between skull movement and brain movement causes stretching of veins connecting the subdural space (the space beneath the dura mater of the brain) to the surface of the brain, resulting in minor disruptions of the brain structures. Common causes of concussion are a fall, a motor vehicle crash, a sports-related injury, and a punch to the head. In high school athletes, the rate of concussions per 1,000 exposures for boys is 0.59 for football, 0.25 for wrestling, and 0.18 for soccer. For girls, the rate of concussions per 1,000 exposures is 0.23 for soccer, 0.09 for field hockey, and 0.16 for basketball. Boxing has the highest rate of head injuries compared to all other sports.
Genetic considerations
Not applicable.
Gender, ethnic/racial, and life span considerations
Cerebral concussions can be experienced by patients of all ages and both genders, but males are affected at higher rates than females. Trauma, however, is the leading cause of death between the ages of 1 and 44. In addition, trauma is the leading cause of health-related problems in this age range. For these reasons, most instances of cerebral concussion occur in the first four decades of life. There are no known ethnic or racial considerations.
Global health considerations
Internationally, falls from heights of less than 5 meters are the leading cause of injury overall, and automobile crashes are the next most frequent cause. Both have the potential to cause a cerebral concussion.
Assessment
History
If the patient cannot report a history, speak to the life squad, a witness, or a significant other to obtain a history. Determine if the patient became unconscious immediately and for how long—a few seconds, minutes, or an hour—at the time of the trauma. Find out if the patient experienced momentary loss of reflexes, arrest of respirations, and possible retrograde or anterograde amnesia. Elicit a history of headache, drowsiness, confusion, dizziness, irritability, giddiness, visual disturbances (“seeing stars”), and gait disturbances.
Mild cerebral concussions can cause headaches, dizziness, memory loss, momentary confusion, residual memory impairment, and retrograde amnesia; there is no loss of consciousness. Classic cerebral concussions cause a loss of consciousness lasting less than 24 hours; the patient usually experiences confusion, disorientation, and amnesia upon regaining consciousness. A postconcussive syndrome that may occur weeks and even months after injury may lead to headache, fatigue, inattention, dizziness, vertigo, and memory deficits.
Physical examination
The most common symptoms of a concussion include confusion, emotional lability, pain, dizziness, memory loss, and visual disturbances. First evaluate the patient’s airway, breathing, and circulation (ABCs). After stabilizing the patient’s ABCs, perform a neurological assessment, paying special attention to early signs of ICP: decreased level of consciousness, decreased strength and motion of extremities, reduced visual acuity, headache, and pupillary changes.
Check carefully for scalp lacerations. Check the patient’s nose (rhinorrhea) and ears (otorrhea) for CSF leak, which is a sign of a basilar skull fracture (a linear fracture at the base of the brain). Be sure to evaluate the patient’s pupillary light reflexes. An altered reflex may result from increasing cerebral edema, which may indicate a life-threatening increase in ICP. Pupil size is normally 1.5 to 6.0 mm. Several signs to look for include ipsilateral miosis (Horner’s syndrome), in which one pupil is smaller than the other with a drooping eyelid; bilateral miosis, in which both pupils are pinpoint in size; ipsilateral mydriasis (Hutchinson’s pupil), in which one of the pupils is much larger than the other and is unreactive to light; bilateral midposition, in which both pupils are 4 to 5 mm and remain dilated and nonreactive to light; and bilateral mydriasis, in which both pupils are larger than 6 mm and are nonreactive to light.
Check the patient’s vital signs, level of consciousness, and pupil size every 15 minutes for 4 hours. If the patient’s condition worsens, he or she should be admitted for hospitalization. Continue neurological assessment throughout the patient’s hospital stay to detect subtle signs of deterioration. Observe the patient to ensure that no other focal lesion, such as a subdural hematoma, has been overlooked.
Psychosocial
The patient with a concussion has an unexpected, sudden illness. Assess the patient’s ability to cope with the potential loss of memory and temporary neurological dysfunction. In addition, assess the patient’s degree of anxiety about the illness and potential complications. Determine the significant other’s response to the injury. Expect parents of children who are injured to be anxious, fearful, and sometimes guilt-ridden.
Diagnostic highlights
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Computed tomography | Intact cerebral anatomy | Identification of size and location of site of injury | Shows anterior-to-posterior slices of the brain to highlight abnormalities |
Other Tests: Skull x-rays; magnetic resonance imaging; cerebral spine x-rays; and a glucose test, using a reagent strip, of any drainage suspected to be CSF
Primary nursing diagnosis
Diagnosis
Altered thought process related to cerebral tissue injury and swellingOutcomes
Cognitive ability; Cognitive orientation; Concentration; Decision making; Identity; Information processing; Memory; Neurological status: ConsciousnessInterventions
Cerebral perfusion promotion; Environmental management; Surveillance; Cerebral edema management; Family support; Medication managementPlanning and implementation
Collaborative
Patients with mild head injuries are often examined in the emergency department and discharged to home. Generally, a family member is instructed to evaluate the patient routinely and to bring the patient back to the hospital if any further neurological symptoms appear. Parents are often told to wake a child every hour for 24 hours to make sure that the patient does not have worsening neurological signs and symptoms. Treatment generally consists of bedrest with the head of the bed elevated at least 30 degrees, observation, and pain relief. Neurological consultation after 2 to 4 weeks should occur before the athlete resumes a sport. Patients should be evaluated for a postconcussive syndrome with symptoms such as recurrent headaches, dizziness, memory impairment, ataxia, sensitivity to light and noise, concentration and attention problems, and depression or anxiety.
Pharmacologic highlights
General Comments: Narcotic analgesics and sedatives are contraindicated because they may mask neurological changes that indicate a worsening condition. There is no indication that medication improves recovery after a concussion.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Acetaminophen | 325–650 mg PO q 4–6 hr | Nonnarcotic analgesic thought to inhibit prostaglandin synthesis in the central nervous system | Manages headache |
Independent
Generally, patients are not admitted to the hospital for a cerebral concussion. Make sure that before the patient goes home from the emergency department, the significant others are aware of all medications and possible complications that can occur after a minor head injury. Teach the patient and significant others to recognize signs and symptoms of complications, including increased drowsiness, headache, irritability, or visual disturbances that indicate the need for reevaluation at the hospital. Teach the patient that occasional vomiting after sustaining a cerebral concussion is normal. The patient should not go home alone, because ensuing complications are apt to include decreased awareness and confusion.
If the patient is admitted to the hospital, institute seizure precautions if necessary. Ensure that the patient rests by creating a calm, peaceful atmosphere and a quiet environment. Limit visitors to the immediate family or partner and encourage the patient to rest for 24 hours without television or loud music.
Evidence-Based Practice and Health Policy
Register-Mihalik, J.K., Guskiewicz, K.M., McLeod, T.C., Linnan, L.A., Mueller, F.O., & Marshall, S.W. (2013). Knowledge, attitude, and concussion-reporting behaviors among high school athletes: A preliminary study. Journal of Athletic Training, 48(5), 645–653.
- Health providers should be aware of the tendency toward concussion underreporting, especially among athletes.
- Investigators conducted a study among 167 male and female high school athletes from 28 schools in 9 states and across 6 different sports to determine attitudes and behaviors regarding concussion reporting.
- Of the sample, 53% reported having at least one possible concussion; however, only 16.9% of these athletes reported the incident to a coach or medical professional. Of the 84 reports that a concussion actually occurred, less than half of these events were reported to a coach or medical professional.
- The most common reasons for not reporting a potential or actual concussion included not thinking it was serious enough to report (70.2%), not wanting to be removed from the game (36.5%), not wanting to let their teammates or coaches down (27% and 23%, respectively), not realizing the event was a concussion (14.9%), and not wanting to be removed from practice (13.5%).
Documentation guidelines
- Trauma history, description of the event, time elapsed since the event, whether the patient had a loss of consciousness and, if so, for how long
- Adequacy of ABCs; serial vital signs
- Appearance: Bruising or lacerations, drainage from the nose or ears
- Physical findings related to site of head injury: Neurological assessment, presence of accompanying symptoms, presence of complications (decreased level of consciousness, unequal pupils, loss of strength and movement, confusion or agitation, nausea and vomiting)
- Patient’s and family’s understanding of and interest in patient teaching