a. Patient should be transported to the nearest emergency department if unconscious or if worrisome signs are noted. Perform thorough neurologic exam, and admit any patient with intracranial pathology on imaging or deficits on neurologic exam. Patients with persistent unconsciousness should be transported to a trauma center.

b. Obtain CT or MRI scan if symptoms persist for > 1 week.

c. Following brief (seconds) grade 3 concussion, patient may return to sports activity if asymptomatic for 1 week (at rest and exertion). Following prolonged (minutes) grade 3 concussion, patient may return to sports activity if asymptomatic for 2 weeks at rest and exertion.

d. Following a second grade 3 concussion, patient should refrain from activity for a minimum of 1 month once symptom-free.

e. Patients with any abnormal findings on CT or MRI scan (eg, edema or contusion) should terminate sports activities for remainder of the season and be discouraged from future competition.

D. Other Conditions. Initial and subsequent therapy is based on diagnosis and severity of presenting features of the underlying conditions.

Problem Case Diagnosis. The 12-year-old boy has a grade 2 concussion. According to the history, his parents had more difficulty than usual awakening him that morning, and he was sleepy on the school bus and during first period in school. No involuntary movements or prior spells had been noted. Patient had been hit in the head while playing basketball the night before. He complained of headache and nausea but did not have a medical evaluation following the incident. His prenatal, birth, developmental, family, and past history was otherwise unremarkable. Physical exam was significant for frontal ecchymosis, stiff neck, and occipital scalp hematoma. Neurologic exam was significant for lethargy, in addition to memory, thinking, and concentration problems. Drug toxicology screening and head CT scan were normal.

Teaching Pearl: Question. Is a neuroimaging study the most useful way to monitor a patient's progress after a concussion?

Teaching Pearl: Answer. Microscopic changes in the brain may not be evident on neuroimaging studies; therefore, history and neu-ropsychological exam are the most useful tools to follow a patient's progress after concussion.

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