Concussion Assessment Quiz

Concussion

• Defined as a "traumatically induced transient disturbance of brain function that involves a complex pathophysiological process" (Harmon et al, 2013).
• Often a subset of mild traumatic brain injury, at the less severe end of the brain injury spectrum (Harmon et al, 2019).
• One of the most difficult athletic injuries to diagnose and manage (Tamara et al, 2017).
• Caused when the force from a blow to the head, sudden deceleration, or other impact to the body travels to the head. The force causes the brain to move around inside the skull.

Pathophysiology

• Cascade of cellular and molecular events.
• Mechanical forces can stretch or strain brain tissue.
• Damage to neurons, axons, and blood vessels.
• Disruption of ions (e.g., potassium and calcium).
• Imbalance of neurotransmitters.
• Potential inflammatory response.

Cognitive Symptoms

• Feeling mentally foggy
• Difficulty concentrating
• Difficulty remembering
• Repeating questions
• Feeling mentally slowed down
• Forgetful of recent information
• Confused about recent events
• Answering questions slowly

Physical Symptoms

• Headache
• Nausea/vomiting
• Balance problems
• Numbness/tingling
• Sensitivity to light/noise
• Visual problems
• Dizziness
• Dazed or stunned

Emotional Symptoms

• Irritability
• Sadness
• More emotional
• Nervousness

Sleep Symptoms

• Drowsiness
• Sleeping less than usual
• Sleeping more than usual
• Trouble falling asleep

How to Recognize a Concussion - Criteria 1

• Confirmed loss of consciousness (LOC)
• Suspected LOC
• Convulsion
• Tonic posturing
• Balance disturbance/ataxia
• Clearly dazed

How to Recognize a Concussion - Criteria 2

• Head impact where diagnosis not immediately apparent
• Possible behavior change
• Possible confusion
• Injury observed with potential for concussion
• Possible transient or sub-threshold criteria 1 signs (e.g., possible LOC, possible balance disturbance)

5-Step Analysis

• Head impact (Time 0)
• Immediate response (0-2 seconds)
• Delayed response (3-7 seconds+)
• Returning to feet
• Return to play

GRTP Flowchart

• Clearance by healthcare professional (HCP) or doctor recommended
• Routine return to play pathway for adults & U19
• Different timeframes for return to play (RTP) based on age group/stage
• Follow specific guidelines/flowchart as directed by physician

Airway Anatomy and Obstruction

• Common Obstructions: Tongue, Oedema (swelling), Foreign material, Blood, Vomit, Teeth, Protective Equipment
• Upper Airway: Nasal cavity, Pharynx, Larynx
• Lower Airway: Trachea, Primary bronchi, Lungs
• Additional: Bronchospasm, Secretions, Oedema, trauma

Airway Noises

• Stridor: Harsh, high-pitched noise during inspiration, often suggestive of upper airway obstruction.
• Snoring: Partial obstruction of the pharynx by the soft palate or tongue.
• Gurgling: Secretions or fluids in the upper airway.
• Choking: Mechanical obstruction to airflow, often a foreign body.
• Hoarseness: Abnormal voice due to vocal cord irritation or injury.

Suction

• Suction only under direct visualization.

Airway Adjuncts

• Oropharyngeal Airway (OPA): Device inserted into the mouth to maintain an open airway.
• Sizing: Use incisors to appropriately size the airway.
• Insertion: Inverted & With Tongue Depressor
• Nasopharyngeal Airway (NPA): Device inserted through the nose.
• Sizing: Determine size by measuring from the tip of the nose to the tragus of the ear.
• Insertion: Lubricate & bevel against the septum (and if resisted, rotate)
• Gold Standard - Supraglottic Airway (I-Gel): Advanced airway device.

Airway Adjunct Contraindications

• OPA: Conscious or semi-conscious patient with oral trauma or obstruction, severe trismus (lockjaw), foreign body obstruction, size too small to be effective.
• NPA: Conscious or semi-conscious patient with nasal pathologies or obstructions, coagulopathy, severe nasal trauma or severe facial trauma.
• I-Gel: Conscious or semi-conscious patient with complete airway obstruction, high risk for aspiration, massive facial trauma or airway deformity , or tracheal pathology

Breathing Masks

• Non-rebreather mask: Used for emergencies or shock management. Creates a seal and has a reservoir to hold and deliver oxygen. Flutter valves allow exhaled air to escape.
• Bag-valve mask (BVM) External management of the airway and breathing for patients who are not unconscious. Used for abnormal breathing rates (<10 or > 30).

Acute Medical Emergencies

• Diabetic Collapse
• Fainting
• Acute Cerebral Event
• Asthma
• Anaphylaxis
• Heat illness

Diabetic Collapse

• Body's inability to regulate blood sugar levels (high or low).
• Hypoglycaemic (low blood sugar) <3.0 mmol.
• Signs and symptoms include: Shaking, trembling, sweating, headache, difficulty concentrating, slurring of speech, aggression/confusion, fitting/seizures, unconsciousness.
• Treatment: Confirm diagnosis by blood glucose measurement. Co-operative patients get oral glucose. More severe cases, apply sugary substance to buccal area.

Fainting

• Inadequate cerebral perfusion.
• Commonly occurs with low blood pressure (BP).
• Someone might have a history of repeated faints.
• Signs and symptoms: The patient feels faint/ lightheaded/dizzy, slow pulse rate, low BP, Pallor and sweating, Nausea and vomiting, Loss of consciousness.
• Treatment: Lay flat, raise legs, loosen clothing, O2 at 15 L/min. If unresponsive, monitor for signs of life.

Asthma

• Common respiratory illness affecting ~5% of the population.
• Issue is bronchospasm, constriction of surrounding muscles, causes narrowing of the lower airways.
• Airway inflammation causes swelling and further narrowing.
• Signs and symptoms include wheezing, coughing, tight chest, breathlessness, cyanosis, tripod position, accessory muscle breathing.
• Categories of asthma: Moderate, Acute severe, Life-threatening.
• Treatment: Based on the category.

Anaphylaxis

• Severe, potential life-threatening reaction to a trigger (e.g., allergies).
• Body overreacts to a substance causing symptoms (S&S).
• Signs and symptoms: Sudden collapse, dizziness, cold and clammy skin, confusion, sense of impending doom, loss of consciousness, swelling of tongue/throat, difficulty swallowing/speaking, horse voice, noisy breathing..
• Treatment: Confirm condition as anaphylaxis, support airway, give epinephrine (EpiPen), remove trigger, lay flat (unless breathing/conscious problems), elevate legs, and potentially subsequent epinephrine injection.

Chest Injuries

• Potentially Fatal Chest Trauma: Airway obstruction (A), Tension Pneumothorax (T), Open Pneumothorax (O), Massive Hemorrhagic Thorax (M), Flail Chest (F), Cardiac Tamponade (C).
• Airway Obstruction: Laryngeal trauma, hoarseness, subcutaneous emphysema.
• Tension Pneumothorax: Air in the pleural cavity, increasing pressure, causing collapse of the lung and shifting of the mediastinum.
• Open Pneumothorax: A sucking chest wound, a puncture wound allowing air to enter the pleural space.
• Massive Hemorrhagic Thorax: Significant blood loss in the chest cavity.
• Flail Chest: Multiple rib fractures causing a segment of the rib cage to detach, causing paradoxical breathing.
• Cardiac Tamponade: Excess fluid/blood accumulation in the pericardial sac, hindering heart function.
• How Breathing Works: Describes the role of the parietal pleura, visceral pleura, pleural space, and lubricating fluid.

Spinal Injuries

• Although rare in sport, spinal injuries, especially those connected with cord damage need attention.
• Typically low velocity.
• Secondary pathology from hypoxia is often the cause of permanent damage.
• Effective management is critical to prevent lasting issues.

Shock

• What is Shock?: Body's response to inadequate blood flow. Hypoperfusion (decreased flow) causes decreased blood flow and oxygenation to the brain. Recognition includes tachycardia, vasoconstriction, decreased cardiac output, decreased conscious state, and decreased arterial pressure.
• Types of Shock: Hypovolemic (fluid loss), Hemorrhagic (blood loss), Anaphylactic (allergy), Septic (infection), Neurogenic (autonomic nervous system dysfunction), Cardiogenic (heart dysfunction), Hypoglycemic (low blood sugar), Psychogenic (response to stress)

Possible Pupil Checks

• Pupils: Equal and responsive/reactive to light is typical.
• Possible Conditions Affecting Pupils: Holmes-Adie syndrome, Argyll Robertson pupil, Horner's syndrome, Midbrain compression, Pontine stroke.

Monday Seminar

• Mock online exam.
• Approximately 20 minutes long.
• Sample exam questions.
• Idea of content and phrasing.
• Electronic devices for the exam.
• PowerPoint with answers afterwards.