View source for Mild traumatic brain injury

==Background==
[[File:Mild TBI.JPG|thumb]]
*Definition: [[GCS]] 14-15
*Neurologic dysfunction that varies without gross lesions (ie patients have trouble with memory, attention, and executive functioning
*Occurs after a blunt force or acceleration-deceleration [[head injury]]
*Likely secondary to metabolic insult ie low oxygen state, ion changes
*Structural imaging on [[brain MRI|MRI]] or [[head CT|CT]] might not indicate any injury
*Often evidence on microscopic level of injury with histology
*Important to not expose the already injured brain to repeated insults which is why there are usually worsening symptoms after a repeat concussion

===Epidemiology===
*2.5 million people sustain a TBI in the United States every year
*75 to 95 percent, are mild
*Most common causes of TBI are motor vehicle accidents (20 to 45 percent), falls (30 to 38 percent), occupational accidents (10 percent), recreational accidents (10 percent), and assaults (5 to 17 percent)

{{TBI pathophysiology}}

==Clinical Features==
*Most consistent abnormality is subtle impairments in cognitive function (concussion symptoms)
**Attention, concentration, amnesia, memory, processing speed, reaction time, calculation, executive function
*Physical signs/symptoms
**[[Headache]], [[dizziness]], [[insomnia]], [[fatigue]], uneven gait, nausea/[[vomiting]], [[blurred vision]], [[seizure]]
**Postconcussive anosmia (affecting taste as well)
*Behavioral changes
**Irritability, [[depression]], [[anxiety]], sleep disturbances, problems related to school/work, emotional lability, loss of initiative, loneliness, and helplessness

==Differential Diagnosis==
{{Head trauma DDX}}

==Evaluation==
{{Head trauma workup}}

===Westmead post-traumatic amnesia scale===
''Any wrong answer to following questions is considered positive for cognitive impairment after head injury ''
*What is your name?
*What is the name of this place?
*Why are you here?
*What month are we in?
*What year are we in?
*What town/suburb are you in?
*How old are you?
*What is your date of birth?
*What time of day is it? (morning, afternoon, evening)
*Three pictures are presented for subsequent recall

===Diagnosis===
*Clinically made, no reliable test that can confirm diagnosis of concussion
*Signs and symptoms may occur immediately or be delayed by days-weeks (see also [[post-concussive syndrome]])

===Types===
*Simple concussion
**Gradual resolution of symptoms within 7-10d
*Complex concussion
**Persisting symptoms or cognitive impairment
**Symptoms with exertion

==Management==
===Simple===
*Limitations on playing and training while symptomatic
*Follow up with primary care provider

===Complex===
*Refer to sports medicine or concussion specialist

==Disposition==
===Admit===
Patient requires inpatient observation if GCS <15, seizure activity present, anticoagulation or bleeding diathesis, or no responsible caregiver to discharge to
===Discharge===
Patient may be discharged for outpatient observation if (all of the following):
*No head CT required per above criteria '''OR''' head CT performed and not requiring neurosurgical intervention
*Patient GCS 15 on discharge
*No [[seizures]]
*No [[anticoagulation]] or [[coagulopathy|bleeding diathesis]]
*Responsible caregiver at home to discharge to

====Discharge instructions====
*Given good follow up instructions detailing a graded return-to-activity program and symptoms to anticipate during recovery <ref>Ronsford J, et al. Impact of early intervention on outcome after mild traumatic head in adults. 2002</ref>
*Encourage cognitive rest and avoidance of repetitive head injuries
*Discharge patient to care of responsible individual
*Patients might not understand discharge instructions so repeat them to the individual taking care of the patient
*In one study of adolescents, strict rest immediately after mild TBI offered no benefit. <ref>Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015; 2(135):213-223.</ref>
*Physical activity at any level (light aerobic, moderate, full) within first 7 days compared with no activity associated with lower rates of persistent symptoms at 28 days (29% vs. 40%)<ref>Grool AM et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514.</ref>
**Multicohort study - 2400 children, aged 5-18, in the emergency department
**Still recommend strict rest for first 24-48 hours
*Follow up for full examination, gait and cognition testing
**Mini-Mental State Exam
**Standardized Assessment for Concussion
***Takes 10-15 mins to administer, often not performed in ED

==Prognosis==
''See also [[post-concussive syndrome]]''
*At 3 mo after injury 20-40% are symptomatic
**With treatment for the most common symptoms of [[headache]], difficulty concentrating, and short-term memory difficulties being rest and (in some circumstances) [[NSAIDS]]. 
*At 1 yr after injury 15% are symptomatic

==See Also==
*[[Head Trauma (Main)]]
*[[Severe traumatic brain injury]]

==References==
<references/>

[[Category:Pediatrics]]
[[Category:Trauma]]
[[Category:Neurology]]