RISK FACTORS Those that predispose to falls, MVA, etc. including drugs and alcohol. Additionally, there is some association with litigation, female gender, preexisting headaches, and low socioeconomic status. However, these factors account for only a minority of the cases (eg, men are almost as likely as women to have symptoms, patients without pending litigation are almost as likely as those with pending litigation to have symptoms, etc.)
APPROPRIATE HEALTH CARE An outpatient setting with involvement of a primary care physician, neurologist, and psychologist as appropriate. Many cases can be handled solely by the patient’s primary care physician.
GENERAL MEASURES
• Address the patient’s symptoms such as neck pain, headaches, depression, etc. using the usual medications
• Involvement of vocational rehabilitation may be necessary
• Behavioral therapy, etc. can be tried, but there is no good evidence that this is effective
SURGICAL MEASURES N/A
ACTIVITY Sports activity, etc., should be limited based on degree of injury. Parents and coaches will often try to return an athlete to sports competition prematurely. The American Academy of Neurology has published these guidelines (226 MMWR March 14, 1997). A second impact syndrome phenomenon occurs. The second injury, while in and of itself may be mild, is cumulative with the first and may be fatal. Recommendations are verbatim from MMWR.
. Grade 1 concussion:
. Management: the athlete should be removed from sports activity, examined immediately and at 5-minute intervals, and allowed to return that day to the sports activity only if post-concussive symptoms (headache, vomiting, etc.) resolve within 15 minutes.
Any athlete who incurs a second Grade 1 concussion on the same day should be removed from sports
activity until asymptomatic for 1 week.
. Grade 2 concussion:
. Management: The athlete should be removed from sports activity and examined frequently to assess the
evolution of symptoms, with more extensive diagnostic evaluation if the symptoms worsen or persist for > 1 week. The athlete should return to sports activity only after asymptomatic for 1 full week. Any athlete who incurs a Grade 2 concussion subsequent to a Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 2 weeks.
. Grade 3 concussion:
. Management: the athlete should be removed from sports activity for 1 full week without symptoms if the loss of consciousness is brief or 2 full weeks without symptoms if the loss of consciousness is prolonged. If still unconscious or if abnormal neurologic signs are present at the time of initial evaluation, the athlete should be transported by ambulance to the nearest hospital emergency department. An athlete who suffers a second Grade 3 concussion should be removed from sports activity until asymptomatic for 1 month. Any athlete with an abnormality on computerized tomography (CT) or magnetic resonance imaging (MRI) of brain consistent with brain swelling, contusion, or other intracranial pathology should be removed from sports activities for the season and discouraged from future return to participation in contact sports.
PATIENT EDUCATION Discussion with patient and family about long term prospects, etc.
DRUG(S) OF CHOICE
. Sleep disorders/depression/headache:
. Amitriptyline in age appropriate doses or other tricyclic drug
. SSRIs are less well studied in PCS, but can be used for depression
. Benzodiazepines should be avoided if possible
. Neck pain/headache:
. NSAIDs
. Avoid narcotics if possible
PATIENT MONITORING As needed. Each case is individualized.
PREVENTION/AVOIDANCE Discussing the avoidance of drugs and alcohol with teens at the time of a sports physical. Discussion of seat-belt use.
POSSIBLE COMPLICATIONS Loss of source of income and resulting problems such as loss of house, strain on the family, etc.
EXPECTED COURSE/PROGNOSIS
Those not better by 1 year will probably not get better. It is of note that the resolution of litigation does not generally result in improvement of this disorder. Outcome correlates better with length of post traumatic
amnesia than GCS.