A 65 y/o male with atrial fibrillation on aspirin presents with confusion after an unwitnessed fall. Patient has persistent symptoms of confusion for 3 hours while in ED with difficulty walking after return to baseline. His CT head is normal. MRI is unremarkable. Thirteen hours later, patient still has memory abnormalities. The patient is diagnosed with a concussion.
Take Away #1:
Look out for concussive type syndromes:
(Grading score per American Academy of Neurology)
Mild: Confusion, symptoms < 15min, no loss of conscious (LOC)
Moderate: symptoms > 15min, no LOC
Severe: LOC
Schwanerism: Use common sense, LOC should be worked up for other causes as well. Observation may be endgame if the patient cannot ambulate or is unsafe to go home, or may not have capacity.
Take Away #2:
Perform an appropriate history and neurological exam, looking for specific signs or clues that could indicate concussion.
Was there LOC? Seizure following event? Memory impairment? Repetition?
Serial 7’s, remember 5 objects, spell "world" backwards, GCS
Ocular exams to perform:
Ocular alignment
Horizontal and Vertical Saccades
Smooth pursuit
Near point convergence (normal < 6cm)
Don’t forget about gait and balance!
Take Away #3:
Remember to risk stratify pediatrics patients for imaging using PECARN:
If <2 yrs:
If GCS <14, severe mechanism, patient not acting normal per patient, temporal scalp hematoma: Observation vs CT
If >2 yrs:
If GCS <14, AMS, signs of basilar skull fx, hx of LOC or vomiting or severe mechanism: Observation vs CT
Dan Singer, MD is a third year resident at Stony Brook Emergency Medicine.
References
Edited by Bassam Zahid, MD