Brain TumoursTriad | Other S&S | Headache | Nausea | Vomiting | Worse first thing in the morning | Convulsions | Valsalva movements make it worse | | | new onset/change in HA | | | Seizures | | | Confusion | | | Dysphagia | | | Motor Weakness | | | Personality Changes | | | Memory Loss |
Triad in childrenDizziness | Headache | Vomiting |
Temporal ArteritisS&S | Persistant unilateral throbbing over temporal region + scalp tenderness | Associated with PMR - look for bilateral inflammatory signs over shoulder/hip area | >50y | Severe burning - worse in morning & constant | Malaise, vague aches, pains, weight loss | ESR/CRP elevated |
MangementUrgent referral (same day) to GP - risk of blindness |
| | Mild Traumatic Brain InjuryCommon in teens and young adults | Athletes more at risk - football, boxing, hockey, soccer, MMA, military personnel, victims of domestic abuse, motor accidents |
Concussion- One type of brain injury | - Subconcussive injury = traumatic impact to the head that does not result in immediate clinical symptoms | - Simple concussion = progressively resolves after 7-10 days without complications | - Complex concussion = persistent symptoms and Hx of loss of consciousness >1 minute, recurrence/exacerbation on exertion, prolonged impairment of cognitive function, seizure | Mechanical insult - complex cascade of biochemical dysfunction - mitrochondrial dysfunction - disrupts brain's neuronal homeostasis |
Presentation- Headache | - Confusion, light-headedness/dizziness, visual disturbances, tinnitus, lethargy, insomnia, photophobia, irritability, mood changes, cognitive difficulties | - Impaired memory & leaning, reduced planning, inability to switch mental tasks, attention deficits, slower information processing, slowed reaction times | - Symptoms worse with physical exertion/stress |
On field assessment of injured athlete = ruling out emergent situations
Palpation of head, neck, face , nose and TMJ for f#/injuries
Move fingers and toes - upper and lower sensation, strength and function Red flags- GCS <15 | - Deteriorating mental status | - Potential spinal injury | - Progressive neurological signs/symptoms | - Persistent vomiting | - Suspected skull f# | - Seizures | - Coagulopathy | - Prior neurosurgery | - Multiple injuries |
Questions (Maddocks)What ground/field/rink are we playing at? | What team are we playing today | What half/quarter/period is it? | How far into the game is it? | Which side scored last? | What team did we play last game? | Did we win last game? |
- Sideline for evaluation if suspected concussion (motor, sensory, reflex tests, CN evaluation, coordination and balance assessment)
- Difficulty with these questions = out and not allowed to play
- SCAT3
- Ask about concussion S&S What to do nextOnce concussed patient is out of the game, an attendant should stay with them for 24 hours post concussion | Attendant should observe patient every 4 hours | Should be alert for: worsening ha, irritability, persistent nausea/vomiting, difficulting speaking, swallowing, tinnitus, SOB, light headiness, numbness, confusion, memory loss, clear CSF discharge from nose/ears, unequal pupils, fever, visual disturbances, seizures, LOC, easily aroused | Drink only clear fluids for 8-12 hours | No alcohol | Diet should begin light and progress to normal over 24 hours | Sedatives, sleeping pills, aspirin and ibuprofen should be avoided | Avoid physical and mental activity for first 24 hours - school, work, texting, video games, driving, operation of dangerous tools or heavy equipment | Should sleep with head elevated for 24 hours | Follow up assessment - did you hit your head? Lose conciousness? experience amnesia, loss of memory, disorientation/confusion? Dizziness or unsteadiness? Memory problems/forgetfulness? Concentration/attention problems? |
ImagingMay be used to rule out Cx injury | Canadian CT head rule - witnessed loss of conciousness,amnesia/disorietnation | MRI for: GCS <15 at 2 hours post injury
>2 episodes of vomiting
>65 or older
Suspected skull f# (haemotympanum, raccoon eyes, CSF otorrhoea/rhinorrhoea, battles sign (bruising over mastoid)
Pre injury amnesia >30 mins
Dangerous mechanism of injury - struck by motor vehicle, MVA ejection, fall from >3 feet |
Management- Recovery period = 100 days | - Some patients have post concussion syndrome within 1-2 weeks up to 3 months | - Delayed recovery factors = >4 symptoms
HA >60 hours
Pre-injury HA
Self reported fatigue/foginess
prior mTBI
Hx of PTSD, ADHD, learning disability
advancing age
no and proximity of concussions
Duration of concussion (>10 days)
prolonged loss of consciousness (>1 minute)
amnesia
convulsions
co-morbidities
Medication | - Allowed to play when:
Complete clearing of symptoms at rest - no pain meds
No symptoms after provocative testing - cycling, running, cardio exercises
Full return of cognitive ability, memory and concentration | - Can do light aerobic activity after symptoms resolve if it does not excaberate symptoms then progressive more demanding activity should be considered (70%) | - Multiple concussed patients increased risk of Alzheimers, ALS , Suicide, Parkinsons and Dementia | - Assess Paraspinals - suboccipitals | - Patients who worsen/do not show improvement after 3-5 days should be referred to a specialist | - EPA/DHA/Magnesium |
Thunderclap HAS&S | Causes | Management | Sudden, abrupt Headache - Reaches peak @ 1 hour | SAH | REFER IMMEDIATELY TO HOSPITAL | "Worse Headache of their life" | Intracranial haematoma | DON'T LET THEM DRIVE | "Feels as though they are being hit on the back of the head" | Cerebral venous sinus thrombosis | Very Different type of Headache | Cervical Artery dissection | | | Ischaemic Stroke |
MeningitisS&S | Severe Headache | Neck Stiffness | High Fever | Altered Mental State | Photo/Phonophobia |
ManagementRefer immediately to hospital - dial 999 | CRP, FBC, blood cultures, lx puncture |
Serious Signs of HA in ChildrenPresent in the morning | Wakes Child at night | No PMHx | No Family Hx | Associated Poor health | Associated Neuro symptoms | Presents unilaterally |
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