​Kembara Xtra - Medicine - Mild Traumatic Brain Injury

​Kembara Xtra - Medicine - Mild Traumatic Brain Injury 
Postconcussion syndrome (PCS) is a group of symptoms that can last for weeks to years following a concussion (mild traumatic brain injury [mTBI]). It includes physical, cognitive, and/or behavioral problems.
When concussion symptoms change into postconcussive syndrome is unknown. According to a recent consensus, this is defined as ongoing symptoms that last longer than 10 to 14 days in adults and 4 weeks in children.
● PCS symptoms may include - Mindful
Reduced academic/intellectual performance, poor organization, lack of focus, and a slow response time to physical stimuli
 Headache, Nausea, Changes in vision
 Tinnitus Light and noise sensitivity Dizziness and balance issues
 Exhaustion and disturbed sleep
Behavior, depression, irritability/emotional instability, apathy, and an increased sensitivity to alcohol
The history and clinical symptoms are used to make the diagnosis.

Incidence
Between 5% and 80% of patients with mTBI are reported to experience PCS development.
80-90% most concussion sufferers recover from postconcussion symptoms within 7 to 10 days, with children and adolescents taking a little longer. This is largely because it is difficult to distinguish postconcussion symptoms from PCS. Patients who experience persistent concussive symptoms are given a PCS diagnosis.
Prevalence
Females are slightly more likely than males to have persistent symptoms after a concussion.

Pathophysiology and Etiology 

Controversial; specific mechanism(s) are unknown; subsequent brain injury results from inflammation caused by microscopic axonal injury from shearing pressures.
Conflicting evidence on structural brain damage and the relationship between imaging and symptoms of physical illness PCS is still challenging to identify and treat because its etiology is poorly understood and because its symptoms overlap with those of other psychiatric disorders.
- It is unknown what causes postconcussion symptoms to linger and progress to postconcussion syndrome in just some people with mTBI.
- The development of PCS is frequently linked to behavioral factors, which may also contribute to this relationship. Differentiating some behavioral disorders from PCS might be difficult. Evaluation in neuropsychiatry may be beneficial.
- Patients with severe symptom burden after mTBI are more likely to develop PCS.

Risk Elements 
The strength of the initial symptoms is the best predictor.
Retrograde amnesia, difficulty focusing, disorientation, sleeplessness, loss of balance, sensitivity to noise, or visual disruption are some of the initial symptoms. Existing mental disorders such as posttraumatic stress disorder (PTSD), anxiety, depression, and personality disorders Low socioeconomic status; unclear if prior history of concussion(s) is a risk factor for PCS; preexisting expectation of poor outcomes following mTBI; nonsport concussion/mTBI; loss of consciousness is NOT indicative of PCS.

Prevention 

 Concussion, PCS, and appropriate safety rules education for athletes, coaches, parents, and sports trainers Precautions for head injuries are suggested. There is insufficient proof that these lower the incidence of mTBI/PCS.
 Anxiety and depression screening and treatment

Associated Conditions Compulsive, histrionic, and narcissistic personality disorders, as well as ADHD, anxiety, depression, fibromyalgia, and depression


Detailed information about a recent impact and a closed head injury, including:
- Injury timing in relation to symptoms
- Prior head traumas, such as concussions, and the circumstances surrounding such incidents - Previous social, mental health, or medical histories
Reporting of neurologic, cognitive, or behavioral symptoms by the patient or family - Thorough descriptions of concomitant symptoms, intensity, and duration

clinical assessment 

thorough neurological examination that includes the following
Glasgow Coma Scale (GCS), Patient Health Questionnaire-9 (PHQ-9), Anxiety/Depression Screening, and GAD-7
● There are also other screening and diagnostic tools that can be used, such as the Sport Concussion Assessment Tool [SCAT], the NFL Sideline Concussion Assessment Tool, and computerized neuropsychiatric testing.


Differential diagnosis: postconcussive symptoms; PTSD; anxiety/depression; personality disorders; migraines; fibromyalgia; evolving intracranial hemorrhage; exposure to toxins, including illicit and prescription drugs; and endocrine/metabolic abnormality. 

diagnostic procedure 

Initial examinations (lab, imaging)
In the proper clinical environment, take into account infection, intoxication, and endocrine or metabolic abnormalities.
Brain imaging is not always necessary for the first assessment of mTBI and PCS.
Imaging is indicated if cervical spine injury is suspected and is appropriate with comorbidities or anticoagulant medication at the time of injury.
Tests in the Future & Special Considerations
 A number of computerized neuropsychiatric (CNP) tests are accessible to aid in guiding judgments regarding return to play; it is most helpful to compare with baseline scores (if available).
When possible, formal neuropsychiatric assessments are preferable than CNP testing. None of these tests ought to be used independently to make decisions, especially if the patient is still exhibiting symptoms.
Programs for common neuropsychological testing - CNS Vital Signs - Balance Error Scoring System (BESS) - Axon Sports Computerized Cognitive Assessment Tool (CCAT) - Automated Neuropsychological Assessment Metrics (ANAM) - Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)

Management 
The process of returning to full activity should follow current evidence-based guidelines, which call for rapid cognitive rest during the acute period (24 to 48 hours), followed by a gradual return to everyday activities as tolerated.
Controlling cognitive stress and adding more modifications for school might be helpful when possible.
 Disallow people who have had a concussion or PCS from participating in sports activities until their symptoms have subsided and they have stopped taking any medications that could conceal PCS symptoms.
Physical therapy is helpful for people who have both cervical and vestibular issues. Cognitive behavioral therapy is effective in treating persistent mood disorders.
There is scant evidence that medication is effective.
Exercise below the threshold aids in symptom relief.


First Line of Medicine

 Headache and neck discomfort: Prefer non-opioid pain relievers, such as NSAIDs.
The sleepiness brought on by opioid medicines makes cognitive assessment difficult.
 Opiate use may be linked to a higher risk of anxiety and depression in PCS sufferers. Think about an occipital nerve block.
Emotional dysregulation (irritability, sorrow, anxiety, and depression) - Propranolol or amitriptyline alone or in combination - Anxiety/depression screening beginning in the first week post-mTBI
 Tricyclic antidepressants (10–25 mg of amitriptyline at night, for example) SSRIs (such as sertraline 25 mg per day titrated to an effective dose with a daily maximum of 200 mg) for persistent depression symptoms - Take into account referring to behavioral health specialist(s).
Sleep dysregulation and good sleep habits
- Melatonin, which older children and adults can take up to 3 mg of and up to 5 mg of. - Trazodone (25–50 mg at bedtime)
 Cognitive problems (lack of clarity, fuzziness, and sleepiness) - Neuropsychological testing - Neurostimulants including atomoxetine, methylphenidate, and amantadine (100 mg BID), as well as emotional problems


Referral: Occupational therapy for vocational rehabilitation; physical therapy for vestibular rehabilitation; neuropsychiatric therapy, including a thorough cognitive evaluation for potential TBI rehabilitation; cognitive-behavioral therapy for symptoms of anxiety and depression; neurology referral if primary care interventions for seizures, headache, vertigo, or cognition are unsuccessful; and, if necessary, substance abuse counseling. 

Alternative Medicine: Potential advantages of hyperbaric oxygen therapy in military veterans with concurrent PCS and PTSD. Massage therapy, osteopathic manipulative therapy, and acupuncture for headache and neck discomfort. 

Take Action 
Establish a frequent follow-up schedule to assess the effectiveness of pharmacologic therapy, the need for neuropsychiatric examination, and the persistence of symptoms.
patient observation
Think about repeated neuropsychological evaluations.
 Adhere to return-to-play recommendations while starting a sport or physical exercise regimen.


The prognosis is typically favorable. Adolescents may heal more slowly than adults. The majority of patients get better within 3 months.


Complications: Repeated head injuries or returning to play before PCS has completely resolved might make symptoms worse or last longer.
There have been case reports of second-impact syndrome, a rare but possibly lethal disorder caused by a second head injury shortly after the first.