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Friday, March 1, 2013

WHIPLASH, POST CONCUSSION SYNDROME, MILD TRAUMATIC BRAIN INJURY, Emergency Medical Condition, EMC.

          WHIPLASH, POST CONCUSSION SYNDROME, MILD TRAUMATIC BRAIN INJURY.  Emergency Medical Condition.  EMC.

Dr. Alan Himmel

I thought this would be an interesting topic due to the fact that symptoms of concussion due to whiplash, many times are routinely overlooked.  Many times, a patient seeks treatment for whiplash pain due to an auto accident, only to be treated for the typical musculo-skeletal symptoms and neurological symptoms, which include but is not limited to neck pain, shoulder pain, radiating extremity pain, tingling and numbness.  These complaints are almost universal among whiplash victims.

But what about other symptoms like headache, vertigo, fatigue, irritability, impaired memory?  The more severe case includes convulsions, loss of hearing, seizures, and loss of consciousness.  (5) Over the years I have had dozens of patients tell me that ever since the accident, they feel like they are "in a fog."    They describe it as the inability to think clearly.  If you are a healthcare practitioner you should be cognizant of these post concussion symptoms as they are commonly caused by automobile accidents, and they are an indication that the patient may have a mild traumatic brain injury.  (1)  If you are a patient who is experiencing any of the above signs or symptoms, please do not ignore this potential emergency medical condition.  Misdiagnosing or ignoring this altogether could lead to serious and permanent long term disability.

It has been estimated that there are between 1.6 million and 3.8 million individual cases of injuries that cause post-concussion-symptoms. (2) And, concussions are seen in approximately 6 in every 1000 injuries. (3) I often wonder how much higher this number would be if all cases were diagnosed, because many people never seek medical care.  There are a lot of variables here.  In fact, this is an injury that is very prevalent in athletics and contact sports, like football and ice hockey, but on the amateur level, many times these mild traumatic brain injuries are simply ignored.  Time and time again, I even see the diagnosis of concussion being missed by physicians at emergency departments.

The concussion could occur when there is an impact to the head, or the head is thrown around due to  unexpected forces to the body, such as from a car crash, a serious football tackle, etc.



The image above shows how the brain which is surrounded by fluid for protection, is moved forcefully and collides with the inside of the skull.  

The image above shows the resulting bruise to the brain, which has just crashed into  the  inside of the skull.

To get an idea of the potential seriousness of these types of head injuries, you don't have to look very far.  There have been several incidents in professional sports, particularly football, where it is has been shown that repeated concussions to the brain caused very serious and chronic outcomes.  Over the long haul, patients who have had concussions suffer from depression, chronic headaches, mood swings, early dementia, memory problems and other psychological disorders.(4)

Treatment for concussion generally involves rest, including cognitive rest, by eliminating anything that requires concentration or memory, including taking time off from school.  Reducing physical activity is important and generally if the injury happened playing sports, the individual would be taken out of the game for a while, at least until all the symptoms have disappeared.  Once the patient is symptom free, he must be gradually be introduced back into the physical activity in small steps.  You don't want to just throw yourself back into the game, as symptoms could return.

You have to listen to what the patient has to say and do a thorough exam.  Be aware that there a lot of forces involved even in small impact collisions.  Don't overlook or brush it off when a patient tells you that since the accident they are having a hard time concentrating.  Put the pieces together.  You may have a case of post concussion syndrome which is an Emergency Medical Condition or EMC.



1.   2012;2012:528265. doi: 10.1155/2012/528265. Epub 2012 May 22.

Postconcussion symptoms in patients with injury-related chronic pain.

Source

Department of Community Medicine and Rehabilitation, Umeå University Hospital, Umeå University, Building 9A, 90185 Umeå, Sweden.  

2.. 2012 Nov;40(4):73-87. doi: 10.3810/psm.2012.11.1990.

Postconcussion syndrome: a review of pathophysiology and potential nonpharmacological approaches totreatment.

Source

Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. maroonjc@upmc.edu

3.   Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L, et al. (2004). "Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury". Journal of Rehabilitation Medicine 36 (Supplement 43): 28–60. doi:10.1080/16501960410023732PMID 15083870

4.   Cantu RC (2007). "Chronic traumatic encephalopathy in the National Football League".Neurosurgery 61 (2): 223–5.  PMID 17762733 

5.  "Information about NICE clinical guideline" (PDF). National Institute for Health and Clinical Excellence. September 2007. Retrieved 2008-01-26.