MILD TO MODERATE HEAD INJURIES

A.

The distinction between mild and moderate head injuries is based on the initial Glasgow Coma Scale score and appearance of the initial CT scan of the brain. Patients who have an initial GCS score of 13 to 15 are considered to have a mild brain injury. Those patients with a GCS score of 9 to 12 are classified as having a moderate brain injury. Some recommend that any patient who has a posttraumatic abnormality such as contusion or subdural or epidural hematoma on initial

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CT scan should be classified categorically as either a moderate or severe head injury patient regardless of initial GCS score. As many as 10% to 35% of those patients with GCS scores of 13 to 15 will have posttraumatic abnormalities on CT scan, and 2% to 9% ultimately will require a craniotomy for these lesions. Except for these empiric classification systems, the distinction between mild and moderate head injury is one of degree of severity of parenchymal injury. Thus, these two categories will be considered together in this section.

B.

Most patients with mild head injury can be observed safely in the emergency department and discharged, although a few are at risk for delayed posttraumatic intracerebral hematomas or brain swelling. Identification of these patients requires careful neurologic assessment and liberal use of the CT scan.

• Clinical characteristics associated with an increased risk for subsequent brain swelling or hemorrhage are loss of consciousness associated with posttraumatic or retrograde amnesia. These patients should have a CT scan of the head.
• Patients with an abnormal CT scan or those who have a focal neurologic deficit on evaluation in the emergency department should be admitted for observation.
• PTS with a coagulopathic state or taking anticoagulants.

C.

Decision on return to play after sports-related head injuries is determined by loss of consciousness or amnesia (Tables 17-1 and 17-2). The following guidelines are recommended (asymptomatic refers to no symptoms after provocative testing (e.g., a neurologic exam after 10 pushups or 10 situps) and based on their grade:

TABLE 17-1 Grading of Sports-Related Head Injury
Author Grade I Grade II Grade III AAN 1997 No LOC Symptoms <15 min No LOC Symptoms > min LLOC Cantu 1998 No LOC PTA <1 h LOC <5 min PTA 1–24 h LOC >5 min PTA 1–24 h Colorado Medical Society 1991 No LOC Confusion No amnesia No LOC Confusion and amnesia LOC Torg 1985 No LOC PTA only LOC <few min PTA or retrograde amnesia LOC Confusion and amnesia

TABLE 17-2 Return to Competition
Concussion Grade First Concussion Second Concussion Third Concussion Grade I Return if asymptomatic >30 min Return after 2 weeks and asymptomatic for 1 week End season Grade II Return after 2 weeks and asymptomatic for 1 week Return after 4 weeks and asymptomatic for 1 week End season Grade III Return in 1 month and asymptomatic for 1 week End season End season? End career?

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• No loss of consciousness and no amnesia following a minor head injury: The patient can return 5 to 15 minutes after becoming completely lucid and asymptomatic.
• Posttraumatic amnesia but no loss of consciousness or retrograde amnesia: No return to play that day.
• Posttraumatic and retrograde amnesia with loss of consciousness: No return to play for 1 week after becoming completely lucid and asymptomatic and only after a detailed neurologic examination and CT scan.
• Posttraumatic and retrograde amnesia and prolonged loss of consciousness: No return to play for 1 month and only after detailed neurologic evaluation and CT scan.

D.

The likelihood of sustaining one or more head injuries after an initial minor head injury is increased, and subsequent head injuries have an additive, deleterious effect on complex processing abilities and reaction times.