A 16-year-old-girl comes to the clinic for follow-up after sustaining a head injury 7 days ago. The patient was playing soccer and her head collided with another player. She was seen in the office that day and diagnosed clinically with a concussion. The patient was instructed to rest for 2 days before beginning a gradual return-to-play program. She participated in light aerobic activity yesterday and began moderate aerobic activity exercises today. During training today, she developed nausea and felt dizzy. The patient has no chronic medical conditions. Blood pressure is 112/76 mm Hg, pulse is 90/min, and respirations are 16/min. The patient is alert and oriented. Cardiopulmonary examination is normal. Cranial nerves are intact. Strength is normal. Sensations and reflexes are equal bilaterally. Cerebellar examination and gait are normal. Which of the following is the best next step in management of this patient?

Question

A 16-year-old-girl comes to the clinic for follow-up after sustaining a head injury 7 days ago.  The patient was playing soccer and her head collided with another player.  She was seen in the office that day and diagnosed clinically with a concussion.  The patient was instructed to rest for 2 days before beginning a gradual return-to-play program.  She participated in light aerobic activity yesterday and began moderate aerobic activity exercises today.  During training today, she developed nausea and felt dizzy.  The patient has no chronic medical conditions.  Blood pressure is 112/76 mm Hg, pulse is 90/min, and respirations are 16/min.  The patient is alert and oriented.  Cardiopulmonary examination is normal.  Cranial nerves are intact.  Strength is normal.  Sensations and reflexes are equal bilaterally.  Cerebellar examination and gait are normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bff1_d4e1_8f63_47fc461dc1e4_MD0005_00 Concussion is a mild traumatic brain injury caused by axonal shearing from rapid rotational acceleration of the brain during a fall or strike to the head. Children and adolescents playing contact sports (eg, soccer) are at increased risk for concussions. Patients are usually diagnosed clinically based on the presence of a neurologic disturbance (eg, headache, cognitive dysfunction) after head trauma. Neuroimaging is not typically required unless high-risk features for structural intracranial injury are present (ie, altered mental status, loss of consciousness, severe headache/vomiting, severe mechanism of injury, signs of basilar skull fracture). Initial management is physical and cognitive rest for 24-48 hours. Athletes should then follow a gradual return-to-play protocol with progressive intensity of physical exercise (eg, light aerobics → moderate noncontact activity → competitive play) as tolerated. If symptoms worsen at any level of exertion, a 24-hour rest period is recommended before returning to the previous step in the protocol that did not exacerbate symptoms. In this case, the patient tolerated light aerobics but developed dizziness and nausea with moderate exercise; therefore, she should rest for a day and then return to light aerobic activity. (Choice A) Refraining from contact sports for prolonged periods may be appropriate for a patient with persistent neurocognitive deficits due to multiple concussions, which are not seen in this patient. (Choice B) Brain imaging to exclude structural intracranial injury may be considered for worsening symptoms despite appropriate rest and adherence to the gradual return-to-play protocol. In contrast, this patient's symptoms that wax and wane with exertion are typical of a concussion and can be managed by adjusting the activity level. (Choice C) Continuing moderate exercise despite worsening symptoms can lead to chronic postconcussive symptoms and is not recommended. (Choice D) Physical rest for a week prolongs the recovery time and increases the risk of deconditioning. Early return to light exercise is safe as long as the progression of intensity is gradual. Educational objective: Concussion is a mild traumatic brain injury characterized by neurologic disturbance without structural intracranial injury. Management involves a gradual return-to-play protocol with increasing intensity of physical activity. When symptoms develop with progressive exertion, patients should rest and return to the previously tolerated activity level. References: American Medical Society for Sports Medicine position statement: concussion in sport. (http://www.ncbi.nlm.nih.gov/pubmed/23243113)

A 16-Year-Old-Girl Comes to the Clinic for Follow-Up After Sustaining