Ignoring Concussions Can Pose Dangers

Pharmacy Times Health Systems Edition, March 2022, Volume 11, Issue 2

Patients may not admit or recognize when they have a brain injury, but pharmacists can be a valuable resource.

Traumatic Brain Injury (TBI) is a leading cause of death and disability in the United States, affecting an estimated 2.5 million individuals each year.1 The actual number likely is larger, because this statistic does not include TBIs that go untreated or that are treated in primary care, urgent care, or at the site of injury, such as a sports field. Mild TBIs, or concussions, account for more than 75% of TBI cases and are the result of a blow, bump, or jolt to the head or from a hit to the body that causes the brain and head to move rapidly back and forth.1-3 For most individuals, a concussion and concussion symptoms resolve
over time. However, in a small subset, postconcussive syndrome is present.

Epidemiology

The American Academy of Neurology defines concussion as a “clinical syndrome of biomechanically induced alteration of brain function typically affecting memory and orientation, which may involve loss of consciousness.”4 The sudden impact or movement that results in a concussion can alter the brain’s physiology, cause oxidative stress, and damage and stretch brain cells.5

In the United States, the highest rates of concussion are seen in individuals younger than 24 years and those older than 75 years.

Falls and motor vehicle accidents are the most common causes of concussion
in those 75 years and older, with this age group having the highest number and rate of TBI-related deaths and hospitalizations.1 Among those aged 15 to 24 years, motor vehicle accidents and sports are leading causes of concussions, and in children aged 0 to 4 years, falls are the primary cause.

Males are more likely to suffer head injuries, and it is postulated that this reflects their more frequent engagement in contact sports and high-risk activities.6 Other risk factors are a history of hospital admissions for intoxication and lower cognitive function or socioeconomic status.

Pediatric patients are more susceptible to the effects of concussions because of their developing nervous systems, increased chemical and metabolic changes that occur in the brain, and lack of musculature to absorb force.7 Pathophysiologic injury to the brain can affect a child’s ability to function cognitively, physically, and psychologically and has been the subject of much research.

Clinical Features

Concussion diagnosis involves a medical history, neurological examination, and
sign and symptom evaluation. Symptoms vary among individuals and can change throughout recovery. A mild TBI has a Glasgow Coma Scale score of between 13 and 15 measured approximately 30 minutes after the injury.

Amnesia and confusion with or without a preceding loss of consciousness may be apparent immediately after the head injury or several minutes later.1,2,7 Other early signs of concussion cover a spectrum of behavioral, cognitive, emotional, and physical symptoms.

Dizziness and headaches are the most common symptoms, but patients can also experience acute nausea, lack of awareness of surroundings, and vomiting.2,5 Over the following days and hours, patients may complain about lethargy, mood and/or sleep disturbances, sensitivity to light or noise, and trouble concentrating.

Many concussions do not have observable findings, but signs may include incoordination, such as disorientation, emotions out of proportion to the circumstances, stumbling or inability to walk, incoherent or slurred speech, memory deficits, trouble focusing, and a vacant stare.8

Acute Management

Important considerations in the management of mild TBI include identification of immediate neurologic emergencies, prevention of cumulative chronic brain injury, and recognition and management of neurologic damage.9 Observation either at home or in an acute setting is recommended for at least 24 hours after a mild TBI because of the risk of intracranial complications.9 Imaging is suggested in a subset of patients with concussion to identify injuries that require immediate neurosurgical intervention or neurologic evaluation with medical management.

Posttraumatic seizures are those that happen within the first week after head injury, and these occur in less than 5% of mild or moderate TBI cases. Approximately half of patients who experience seizures will have the first occurrence within the first 24 hours. These seizures are considered acute events and not epilepsy.

A patient may experience a variety of symptoms while recovering from a concussion. In most instances, sticking to cognitive and physical rest followed by gradual resumption of activities will improve symptoms. Medication may be prescribed for symptom management, such as headache relief. However, pharmaceutical therapies are not heavily relied upon and not used to speed recovery.

Once under observation, patients must to understand when to seek additional medical help. Bowel or urinary incontinence, confusion, fever, inability to awaken a patient, numbness or weakness involving any part of the body, seizures, severe or worsening headaches, stiff neck, unsteadiness, vision problems, and vomiting are all symptoms warranting immediate medical attention.2,3

Postconcussive Syndrome

Most individuals who suffer concussion can recover safely at home after seeing a medical provider and will experience spontaneous resolution of symptoms. Most individuals recover from a mild TBI within 10 to 14 days, and symptoms are improved or resolved at 1 month.

Postconcussive syndrome is present when symptoms last beyond the expected recovery period after the initial injury. Because a head injury in a child influences a growing brain, prolonged symptoms lasting more than
3 to 4 weeks in this age group may require a multidisciplinary approach.10

There is also research around second impact syndrome, especially among athletes. Premature return to play places an athlete at greater risk for recurring concussion or subsequent injury.4,8 Return to play for athletes should be done after an adequate recovery period, not until a patient is asymptomatic off medication, and under medical supervision.

Pharmacist's Role

Individuals may not admit or recognize when they or someone in their care is having symptoms of a concussion. Pharmacists can help patients identify when they should get emergency help or see their health care providers for evaluation. Pharmacists can also be a valuable resource in symptom management and for multidisciplinary management of postconcussive syndrome.

Joanna Lewis, PharmD, MBA, is the 340B compliance coordinator at Baptist Health in Jacksonville, Florida.

References

1. Symptoms of mild TBI and concussion. CDC. Updated May 12, 2021. Accessed January 13, 2022. https://www.cdc.gov/traumaticbraininjury/concussion/symptoms.html

2. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. CDC. September 2003. Accessed February 10, 2022. https://www. cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf

3. Vos PE, Battistin L, Birbamer G, et al; European Federation of Neurological Societies. EFNS guideline on mild traumatic brain injury: report of an EFNS task force. Eur J Neurol. 2002;9(3):207-219. doi:10.1046/j.1468-1331.2002.00407.x

4. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250-2257. doi:10.1212/ WNL.0b013e31828d57dd

5. Lumba-Brown A, Yeates KO, Sarmiento K, et al. Diagnosis and management of mild traumatic brain injury in children: a systematic review. JAMA Pediatr. 2018;172(11):e182847. doi:10.1001/ jamapediatrics.2018.2847

6. Kraus JF, McArthur DL. Epidemiologic aspects of brain injury. Neurol Clin. 1996;14(2):435- 450. doi:10.1016/s0733-8619(05)70266-8

7. Sarmiento K, Waltzman D, Lumba-Brown A, Yeates KO, Putukian M, Herring S. CDC guide- line on mild traumatic brain injury in children: important practice takeaways for sports medicine providers. Clin J Sport Med. 2020;30(6):612-615. doi:10.1097/JSM.0000000000000704

8. Kelly JP, Rosenberg JH. Diagnosis and management of concussion in sports. Neurology. 1997:48(3):575-580. doi:10.1212/wnl.48.3.575

9. Lawler KA, Terregino CA. Guidelines for evaluation and education of adult patients with mild traumatic brain injuries in an acute care hospital setting. J Head Trauma Rehabil. 1996;11(6):18- 28. doi:10.1097/00001199-199612000-00005

10. Broshek DK, De Marco AP, Freeman JR. A review of post-concussion syndrome and psychological factors associated with concussion. Brain Inj. 2015;29(2):228-237. doi:10.3109/026 99052.2014.974674