Cerebral Concussion
INTRODUCTION
DRG Category: 027
Mean LOS: 3.9 days
Description MEDICAL: Traumatic Stupor and Coma, Coma > 1 hour
DRG Category: 028
Mean LOS: 5.5 days
Description MEDICAL: Traumatic Stupor and Coma, Coma > 1 hour, Age > 17 with CC
DRG Category: 002
Mean LOS: 9.8 days
Description SURGICAL: Craniotomy for Trauma, Age > 17
The words "concuss" means to shake violently. Cerebral concussion is defined as a transient,
temporary, neurogenic dysfunction caused by mechanical force to the brain. Cerebral concussions are
the most common form of head injury. Concussions are classified as mild or classic, based on the
degree of symptoms, particularly those of unconsciousness and memory loss. Mild concussion is a
temporary neurological dysfunction without loss of consciousness or memory. Classic concussion
includes temporary neurological dysfunction with unconsciousness and memory loss. Recovery from
concussion usually takes minutes to hours. Most concussion patients recover fully within 48 hours, but
subtle residual impairment may occur.
In rare cases, a secondary injury caused by cerebral hypoxia and ischemia can lead to cerebral edema
and increased intracranial pressure (ICP). Some patients develop a postconcussion syndrome
(postinjury sequelae after a mild head injury). Symptoms may be experienced for several weeks and, in
unusual circumstances, may last up to 1 year. In rare situations, patients who experience multiple
concussions may suffer long-term brain damage. Complications of cerebral concussion include seizures
or persistent vomiting. In rare instances, a concussion may lead to intracranial hemorrhage (subdural,
parenchymal, or epidural).
CAUSES
The most widely accepted theory for concussion is that acceleration-deceleration forces cause the
injury. Sudden and rapid acceleration of the head from a position of rest makes the head move in
several directions. The brain, protected by cerebrospinal fluid (CSF) and cushioned by various brain
attachments, moves more slowly than the skull. The lag between skull movement and brain movement
causes stretching of veins connecting the subdural space (the space beneath the dura mater of the
brain) to the surface of the brain, resulting in minor disruptions of the brain structures. Common causes
of concussion are a fall, a motor vehicle crash, a sports-related injury, and a punch to the head.
GENETIC CONSIDERATIONS
Not applicable.
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
Cerebral concussions can be experienced by patients of all ages and both genders, but males are
affected at higher rates than are females. Trauma, however, is the leading cause of death between the
ages of 1 and 44. In addition, trauma is the leading cause of health-related problems in this age range.
For those reasons, most instances of cerebral concussion occur in the first 4 decades of life. There are
no known ethnic or racial considerations.
ASSESSMENT
HISTORY. If the patient cannot report a history, speak to the life squad, a witness, or a significant
other to obtain a history. Determine if the patient became unconscious immediately and for how long—a
few seconds, minutes, or an hour—at the time of the trauma. Find out if the patient experienced
momentary loss of reflexes, arrest of respirations, and possible retrograde or antegrade amnesia. Elicit
a history of headache, drowsiness, confusion, dizziness, irritability, giddiness, visual disturbances
(seeing stars), and gait disturbances.
Mild cerebral concussions can cause headaches, dizziness, memory loss, momentary confusion, residual
memory impairment, and retrograde amnesia; there is no loss of consciousness. Classic cerebral
concussions cause a loss of consciousness lasting less than 24 hours; the patient usually experiences
confusion, disorientation, and amnesia upon regaining consciousness. A postconcussive syndrome that
may occur weeks and even months after injury may lead to headache, fatigue, inattention, dizziness,
vertigo, and memory deficits.
PHYSICAL EXAM. First evaluate the patient's airway, breathing, and circulation (ABCs). After
stabilizing the patient's ABCs, perform a neurological assessment, paying special attention to early signs
of ICP: decreased level of consciousness, decreased strength and motion of extremities, reduced visual
acuity, headache, and pupillary changes.
Check carefully for scalp lacerations. Check the patient's nose (rhinorrhea) and ears (otorrhea) for CSF
leak, which is a sign of a basilar skull fracture (a linear fracture at the base of the brain). Be sure to
evaluate the patient's pupillary light reflexes. An altered reflex may result from increasing cerebral
edema, which may indicate a life-threatening increase in ICP. Pupil size is normally 1.5 to 6.0 mm.
Several signs to look for include ipsilateral miosis (Horner's syndrome), in which one pupil is smaller
than the other with a drooping eyelid; bilateral miosis, in which both pupils are pinpoint in size;
ipsilateral mydriasis (Hutchinson's pupil), in which one of the pupils is much larger than the other and is
unreactive to light; bilateral midposition, in which both pupils are 4 to 5 mm and remain dilated and
nonreactive to light; bilateral mydriasis, in which both pupils are larger than 6 mm and are nonreactive
to light.
Check the patient's vital signs, level of consciousness, and pupil size every 15 minutes for 4 hours. If
the patient's condition worsens, he or she should be admitted for hospitalization. Continue neurological
assessment throughout the patient's hospital stay to detect subtle signs of deterioration. Observe the
patient to ensure that no other focal lesion, such as a subdural hematoma, has been overlooked.
PSYCHOSOCIAL. The patient with a concussion has an unexpected, sudden illness. Assess the
patient's ability to cope with the potential loss of memory and temporary neurological dysfunction. In
addition, assess the patient's degree of anxiety about the illness and potential complications. Determine
the significant other's response to the injury. Expect parents of children who are injured to be anxious,
fearful, and sometimes guilt-ridden.
Diagnostic Highlights
Test Normal Result Abnormality with Condition Explanation
Computed Intact cerebral Identification of size and Shows anterior to posterior slices of
tomography anatomy location of site of injury the brain to highlight abnormalities
Other Tests: Skull x-rays, magnetic resonance imaging, (MRI), cerebral spine x-rays, and glucose test,
using a reagent strip, of any drainage suspected to be cerebral spinal fluid.
PRIMARY NURSING DIAGNOSIS
Altered thought process related to cerebral tissue injury and swelling
OUTCOMES. Cognitive ability; Cognitive orientation; Concentration; Decision making; Identity;
Information processing; Memory; Neurological status: Consciousness
INTERVENTIONS. Cerebral perfusion promotion; Environmental management; Surveillance; Cerebral
edema management; Family support; Medication management
PLANNING IMPLEMENTATION
COLLABORATIVE
Patients with mild head injury often are examined in the emergency department and discharged home.
Generally, a family member is instructed to evaluate the patient routinely and to bring the patient back
to the hospital if any further neurological symptoms appear. Parents are often told to wake a child every
hour for 24 hours to make sure that the patient does not have worsening neurological signs and
symptoms. Treatment generally consists of bedrest with the head of the bed elevated at least 30
degrees, observation, and pain relief.
Pharmacologic Highlights
General Comments: Narcotic analgesics and sedatives are contraindicated because they may mask
neurological changes that indicate a worsening condition
Medication or Drug Dosage Description Rationale
Class
Acetaminophen 325–650 mg Nonnarcotic analgesic that is thought to inhibit Manages
PO q 4–6 hr prostaglandin synthesis in the central nervous headache
system
INDEPENDENT
Generally, patients are not admitted to the hospital for a cerebral concussion. Make sure that before the
patient goes home from the emergency department, the significant others are aware of all medications
and possible complications that can occur after a minor head injury. Teach the patient and significant
other(s) to recognize signs and symptoms of complications, including increased drowsiness, headache,
irritability, or visual disturbances that indicate the need for re-evaluation at the hospital. Teach the
patient that occasional vomiting after sustaining a cerebral concussion is normal. The patient should not
go home alone, because ensuing complications are apt to include decreased awareness and confusion.
If the patient is admitted to the hospital, institute seizure precautions if necessary. Ensure that the
patient rests by creating a calm, peaceful atmosphere and a quiet environment. Limit visitors to the
immediate family or partner, and encourage the patient to rest for 24 hours without television or loud
music.
DOCUMENTATION GUIDELINES
• Trauma history, description of the event, time elapsed since the event, whether or not the patient
had a loss of consciousness and, if so, for how long
• Adequacy of airway, breathing, circulation; serial vital signs
• Appearance: Bruising or lacerations, drainage from the nose or ears
• Physical findings related to site of head injury: Neurological assessment, presence of accompanying
symptoms, presence of complications (decreased level of consciousness, unequal pupils, loss of
strength and movement, confusion or agitation, nausea and vomiting)
• Patient's and family's understanding of and interest in patient teaching
DISCHARGE HOME HEALTHCARE
MEDICATIONS. Instruct the patient or caregiver not to administer any analgesics stronger than
acetaminophen. Explain that aspirin may increase the risk of bleeding.
COMPLICATIONS. Explain that a responsible caregiver should continue to observe the patient at home
for developing complications. Instruct the caregiver to awaken the patient every 1 to 2 hours
throughout the night to assess her or his condition. Explain that the caregiver should check the patient's
orientation to place and person by asking "Where are you? Who are you? Who am I?" Teach the patient
and caregiver to return to the hospital if the patient experiences persistent or worsening headache,
blurred vision, personality changes, abnormal eye movements, a staggering gait, twitching, or constant
vomiting. Teach the patient to recognize the symptoms of postconcussion syndrome, which may last for
several weeks and include headache, dizziness, vertigo, anxiety, and fatigue.
PARENT TEACHING. When the patient is a child, teach the parent(s) that it is a common pattern for
children to experience lethargy and somnolence a few hours after a concussion, even if they have
manifested no ill effects at the time of the trauma. Such responses do not necessarily indicate serious
injury. If the symptoms persist or worsen, explain that the parent(s) should notify the healthcare
provider immediately.
Nursing diagnosis: altered thought proses related cerebral tissue injury and swelling
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