Morning Report: 11/8/2013 - The Original Kings of County

Here’s Dr. DiMare with today’s Morning Report!

Post Traumatic Seizure (PTS)

Seizure after mild to moderate trauma:

– 1.5 to 15% of patients

– Are due to focal, structural changes as a result of injury

– “Early” – occurring within 1 week of event, but generally not within 1^st 24 hours

– “Late” – occurring more than 1 week after event

– All require advanced imaging such as MRI

– All require EEG

– All require anti-epileptic drugs and neurological follow up

– Increased risk of developing long term epilepsy

– Increased incidence with ICH, trauma requiring surgical intervention, depressed skull fracture

Concussive Convulsions

– Often referenced in sports medicine literature

Australian football– 4 concussions per 1000 player hours

– Associated with 1 in 70 concussions

– Exact cause is unknown

Thought to be from a brief, immediate loss of cortical inhibitory function, possibly with reflex brain stem release
RAS is released from cortical control

– Neuropsychological testing shows cortical slowing

same as post concussive findings

– Immediately following trauma (within seconds)

– Generally follow typical pattern of tonic muscle contraction followed by clonic jerking of limbs

– Last between 30-180 seconds

– If present, post ictal phase is short

– Often involve patient being amnestic to event

– No increase in incidence of post traumatic epilepsy

At 3.5 years, 0 of 22 patients had recurrent seizure

– Do not require AEDs

ED management of concussive convulsions

– CT scan?

If you would have scanned them before than scan them now
Current guidelines suggest CT for patients with LOC and convulsion, even with GCS of 15 and non focal neuro exam
22 patients in study, none had positive CT scan

– C spine immobilzation?

Clear collar the same way you would have before
- NEXUS Canadian, etc.

– CONCUSSION INSTRUCTIONS!!!

By definition these patients have all suffered a concussion
- Cognitive rest
- No return to play until cleared by another physician (PMD or neuro)
- 85-90% recover completely within 12 weeks

References:

McCrory PR, Berkovic SF. Concussive convulsions: incidence in sport and treatment recommendations. Sports Med. 1998; 25:131–6

McCrory PR, Berkovic SF, Bladin P. Retrospective study of concussive convulsions in elite Australian rules and rugby league footballers: phenomenology, etiology and outcome. BMJ. 1997;314:171–4.11. McCrory

Perron, A. D., Brady, W. J. and Huff, J. S. (2001), Concussive Convulsions: Emergency Department Assessment and Management of a Frequently Misunderstood Entity. Academic Emergency Medicine, 8: 296–298. doi: 10.1111/j.1553-2712.2001.tb01312.x

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital