Concussion and mild traumatic brain injury — formative SAQs

SAQ 1 — Fourteen-year-old rugby player dazed after a tackle (10 marks, 15 minutes)

A fourteen-year-old boy is playing school rugby when he is tackled and strikes the side of his head on the ground. He is briefly dazed, sits out for two minutes, tells the trainer he feels fine, and returns to play for the remaining ten minutes of the half. That evening he complains of a headache, feels foggy and irritable, and is sensitive to the television. He has vomited once. His Glasgow Coma Scale is 15, his pupils are equal and reactive, his neurological examination is normal, and his cervical spine is non-tender. He had one previous concussion a year ago that resolved in two weeks. [6]

a) Identify the errors in the sideline management, and explain the principle that was breached. State whether this presentation is a concussion and justify your answer with the consensus definition. (4 marks) [4] [6]

b) State your imaging decision and the clinical decision rule you apply, naming the specific factors you weigh. Explain why most children in this situation do not need a computed tomography, and the one feature in this vignette that you must monitor. (3 marks) [1] [2]

c) Outline the stepwise management from this evening, including the duration of rest, the order of the return to learn and return to sport, and the role of the previous concussion in your counselling. Explain the safety-net advice you give the family. (3 marks) [4] [9]

SAQ 2 — Eleven-year-old with symptoms persisting six weeks after a fall (10 marks, 15 minutes)

An eleven-year-old girl fell off her scooter six weeks ago, hit the back of her head, and felt dazed and nauseated for two days. She returned to school after a week of rest at her mother's insistence, but her daily headache, fatigue, poor concentration, and sensitivity to noise have not resolved. She has missed many school days, has withdrawn from her netball team, and her mother reports she is tearful and no longer her usual self. She has a history of migraine and anxiety. Her neurological examination, including fundoscopy, is normal. [8]

a) Define persistent post-concussion symptoms, state the threshold that this child has crossed, and explain why the initial management with a week of rest likely contributed to the current state. (3 marks) [7] [4]

b) List the predictors of a prolonged recovery that are present in this child, and explain why a normal neurological examination does not exclude the diagnosis. State the single most important next step in the management that differs from acute concussion care. (4 marks) [9] [7]

c) Outline the active rehabilitation plan, naming the specific therapies and the role of each (sub-symptom threshold exercise, vestibular or ocular therapy, psychological support, and school liaison). Explain why further rest is the wrong prescription. (3 marks) [7] [3]