Just in the process of writing review article on Concussion and this would
strike me as a TBI/Concussion.  CT scans are useless in evaluating these
sorts of injuries and MRI's are often the same.  It's based on extensive
neurological evaluation and the persistence of symptoms despite a
"negative" evaluation (i.e. CT scan etc).

Interestingly, the "force" associated with the actual blow is often not
perceived to be that "severe" but you will often find that it involves a
sudden back-to-front movement with a rotational aspect.  Part of the reason
that there has been serious push back by many to the concussion and CTE
research is that many of the injuries that are associated with these issues
have historically been perceived as not significant and that all the person
needs to do is shake it off (being "stunned" after "heading" a soccer ball!)

Final note: one of my favorite teaching points for the residents is "always
consider the uncommon presentation of a common illness  before the common
presentation of an uncommon illness".

Just my thoughts...hope it's helpful.

Mike Falk
New York, NY

On Thu, Jan 9, 2014 at 7:09 PM, Brown, Julie C. <
[log in to unmask]> wrote:

> I had a patient recently who had minor head trauma that I suspect may have
> been in absence status.  I wasn't able to find any similar reports in the
> literature.  I'm curious if anyone has seen this before.
> Here is the case:
> A young teen was running around in a skateboard park, playing tag (in
> sneakers, not riding a skateboard).  She fell back onto her occiput,
> possibly on a ramp, so with a little more force than with a typical fall
> from standing on a level surface.  She didn't pass out.  She didn't vomit.
>  Eventually, she was able to describe the event and what happened
> afterwards, including seeing the school nurse and getting picked up by her
> parents.
> On return home, she complained of occipital headache 4/10, nausea,
> dizziness and blurry vision and some varying decreased sensation in her
> right then her left hand.  For these reasons, she was brought to the ED 40
> mins after the event.  On evaluation, she was wretching and ultimately
> started vomiting.  Most of her exam was normal.  Her neuro exam was
> described as follows: Alert, moves all extremities, CN II-XII intact,
> Patient unable to consistently follow directions. When attempting to do
> finger-to-nose testing, patient grabs onto my finger instead of touching
> her nose. Also when testing for pronator drift she touches her wrist and
> palms together and does not hold her arms out straight. When asked if her
> sensation is intact bilaterally, she responds "I'm fine.".
> A head CT was obtained which was normal.  A drugs of abuse urine tox
> screen was negative. The patient was signed out to me with a plan to
> observe for a while and see if she improved, and if not, admit.  During the
> next hour or so, she remained confused, and started to have an unsual,
> rapid, shallow breathing pattern, while awake and talking
> (incomprehensibly) to me.  Repeatedly, when she fell asleep, she
> desaturated, initially to the 80's, then to the 60's, with a good tracing.
>  She was never cyanotic, but her nurse always quickly intervened by waking
> her up.  She was confused and had trouble expressing herself, saying things
> like 'I need to get this before me off my back' when trying to say she
> didn't like her cervical collar and wanted it off.  She could not follow
> commands.  For all these reasons, I consulted our PICU service, thinking
> her respiratory status was not sufficiently stable for the floor.  Half an
> hour later, the PICU attending and I walked into her room together, at
> which time she sat up, was conversant and coherent, described the events of
> the day in detail, denied significant headache, and could follow commands
> and do calculations.  Her breathing pattern was now normal.
> I was baffled at the time, as were her parents.  I let her fall asleep
> again, and when she didn't desaturate further, I admitted her to the ward
> service.  A while afterwards, I went home to sleep.  When I awoke, my very
> first thought on regaining consciousness was "she was in absence status."
>  This seems to make sense to me as it could explain her inability to follow
> commands, her respiratory changes, and her almost instantaneous recovery.
>  I called the inpatient team and suggested a Neurology consult, but the
> Neurologists didn't seem sold (and got a somewhat different version of
> events than what I witnessed), and didn't get an EEG.
> What do you all think?  Was my sleeping brain correct?  Or were these just
> post-concussive symptoms?  Have you ever seen a similar patient with
> absence status following minor head trauma?
> Julie
> ***************************************
> Julie Brown, MD, MPH
> Associate Professor, University of Washington
> Attending Physician, Pediatric Emergency Medicine,
> Seattle Children's Hospital
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