This site was created by Chris Zalesky thanks to  the Support of the Emergency Medicine Foundation SAEMF/EMF Medical Student Grant

What is the Grady Concussion Project?

- In an effort to improve the rate of evaluation for patients with a possible mTBI an EPIC-based screen, Alert, and SMARTFORM will be used to aid patient evaluations

What will you see?

- An Alert will inform you that your Patient has Screened positive for a possible concussion during triage

- The alert will inform you of the Dot Phrase you can use to trigger the Concussion Smart Form

-  This Smart Form will also automatically be available for certain Cheif Complaints (i.e MVC, Assault, Fall)

 Nursing Triage Screen

mTBI Smart Form 

 
 

Exam Details

Big Picture

- mTBIs affect the brain globally and as such an exam investigating their presence and severity are going to investigate larger (less focal) brain functions

Domains

- Visual Ocular Motor system

- Gait & Balance

- Cognition

VOMs Description

Gait & Balance

 

Vestibular Ocular Motor Exam

Ocular Alignment

Purpose: Determine if eye deviation is present through interrogation. 

Exam Conditions: Using youhand or an opaque object you will obscure/cover one eye at a time.

Actions: Begin by having the patient focus on your nose. Then proceed to cover one eye by bringing our hand or opaque object in front of the eye from the lateral to medial side of the eye until the eye is completely covered. While covering the eye observe for any movement of the other eye. Then uncover the covered eye. Do 2 repetitions per eye. 

Abnormal: Observing lateral or medial deviation of the not covered eye

Saccades (Horizontal and Vertical)

Purpose: Test the ability of the eyes to move quickly between targets. 

Purpose: Test the ability of the eyes to move quickly between targets. 

Exam Conditions: Positioned 3ft from the patient hold up two targets (or fingers) equally distanced 1.5ft on either side of the patient’s nose in the horizontal plane. Ensure that the patient must gaze 30 degrees to right or left to focus on the target. Their starting position will be focusing on your nose. Vertical testing will be done in the identical manner but the targets should be 1.5ft above and below the patient’s nose.

Actions: Instruct the patient to move their eyes as quickly as possible to one target and then back to focusing on your nose. One repetition is complete when the eyes move away from and back to the starting position. 10 repetitions are performed Horizontally (5 for each direction). Repeat with your fingers in the vertical plane for Vertical Saccades. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test.

Abnormal: Focus of the eyes will over or undershoot the target and must adjust to focus on the target

Near Point Convergence

Purpose: Measure the ability to view a near target without double vision.

Exam Conditions: Patient should be wearing corrective lenses if needed. 

Actions: Have the patient focus on a target that is an arm’s length away from the patients face and slowly bringthe target toward the tip of the patient’s nose. Tell the patient to say when they see two distinct images or when you observe an outward deviation of one eye. Blurring of the image is ignored. The distance in cm between target and the tip of noseshould be measured and recorded. This is repeated a total of 3 times with measures recorded each time. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. 

Abnormal: Near Point of convergence ≥ 6 cm from the tip of the nose is abnormal. (average male hand width is ~8.4cm and average female hand width is ~7.4cm)

Smooth Pursuit

Purpose: Test the ability to follow a slowly moving target.

Exam Conditions: You should hold a target at a distance of 3 ft. away from the patient.

Actions: Instruct the patient to focus on the target while keeping their head stationary. You will then move the target smoothly in the horizontal plane 1.5 ft. to the right and then 1.5 ft. to the left of midline. One repetition is complete when the target moves to the right, left and returns back to the starting position. 2 repetitions are performed. The target should be moved at a rate requiring ~2 seconds to go fully from right to left. The test is then completed in the vertical plane moving the target at the same rate 1.5 ft. above and 1.5 ft. below midline for 2 complete repetitions. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test.

Abnormal: Seeing the eyes have to readjust to maintain focus or catch up to the target. This appears as a staggered pursuit instead of a smooth pursuit.

Visual-Ocular Reflex (VOR) (Horizontal and Vertical)

Purpose: Assess the ability to stabilize vision as the head moves.

Exam Conditions: Hold a target 3ft away the patient at the midline and eye level.

Actions: Ask patient to rotate their head horizontally while maintaining focus on the target. One repetition is when the head moves 20 degrees away from the target, while maintaining their gaze at the target, and back to the starting position. The head must move 20 degrees to each side at a rate of 180 repetitions/minute which is three/second (turning right, left, right and back to midline in 1 second).10 repetitions are performed. Repeat with patient moving head in the vertical plane. Record: Headache, Dizziness, Nausea and Fogginess ratings 10 sec after the test is completed.

Abnormal: An inability of the patient to maintain focus on target during head movement.

 
 
 
 
 

Gait and Balance

 

Romberg/Balance

Purpose: Assess the patient's ability to integrate sensory and motor domains to maintain body position

Exam Conditions: Have the patient standing. 

Actions: Initially assess the ability of the patient to maintain their body position for ~10 seconds while standing in their normal stance(feet approximately shoulder width apart). This is done once with the patient's eyes open and once with their eyes closed. Further testing is based upon the ability of the patient. The exam can be made more difficult by place the feet together, one in front of the other(tandem), or lifting one off of the floor. Whichever level of exam variations that is used it should be attempted with the patient's eyes open and closed.

Abnormal: An inability of the patient to maintain their body position

Gait

Purpose: Assess the patient's ability to integrate sensory and motor domains to generate coordinated movements

Exam Conditions: Have the patient standing with room to walk at least 10 feet straight forward

Actions: Initially have the patient walk in a straight line with their eyes open. After walking a few steps, have the patient turn 180 degrees and walk back to their starting position. This exam can be repeated with the patient's eyes open and eyes closed. For more advanced gait testing have the patient walk heel to toe (tandem) forwards and then return walking heel to toe backwards. This tandem forwards and backwards gait can also be completed with the patient's eyes open or closed.

Abnormal: Unstable gait or if the patient required adjustment to maintain their balance or direction

 
 

Cognitive Exam

 

Purpose: Understand the cognitive ability of the patient at the time of the exam.

Exam Conditions: Patient awake and alert enough to cooperate

Actions: Portions of this exam can vary from an informal evaluation to a formal evaluation. 

1. Informal: Note how the patient interacts with their care team. Do they repeat themselves often, answer questions slowly, or have an inability to concentrate?

2. Abbreviated: serial 7s from 100 to 65 for ages >14, serial 3’s for ages 8-13; and serial 1’s ages 6-7 

3. Full length Validated testing: Mini-Mental status exam or Standardized Assessment of Concussion (SAC)Link to the right ->>

Abnormal: 

1. Based on clinicians observation

2. More than 4 errors (wrong subtraction, lengthy delays, loss of place) is considered abnormal.

3. Follow formal criteria noted in the document to the right -->

 

Discharge Information and Decision Tools

CDC Pediatric mTBI Discharge Instructions

CDC Adult mTBI Discharge Education