Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends.
Today we’ll be talking about Concussions. For the rest of the Mangled Mondays series, [click here].
1 – nonlethal unless this is a misdiagnosis of a more severe injury
What Is It?
A concussion is a form of trauma to the brain, wherein the brain bounces off the inside of the skull, caused by blunt-force trauma.
A concussion is a form of traumatic brain injury (TBI), known as a Mild TBI, or mTBI. Typically, an mTBI comes with a brief period of unconsciousness (0.5–5 minutes). The length of unconsciousness is often an indicator of the severity of concussion, though not in all cases.
Concussions are the mildest form of traumatic brain injury. Two other entries in this book are labeled TBIs: epidural hemorrhage and subdural hemorrhage (EDH and SDH, respectively).
It’s important to understand the big difference between these injuries. While a concussion may cause some injury to the brain, mostly because of swelling after the impact, a concussion doesn’t cause bleeding inside the skull, while the other two are defined not by the presence of bleeding but by its location.
In the moments after a head injury, it can be downright impossible for a character to tell the difference between these three common head injuries. All three can cause a loss of consciousness; all three can cause seizures due to the impact; all three can cause disturbances in memory or coordination.
The difference is that in a concussion, the character generally improves, starting at about the 24-hour mark; bleeding in the brain may kill a character with EDH or SDH by this time.
Characters who have sustained a concussion will likely not remember the exact cause of it. That’s because the head strike interferes with memory. They’re likely to ask “What happened?” repeatedly, because they may not be able to remember the answer.
It’s also not uncommon for a character to seize after their concussion. This is because the brain has struck the skull and caused itself some disruption; electrical activity fires randomly across the brain from place to place.
The seizure, if it occurs, will likely be fairly short – typically less than a minute – but may be longer. The shaking or spasms will likely involve the whole body (clonic), and there may be a period of rigidity beforehand (tonic). This is what used to be called a grand mal seizure, which is French for big bad seizure. The character may urinate, defecate, or bite their tongue; in the absence of a witness to the event, any of these will be taken as evidence of a seizure by responders and by providers.
After a seizure, it can take between 5 and 15 minutes for the character to regain consciousness, and they will do so slowly and gradually, with various levels of disorientation. This phase is called the postictal phase. Characters won’t know where they are or what has happened, and may behave violently (even normally nonviolent characters may do this; it’s known as postictal psychosis).
It’s also quite possible for a character to have a concussion without losing consciousness. This happens frequently in low-speed collisions such as head-to-head sporting injuries, with American football producing a great many “conscious concussions.”
- Loss of consciousness immediately upon impact.
- Disorientation or dazed appearance.
- Possible loss of bladder and/or bowel control and biting of tongue.
- Difficulty retrieving old memories (retrograde amnesia).
- Difficulty storing new memories (anterograde amnesia).
- Due to anterograde amnesia, the character may repeat the same question numerous
- Pupils are equal on examination.
- Possible swelling or cut at the impact site.
- Inability to recall the injury or events leading up to it, or events afterward.
- Nausea and one or two instances of vomiting.
- Repeated vomiting, or worsening nausea after a few hours, are warning signs of intracranial hemorrhage (moderate to heavy bleeding inside the skull).
How Does It Happen?
A concussion usually occurs…
… when the character’s head meets with a hard surface. This may be a weapon (like a fist or a bottle), but it can be almost any hard surface (such as a wooden table, a concrete floor, or hard plastic in a car).
The brain is a gelatinesque structure inside the cranium (skull). When the head strikes an object, the brain continues moving. A concussion is the result of the brain colliding with the interior aspect, or surface, of the skull.
It’s even possible to have a concussion without the head itself striking anything; severe whiplash (a sprain or strain of the neck) can cause a concussion.
Field care for the concussion may involve the following:
- Removal of a threat, such as eliminating attackers.
- Ensuring that the character is in a safe place.
- Treating the seizure by rolling the character onto their side, protecting their head from any hard objects nearby, and allowing them to seize. Nothing should be placed in the character’s mouth, because of the risk of choking, vomiting, and aspiration.
- Characters who try to stand up may be encouraged to stay down until the worst of their dizziness passes.
- If available, supporting characters will likely want to summon professional medical help (send for a doctor or call 911, as the setting permits.)
- Characters playing sports should not be permitted to continue the game after a head injury that is, or is likely to be, a concussion. Of course, neither stories nor real life always match what should
Concussions do not require surgery, though overlying injuries such as skull fractures might.
Concussions per se do not require hospital admission. They do, however, require evaluation in the emergency department, if one is available.
A character presenting to an ER with a concussion will get a neurological evaluation by an ER doctor. (The doc is likely not to need a neurologist to make a correct diagnosis, but may ask for a consult anyway.)
The doctor or provider may then order routine bloodwork and a CT scan, to rule out a direr brain injury (such as an epidural, subdural, or subarachnoid hematoma, the first two of which make up the next two entries in this book). Blood sugar will also be checked to make sure hypoglycemia isn’t present.
The “may order” above refers to the fact that some concussion patients don’t get scans. It’s realistic for a character to either get a scan or not get one; for the exact guidelines, search for the Canadian Head CT rules. However, as a writer, I say “go for whichever works best for your story.”
If the character suffered a scalp laceration during the concussion, this may need sutures (stitches) or staples. If they have a skull fracture, this will be apparent both clinically and on the CT scan. In fact, it’s an excellent reason for a doctor to order a CT scan. Most skull fractures do not require surgery.
The character can safely be discharged home if there is someone around to care for them for the night. That person will be given instructions to wake the patient up 3–4 hours after falling asleep to make sure that they can be woken up and can answer questions coherently.
There is no value to forcing the character to stay awake; this is a misconception of Hollywood. Rather, the character should be woken only to check and make sure their neurological state isn’t deteriorating in their sleep, which would be a marker of a subdural hemorrhage (SDH).
In the Austere Environment
Caring for a concussed character outside of a hospital setting will involve an initial evaluation and close observation to make sure they’re not getting worse. There are no real interventions to encourage healing except for allowing the character to rest. This especially means brain rest; the character should avoid stimulation with screens, loud music or noise, stress, excess fatigue, etc.
Headache may be treated with acetaminophen (Tylenol) but not ibuprofen (Advil / Motrin) or aspirin, as the latter can encourage bleeding.
If the character has a significant scalp laceration, the wound should be cleaned with water and closed with sutures (a fishing hook and line work well). Superglue is usable but not ideal, as it can damage the skin. It is, however, effective.
The Rocky Road to Recovery
The character will retain all motor skills, though may have some trouble with balance and may have some transient difficulty with exceptionally fine motor skills. The character will remember who they are and the identities of key individuals.
Symptoms after a concussion typically get better within a week, though in some cases, they can last far longer.
Retrograde amnesia is the inability to remember events prior to the injury. This does not include identity amnesia — the character will retain memories of who they are. However, they may not remember the hours, days, or weeks leading up to the concussion.
Anterograde amnesia is the inability to form new memories after the event. This affects everything from remembering where they are (in a new setting) to keeping promises and obligations they’ve made since the injury, since the character doesn’t remember making the commitment. Notebooks and calendars are very helpful for characters suffering anterograde amnesia beyond the first day or two.
Anterograde amnesiacs will often ask the same question repeatedly, even if it’s been answered, because they are unable to recall that their question was asked, let alone answered.
Anterograde amnesia typically lasts for the first 12 to 72 hours after the injury.
Executive dysfunction is a broad term for difficulty with certain aspects of cognition, including maintaining focus, managing time, planning, organizing, prioritizing, etc. Executive dysfunction may mean that characters become easily distracted, behave inappropriately, or are unable to go to work or to school.
If you’d like some story time, my own mTBI in high school obliterated memories of the day. I stored only 5 memories from the moment of my injury through the end of the day. I remember waking up afterward and seeing blood on my hand and being worried; I remember talking to the school nurse and being afraid that she’d figure out I had a pocket knife that I wasn’t supposed to have; I remember someone in the ER cutting off my shirt; I remember waking up in the car on the way home and being cold under my hoodie; and I remember waking up on the couch and trying to watch Lord of the Rings and put on mac’n’cheese. (I burned the mac’n’cheese.) I was very tired the following day and stayed home, but I was back to school on the day after.
Concussions typically have no long-term effects.
However, post-concussion syndrome (PCS) is a possible outcome, in which your character may experience some — but not necessarily all — of their “temporary” disabilities for weeks, months, or years after the fact.
Features of Recovery: Hospital Stay
Characters suffering a concussion with neurological symptoms that are worse than expected will likely be kept overnight for observation, but most characters can go home the same day as their injury, provided they have someone to watch out for them.
Supporting characters will be told to keep an eye on the afflicted, and to wake them every 4 hours for the first 2 days to ensure that they can be woken. (If they cannot be woken, they are likely suffering from a different type of head injury called a subdural hematoma.)
While characters suffering PCS may return to the hospital for follow-ups, they will not be admitted unless their condition worsens severely.
The New Normal
Characters who sustain concussions will, in the absence of post-concussion syndrome, be neurologically intact and recover to their baseline. (No Disability.)
Characters who develop PCS will have some lasting disability. (Partial Disability.) Over time and with support and occupational therapy, they may develop systems to aid them with their ongoing symptoms. These may involve note-taking and journaling.
Characters who incur multiple head injuries over the course of their lifetime may suffer significant neurological trauma from it, even if no one instance is particularly dire. This is known as repetitive head injury syndrome (RHIS). It is also called chronic traumatic encephalopathy, or CTE, and is a common condition among boxers and players of American football.
RHIS affects neurocognitive function, including IQ, reaction time, increases aggressive behavior, and more. RHIS also places your character at significantly elevated risk of depression at all ages, as well as dementia, specifically Alzheimers, as they age.
Worse, RHIS puts your character at risk of sustaining more head injuries! The threshold for an impact to damage the brain is lowered significantly.
In extremely rare cases — only 17 have ever been reported and another 18 suspected — a character who receives a second brain injury while recovering from the first may collapse and die within minutes. This is known as second impact syndrome (SIS). It’s suspected that SIS has to do with the way blood vessels dilate and shrink during recovery, but there haven’t been enough cases to know for sure.
Total Recovery Time (Typical)
Mild: 1 day to 1 week
Moderate: 1–2 weeks
Severe: months to years
Sights: The character may or may not have any external sign of injury. They may get a “goose egg” (hematoma, a “bump” of pooled blood under the skin), a scalp laceration, or nothing at all.
If they seize, the character will have uncontrolled movements of all extremities. They may bite their tongues, and may lose consciousness. If they lost continence, their garments may appear wet from the urine.
Sounds: There should be some sound as the injury occurs, such as, a smack, a whack, or even a crunch.
Smells: If the character lost continence during the seizure, they’ll smell of urine or feces.
Tastes: If the character seized and bit their tongue hard enough to bleed, they will taste blood in their mouth. The character may not taste significantly different to an outside observer.
A neurological exam would be called a “neuro exam.”
A doctor muttering to themselves might say the “cranial nerves are intact.” This refers to a set of nerves that control facial muscles and are not a part of the spinal cord.
“Pupils symmetric” refers to the pupils being equal in size. They may also be said to be PERRL: pupils equal and round, reactive to light.
The character’s level of consciousness is measured with the Glasgow Coma Scale, which produces a score ranging from 3 to 15. (A paper clip has a GCS of 3, as do brain-dead humans. A GCS of 15 is normal, and a person who can open their eyes on their own and follow commands but is confused has a GCS of 14.) When spoken out loud, GCS is spelled out: gee-see-ess.
- Your characters will most likely lose consciousness, but don’t have to.
- One of the features of concussions is that they do not worsen after the injury. Characters should steadily improve.
- Memories of the event, and hours to days before the event, may be lost (retrograde amnesia).
- The character may not be able to store some or any memories from after the event (anterograde amnesia).
- Characters should recover fully, but may have symptoms that last for a long time (post-concussion syndrome, PCS).
- Characters who suffer multiple concussions over time may have significant brain damage because of it (repetitive head injury syndrome, RHIS).
- In extremely rare cases, a character who suffers a second head injury while recovering from the first may suffer extremely rapid deterioration and death (second impact syndrome, SIS).
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.