Concussion

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Concussion

• Jennifer L. Doherty, MS, LAT, ATC
• Management of Medical Emergencies

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Concussion

• Head/Brain injury
• Temporary impairment of brain function
• MOI Direct or Indirect blow to the head

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Concussion

• Serious head injuries almost always represent a
  life-threatening situation
• Must get athlete to the hospital immediately
• Within 30 minutes

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Signs and Symptoms

• Altered level of consciousness (LOC)
• Pain or pressure in the head
• Tingling or loss of sensation in the extremities
• Partial or complete loss of movement in any body
  part

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Signs and Symptoms cont

• Unusual lumps or depressions on the head
• Blood or other fluids in the ears or nose
• Profuse bleeding from the head
• Seizures
• Impaired breathing
• Impaired vision

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Signs and Symptoms cont

• Nausea or vomiting
• Persistent headache
• Loss of balance
• Ecchymosis
• Especially around the eyes or behind the ears

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Signs and Symptoms cont

• The S/S of a head/brain injury may not be
  apparent until hours after the trauma occurs
• Immediate referral to a physician is important
  for the proper treatment of a serious head/brain
  injury

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Primary Assessment

• Must be able to recognize and interpret the S/S
  of a head injury
• If an athlete is unconscious, ALWAYS assume
  injury to the neck as well

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Primary Assessment cont

• Without moving the athlete, assess the airway
• Athlete is breathing
• Airway is obstructed

• Observe for S/S of head and neck injury
• Face color
• Skin condition
• Pulse
• Breathing
• Pupils
• Edema
• Ecchymosis
• Deformity

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Secondary Assessment

• Assess mental orientation and memory
• What is your name?
• How old are you?
• Where are you?
• What game are you playing?
• What is the score?
• What month is it?
• Who is president?
• After 5-10 minutes, ask the same questions again

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Secondary Assessment cont

• Test for Eye signs
• Dilated and/or irregular pupils
• Blurred vision
• Inability for eyes to accommodate rapidly to
  light variance
• Inability for eyes to track smoothly
• nystagmus

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Secondary Assessment cont

• Balance Testing
• Stand with eyes closed
• Stand on one foot
• Stand on one foot with eyes closed
• Finger-to-Nose test
• Babinski Test
• Reflex tested by running a pointed object along
  the bottom of the foot
• Normal response is toe flexion

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Concussion Classification

• There are many ways to classify concussions
• Different Grading Scales exist
• Cantu (1986)
• Colorado Medical Society (1991)
• Torg (1991)
• American Academy of Neurology (1997)
• Guskiewicz/University of North Carolina (1998)

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General Concussion Classification

• Grade I Concussion
• Normal consciousness
• No memory loss
• May elicit mild disorientation
• S/S resolve within 5-15 minutes
• Most common concussion sustained in sports

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General Concussion Classification

• Grade II Concussion
• Normal consciousness
• Confusion
• Post-traumatic amnesia
• Inability to recall events that have occurred
  since the time of injury
• Unsteadiness/Dizziness
• Tinnitus
• Headache

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General Concussion Classification

• Grade II Concussion cont
• Post-concussion Syndrome
• Difficulty concentrating
• Recurring headaches
• Irritability
• S/S may last several weeks
• Athlete may not return to play until all S/S are
  resolved

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General Concussion Classification

• Grade III Concussion
• Normal consciousness
• Confusion
• Post-traumatic amnesia
• Retrograde amnesia
• Inability to recall events that occurred before
  the injury

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General Concussion Classification

• Grade III Concussion cont
• Unsteadiness/Dizziness
• Tinnitus
• Headache
• Confusion

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General Concussion Classification

• Grade III Concussion cont
• This athlete must be referred to a physician for
  a thorough examination
• An intracranial lesion may be present
• Results in intracranial bleeding
• Causes a gradual increase in intracranial pressure

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General Concussion Classification

• Grade IV Concussion
• Loss of consciousness
• Referred to as Paralytic Coma
• Return to consciousness usually within a few
  seconds or minutes
• Post-traumatic amnesia
• Retrograde amnesia
• Post-concussion Syndrome

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General Concussion Classification

• Grade IV Concussion cont
• While returning to consciousness, the athlete
  will display states of
• Stupor
• Confusion
• Delirium
• Medical Emergency
• Suspect neck injury also
• Spine board the athlete
• Transport the athlete to the hospital immediately

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General Concussion Classification

• Grade V Concussion
• Paralytic Coma
• Secondary cardio-respiratory collapse
• The Glasgow Coma Scale is used to determine the
  state of the athlete

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Glasgow Coma Scale
Lowest score 3, Highest score 15
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General Concussion Classification

• Grade VI Concussion
• Death

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Secondary Conditions Associated with Concussions

• Intracranial Hemorrhage
• Skull Fracture
• Epidural Hemorrhage
• Subdural Hemorrhage
• Intracerebral Hemorrhage
• Cerebral Hyperemia
• Cerebral Edema
• Seizures
• Migraine Headaches

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Intracranial Hemorrhage

• Intracranial bleeding
• Venous bleeding
• Slow, insidious onset
• Arterial bleeding
• S/S apparent within a few hours

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Intracranial Hemorrhage

• Early S/S
• Severe head pains
• Dizziness
• Nausea
• Unequal pupil sizes
• Sleepiness

• Severe S/S
• Deteriorating consciousness
• Neck rigidity
• Slow pulse
• Slow respiration
• Convulsions

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Epidural Hemorrhage

• A blow to the head causes a tear in one of the
  arteries of in the dural membrane that covers the
  brain
• Hematoma forms extremely fast
• Within 10 20 minutes after injury

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Epidural Hemorrhage

• Requires surgery to relieve the pressure created
  by the hemotoma
• Death or permanent disability may result

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Subdural Hemmorhage

• A blow to the head causes a tear in one of the
  veins located between the dura mater and the
  brain
• Hematoma forms slowly
• S/S may not be appear until hours after injury

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Subdural Hemmorhage

• Commonly occurs following a contrecoup injury
• May or may not require surgery

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Intracerebral Hemorrhage

• A blow to the head may cause bleeding within the
  brain itself
• Usually results due to a compressive force
  applied to the brain
• Rapid deterioration in neurological function
• Requires immediate hospitalization

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Cerebral Hyperemia

• Vasodilation of cerebral blood vessels following
  a head/brain injury
• Causes an increase in intracranial blood pressure
• Develops within minutes after the injury
• S/S headache, vomiting, sleepiness
• S/S usually resolve within 12 hours after the
  injury

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Cerebral Edema

• Localized swelling of the brain at the injury
  site
• Develops within 12 hours after the injury
• S/S headache, seizures (occasionally)
• Cerebral edema may remain for as long as 2 weeks
  following the injury

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Criteria to Return to Play

• Normal neurological function
• Normal vasomotor functions
• Normal balance
• Free of headaches
• Free of lightheadedness
• Free of dizziness
• Free of seizures

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Criteria to Return to Play Mild Concussion

• First Concussion
• Return to play if asymptomatic
• Second Concussion
• Must be asymptomatic for 1 week
• Third Concussion
• Terminate season
• May play next year if asymptomatic

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Criteria to Return to Play Moderate Concussion

• First Concussion
• Must be asymptomatic for 1 week
• Second Concussion
• Must be asymptomatic for 1 month
• Third Concussion
• Terminate season
• May play next year if asymptomatic

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Criteria to Return to Play Severe Concussion

• First Concussion
• Must be asymptomatic for 1 month
• Third Concussion
• Terminate season
• May play next year if asymptomatic