Closed%20Head%20Injury

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Closed Head Injury

• Martin V. Pusic MD
• Childrens Womens Health Centre
• Division of Emergency Medicine

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Outline

• Concussion
• Intracranial Hemorrhage
• Diffuse Axonal Injury
• Brain Contusion

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Concussion
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Contents

• Defining concussion
• Anatomy of concussion
• Mechanisms of concussion
• Evaluation
• Management recommendations
• Return to play

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Richard Zednik
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Concussion

• Definition
• A concussion is an alteration of mental
  status due to biomechanical forces affectingthe
  brain. A concussion may or may not cause loss of
  consciousness.

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Facts About Concussion

• Centers for Disease Control and Prevention (CDC)
  estimates 300,000 sports-related concussions
  occur per year
• 100,000 in football alone
• An estimated 900 sports-related traumatic brain
  injury deaths occur per year

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Facts About Concussion

• Concussion occurs most often in males and
  children, adolescents and young adults
• Risk of concussion in football is 4-6 times
  higher in players with a previous concussion

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Facts About Concussion

• Concussions per every 100,000 games and/or
  practices at the collegiate level
• Football 27
• Ice Hockey 25
• Mens soccer 25
• Womens soccer 24
• Wrestling 20
• Womens basketball 15
• Mens basketball 12 (Head and Neck
  Injury in Sports, R.W. Dick)

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Anatomy of Concussion

• The brain is a jello-like substance
  vulnerable to outside trauma.
• Skull protects the brain against trauma, but
  does not absorb impact forces.

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Anatomy of Concussion

• Cervical spine -- allows the head to rotate to
  avoid blunt trauma
• However, rotational forces can be the most
  damaging during concussion

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Two Primary Mechanisms of Concussion

• Linear - Example A quarterback falls to the
  ground and hits the back of his head. The
  falling motion propels the brain in a straight
  line downward.
• Rotational- Example When a football player is
  tackled, his head may strike an opponents
  knee this contact to the head can cause
  arotational motion.

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Immediate Signs of Concussion(occurring within
seconds to minutes)

• Impaired attention -- vacant stare, delayed
  responses, inability to focus
• Slurred or incoherent speech
• Gross incoordination
• Disorientation
• Emotional reactions out of proportion
• Memory deficits
• Any loss of consciousness

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Later Signs of Concussion(occurring within hours
to days)

• Persistent headache
• Dizziness/vertigo
• Poor attention and concentration
• Memory dysfunction
• Nausea or vomiting
• Fatigue easily
• Irritability
• Intolerance of bright lights
• Intolerance of loud noises
• Anxiety and/or depression
• Sleep disturbances

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Post Concussion Syndrome

• Lingering symptoms and continuing cognitive
  deficit following a concussion injury
• May occur for weeks or months after injury
• Associated with concussion Grades 2 3

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Related Brain Tissue Injuries

• Hematoma -- blood clot
• Contusion -- brain bruises
• Brain swelling and diminished blood flow to
  sensitive brain tissues

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How is Concussion Assessed?

• AAN guidelines for sideline evaluation
• Standardized Assessment of Concussion (SAC) for
  sideline use
• Standard neuropsychological tests
• Computerized reaction time tests

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AAN Sideline Evaluation

• Mental status testing - Orientation,
  concentration, memory
• Exertional provocative tests - 40-yd. dash,
  push-ups, sit-ups, knee-bends
• Neurological tests - Strength,
  coordination/agility, sensation Neurology,
  March 1997

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Grade 1 Concussion

• Transient confusion
• NO loss of consciousness
• Concussion symptoms or mental status
  abnormalities resolve in less than 15 minutes

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Management RecommendationsGrade 1

• Remove from contest
• Examine immediately and at 5-minute intervals
  for the development of mental status
  abnormalities or post-concussive syndrome at rest
  and with exertion
• May return to contest if mental status
  abnormalities or post-concussive symptoms clear
  within 15 minutes

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Grade 2 Concussion

• Transient confusion
• NO loss of consciousness
• Concussion symptoms or mental status
  abnormalities last more than 15 minutes

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Management RecommendationsGrade 2

• Remove from contest disallow return that day
• Examine on-site frequently for signs of evolving
  intracranial pathology
• A trained person should reexamine the athletethe
  following day
• A physician should perform a neurologic exam to
  clear the athlete for return to play after 1 full
  asymptomatic week at rest and with exertion

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Grade 3 Concussion

• Any loss of consciousness, either brief (seconds)
  or prolonged (minutes)

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Investigations

• CT, MRI rule out other conditions
• PET Scan

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Investigations

• PET Scan

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Management RecommendationsGrade 3

• Transport from the field to the nearest emergency
  department by ambulance if still unconscious or
  worrisome signs are detected (with cervical spine
  immobilization, if indicated)
• A thorough neurologic evaluation should be
  performed emergently, including neuroimaging
  procedures when indicated
• Admit to hospital if any signs of pathology are
  detected or if the mental status remains abnormal

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When to Return to Play

• Grade of concussion
• Grade 1 15 minutes or less
• Multiple grade 1 1 week
• Grade 2 1 week
• Multiple grade 2 2 weeks
• Grade 3 2 weeks
• Multiple grade 3 1 month or longer

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Treatment

• The treating physician can utilize a variety
  of treatment options including
• Analgesics for pain
• Sleeping medication
• Muscle relaxants
• Rehabilitation therapies

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Second Impact Syndrome

• Second concussion occurs while still symptomatic
  healing from previous injury days or weeks
  earlier
• Loss of consciousness not required
• Second impact more likely to cause brain
  swelling and other widespread damage
• Can be fatal -- 50 mortality rate in most
  severe cases
• Higher risk of long-term cognitive dysfunction

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Case Study

• 17-year-old high school football player
• Suffered concussion without loss of consciousness
  during a varsity game
• Complained of headache throughout the next week
• Received no further injuries and did not seek
  medical attention

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Case Study

• Next game
• A week after first concussion
• While carrying the ball, he was struck on the
  left side of his helmet by the helmet of his
  tackler
• He was stunned, but mental functions appeared to
  clear quickly during a brief time out on the field

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Case Study

• He was given the ball during the next play
• His helmet made only slight contact with one of
  several tacklers during the play
• He arose from the pile of players under his own
  power then fell unconscious into the arms of a
  teammate

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Case Study

• He arrived at the local hospital unresponsive,
  pupils fixed and dilated
• All treatment efforts were unsuccessful
• Brain pressure rose stopping blood flow to the
  brain
• 15 hours after his loss of consciousness he was
  pronounced dead (Kelly, et al, JAMA,
  November 27, 1991)

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Prevention Goals

• Identification and educationIts important to
  educate others about ways to prevent concussion
  before it happens
• Implementing sideline evaluations treatment
  recommendations
• Recognize and treat post concussion syndrome
• Prevent second impact syndrome
• Prevent further morbidity
• Prevent fatal injury

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Prevention Tools

• Rule changes
• Play smart, keep the head safe by making
  penalties tougher
• Use helmets and other protective equipment
• Design changes for protective equipment
• Ongoing research
• education, risk factors, early detection of
  concussion using SAC

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Goals for the Future

• Eliminate fatalities -- second impact syndrome
• Prevent morbidity -- post concussion syndrome
• Preserve brain function -- enable young players
  to reach their full potential in life!
• Make sports safer
• Increase awareness about sports-related
  concussions

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Cerebral Hemorrhage
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Case 1

• 4 yo male struck by a car when he ran across
  street. Thrown 10 feet. In ER, he opens his
  eyes when you ask him, he is not moving much but
  he pulls his arm away from the nurse as she
  starts an IV. He is moaning on the ER table.
• What is his GCS?

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Glasgow Coma Scale
Eye Opening Verbal Motor
6 Follows commands
5 Oriented Localizes
4 Spontaneous Confused Withdraws
3 To verbal Inappr words Flexion
2 To pain Nonsp sounds Extension
1 none None none
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Modified GCS for Infants
Eye Opening Verbal Motor
6 Spontaneous
5 Coos, babbles Withdraws to touch
4 Spontaneous Irritable, cries Withdraws to pain
3 To speech Cries to pain Abn flexion
2 To pain Moans to pain Abn extension
1 none None none
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Pathophysiology

• Epidural
• middle meningeal artery/vein, dural sinus
• Subdural
• tear of bridging veins/dura
• Subarachnoid
• blood enters CSF
• Axonal injury
• disruption of axons/blood vessels?brain edema

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Classification Minor HI
Mild Moderate Severe
No LOC LOC lt5 min LOC gt5 min
Normal physical exam Normal physical exam One or more high risk criteria
Initial GCS 15 GCS 13 -15 GCS lt 13
Minor soft tissue injuries

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High Risk Criteria

• Altered LOC unconsciousness, GCSlt13
• Local bony abnormalities
• Skull fracture
• FB with/without laceration
• Puncture wound
• Evidence of Basal Skull Fracture
• Hemotympanum
• Battle sign
• Racoons eyes

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High Risk Criteria (cont)

• Unexplained neurological signs
• Hx previous craniotomy with shunt
• Post-traumatic amnesia
• Severe/worsening headache
• Post-traumatic seizure
• Blood dyscrasia/anticoagualants

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Case 1

• 4 yo male struck by a car when he ran across
  street. Thrown 10 feet. In ER, he opens his
  eyes when you ask him, he is not moving much but
  he pulls his arm away from the nurse as she
  starts an IV. He is moaning on the ER table.
• What is his GCS?

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Case 2

• Death of young girl by flying puck leads to
  calls for safety standards By DONNA
  SPENCERMarch 19, 2002 DONNA SPENCER,
• The Canadian Press

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Case 2

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Case 2 Epidural Hematoma

• Lucent Interval?
• ABC
• Hyperventilation
• Mannitol
• Surgical Decompression

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Case 3 Subdural Hematoma
Afebrile one-year old presents with irritability,
lethargy for two days. At the outset had
sustained a 3-foot fall onto his head
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Case 3
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Case 3

• Always consider
• CHILD ABUSE

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Case 4

• A 9-year old suddenly collapses while playing
  pickup football.

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Case 4 Subarachnoid Hemorrhage

• A 9-year old suddenly collapses while playing
  pickup football.

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Case 5

• An 8-year old hits his head during a high-speed
  motor vehicle collision

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Case 5

• An 8-year old hits his head during a high-speed
  motor vehicle collision

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Case 5 Diffuse Axonal Injury

• White Matter of the Brain
• Nerve cells are connected by axons (long
  projections of nerve cells resembling insulated
  wiring) which connect neurons to other neurons

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Management

• Airway
• Breathing
• Circulation, Cervical Spine Precautions
• Dextrose
• Manage Raised ICP

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• The End
• mpusic_at_cw.bc.ca