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

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

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

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

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

Signs and Symptoms cont… Nausea or vomiting Persistent headache Loss of balance Ecchymosis –Especially around the eyes or behind the ears

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

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

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

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

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

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

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)

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

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

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

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

General Concussion Classification Grade III Concussion cont… Unsteadiness/Dizziness Tinnitus Headache Confusion

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

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

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

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

TypeStimulusType of ResponsePoints EyesOpenSpontaneously To verbal command To pain No response Best Motor Response To verbal command To painful stimulus Obeys Localized pain Flexion-withdrawal Flexion-abnormal Extension No response Best Verbal Response Oriented and converses Disoriented and converses Inappropriate words Incomprehensible sounds No response Lowest score = 3, Highest score = 15 Glasgow Coma Scale

General Concussion Classification Grade VI Concussion Death

Secondary Conditions Associated with Concussions Intracranial Hemorrhage Skull Fracture Epidural Hemorrhage Subdural Hemorrhage Intracerebral Hemorrhage Cerebral Hyperemia Cerebral Edema Seizures Migraine Headaches

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

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

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

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

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

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

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

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

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

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

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

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

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