1. Closed Head Injury Martin V. Pusic MD
Children’s & Women’s Health Centre
Division of Emergency Medicine

2. Outline Concussion Intracranial Hemorrhage Diffuse Axonal Injury
Brain Contusion

3. Concussion

4. Contents Defining concussion Anatomy of concussion
Mechanisms of concussion
Evaluation
Management recommendations
Return to play

5. Richard Zednik

6. Concussion Definition
A concussion is an alteration of mental status due to biomechanical forces affecting the brain. A concussion may or may not cause loss of consciousness.

7. 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

8. 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

9. Facts About Concussion
Concussions per every 100,000 games and/or practices at the collegiate level
Football:
Ice Hockey:
Men’s soccer:
Women’s soccer:
Wrestling:
Women’s basketball: 15
Men’s basketball: (Head and Neck Injury in Sports, R.W. Dick)

10. 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.

11. Anatomy of Concussion
Cervical spine -- allows the head to rotate to avoid blunt trauma
However, rotational forces can be the most damaging during concussion

12. 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 opponent’s knee; this contact to the head can cause a rotational motion.

13. 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

14. 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

15. 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

16. Related Brain Tissue Injuries
Hematoma -- blood clot
Contusion -- brain bruises
Brain swelling and diminished blood flow to sensitive brain tissues

17. How is Concussion Assessed?
AAN guidelines for sideline evaluation
Standardized Assessment of Concussion (SAC) for sideline use
Standard neuropsychological tests
Computerized reaction time tests

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

19. Grade 1 Concussion Transient confusion NO loss of consciousness
Concussion symptoms or mental status abnormalities resolve in less than 15 minutes

20. Management Recommendations Grade 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

21. Grade 2 Concussion Transient confusion NO loss of consciousness
Concussion symptoms or mental status abnormalities last more than 15 minutes

22. Management Recommendations Grade 2
Remove from contest; disallow return that day
Examine on-site frequently for signs of evolving intracranial pathology
A trained person should reexamine the athlete the 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

23. Grade 3 Concussion
Any loss of consciousness, either brief (seconds) or prolonged (minutes)

24. Investigations
CT, MRI – rule out other conditions
PET Scan

25. Investigations
PET Scan

26. Management Recommendations Grade 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

27. 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

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

29. 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

30. 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

31. 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

32. 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

33. 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)

34. Prevention Goals
Identification and education It’s 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

35. 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

36. 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

37. Cerebral Hemorrhage

38. 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?

39. 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

40. Modified GCS for Infants
Eye Opening
Verbal
Motor 6
Spontaneous 5
Coos, babbles
Withdraws to touch 4
Irritable, cries
Withdraws to pain 3
To speech
Cries to pain
Abn flexion 2
To pain
Moans to pain
Abn extension 1
none
None
Let's talk about what kind of injuries may be sustained with a head injury?

41. Pathophysiology Epidural Subdural Subarachnoid Axonal injury
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

42. Classification: Minor HI
Mild
Moderate
Severe
No LOC
LOC <5 min
LOC >5 min
Normal physical exam
One or more high risk criteria
Initial GCS 15
GCS
GCS < 13
Minor soft tissue injuries
As a result many researchers have attempted to develop criteria as predictors of those children who will have a poor outcome.
No study has been able to identify a single criteria in minor HI.
LOC has a poor sensitivity and specificity although frequently considered a risk factor.
Vomiting and Seizures also have poor sensitivity and specificity. Most of the studues examining these as risk factors were retrospective.
As a result there are many classification systems present, and each center will vary. Most however agree that imaging be considered if patients have any signs or symptoms.

43. High Risk Criteria Altered LOC: unconsciousness, GCS<13
Local bony abnormalities
Skull fracture
FB with/without laceration
Puncture wound
Evidence of Basal Skull Fracture
Hemotympanum
Battle sign
Racoon’s eyes

44. High Risk Criteria (cont)
Unexplained neurological signs
Hx previous craniotomy with shunt
Post-traumatic amnesia
Severe/worsening headache
Post-traumatic seizure
Blood dyscrasia/anticoagualants

45. 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?

46. Case 2
Death of young girl by flying puck leads to calls for safety standards By DONNA SPENCER March 19, 2002 DONNA SPENCER,
The Canadian Press

47. Case 2

48. Case 2 – Epidural Hematoma
Lucent Interval?
ABC
Hyperventilation
Mannitol
Surgical Decompression

49. 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

50. Case 3

51. Case 3
Always consider:
CHILD ABUSE

52. Case 4
A 9-year old suddenly collapses while playing pickup football.

53. Case 4 – Subarachnoid Hemorrhage
A 9-year old suddenly collapses while playing pickup football.

54. Case 5
An 8-year old hits his head during a high-speed motor vehicle collision

55. Case 5
An 8-year old hits his head during a high-speed motor vehicle collision

56. 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

57. Management Airway Breathing Circulation, Cervical Spine Precautions
Dextrose
Manage Raised ICP

58. The End