Closed Head Injury

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 affectingthe 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: 27 • Ice Hockey: 25 • Men’s soccer: 25 • Women’s soccer: 24 • Wrestling: 20 • Women’s basketball: 15 • Men’s basketball: 12(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 arotational 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 - 40-yd. dash, push-ups, sit-ups, knee-bends • Neurological tests - Strength, coordination/agility, sensationNeurology, 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 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

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

22. 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

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 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

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 educationIt’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

40. Modified GCS for Infants

41. 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

42. Classification: Minor HI

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 standardsBy DONNA SPENCERMarch 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