CONCUSSION RECOGNITION AND MANAGEMENT

1. CONCUSSION RECOGNITION AND MANAGEMENT Toggenburg Ski Patrol R Eugene Bailey, MD January 22, 2012

2. OBJECTIVES Head Injury – review of treatment What is a concussion? Extent of the problem Recognition and triage Define concussion management team Education / Promotion Our Return to play protocol at ESM Discuss protocol for Toggenburg

3. Feb 2, 2011 – Lindsey Vonn – concussion during practice.

4. Head Injuries

5. Suspect a Head or Spinal Injury • With any unresponsive trauma patient • When wounds or other injuries suggest large forces involved • Observe patient carefully during the initial assessment

6. Injuries to the Head • May be open or closed • Bleeding may be profuse • Closed injuries may involve swelling/ depression at site of skull fracture • Bleeding inside skull may occur with any head injury

7. General Signs and Symptoms • Lump or deformity in head, neck, or back • Changing levels of responsiveness • Drowsiness • Confusion • Dizziness • Unequal pupils

8. General Signs and Symptoms continued • Headache • Clear fluid from nose or ears • Stiff neck • Inability to move any body part • Tingling, numbness, or lack of feeling in feet or hands

9. Assessing an Unresponsive Patient • If no life-threatening condition perform limited physical examination for other injuries • Do not move patient unless necessary • Check for serious injuries • Stabilize head and neck

10. Assessing an Unresponsive Patient • Ask those at scene: • What happened • Patient’s mental status before becoming unresponsive

11. Assessing a Responsive Patient • If nature of injuries suggests potential spinal injury, carefully assess for spinal injury during physical examination • Ask patient not to move more than you ask during the examination

12. Assessing a Responsive Patient • Ask: • Does your neck or back hurt? • What happened? • Where does it hurt?

13. Physical Examination Perform standard examination • When checking torso, look for impaired breathing or loss of bladder/bowel control • Compare strength from one side of body to other • Assess both feet and both hands at same time

14. Physical Examination Perform standard examination • Don’t assume patient without symptoms has no spinal injury. Consider forces involved • When in doubt, keep head immobile while waiting for additional EMS

15. Skill: Head and Spinal Injury Assessment

16. Check the victim’s head.

17. Check neck for deformity, swelling, and pain.

18. Check sensation in feet.

19. Ask victim to point toes.

20. Ask victim to push against your hands with feet.

21. Check sensation in hands.

22. Ask victim to make a fist and curl it in.

23. Ask victim to squeeze your hands.

24. Brain Injuries

25. Brain Injuries • Occur with blow to head with/without open wound • Brain injury likely with skull fracture • Brain swelling/bleeding

26. Signs and Symptoms of a Brain Injury • Severe or persistent headache • Altered mental status (confusion, unresponsiveness) • Lack of coordination, movement problems

27. Signs and Symptoms of a Brain Injury Continued • Weakness, numbness, loss of sensation, paralysis • Nausea and vomiting • Seizures • Unequal pupils • Problems with vision or speech • Breathing problems or irregularities

28. Concussion • Brain injury involving temporary impairment • Usually no head wound or signs and symptoms of more serious head injury • Victim may have been “knocked out” but regained consciousness quickly

29. Signs and Symptoms of Concussion • Temporary confusion • Memory loss about event • Brief loss of responsiveness • Mild or moderate altered mental status • Unusual behavior • Headache

30. Medical Evaluation • Concussion patient may recover quickly • Difficult to determine injury severity • More serious signs and symptoms may occur over time • Patients with suspected brain injuries require medical evaluation

31. Emergency Care for Head Injuries • Perform standard patient care • Use the jaw-thrust to open airway • Follow local protocol re: oxygen • Manually stabilize the head and neck • Don’t let patient move

32. Emergency Care for Head Injuries continued • Closely monitor mental status • Control bleeding. No direct pressure on skull fracture • Monitor vital signs • Expect vomiting • Provide additional care for skull fracture

33. Skull Fracture • Check for possible skull fracture before applying direct pressure to scalp bleeding • Direct pressure could push bone fragments into brain • Skull fracture is life threatening

34. Signs of a Skull Fracture • Deformed area • Depressed or spongy area • Blood or fluid from ears or nose • Eyelids swollen shut or becoming discolored (bruising)

35. Signs of a Skull Fracture • Bruising under eyes (raccoon eyes) • Bruising behind ears (Battle’s sign) • Unequal pupils • An object impaled in skull

36. Emergency Care for Skull Fractures • Care as for any head/spinal injury • Don’t clean wound, press on it, or remove impaled object • Cover wound with sterile dressing

37. Emergency Care for Skull Fractures • If bleeding, apply pressure only around edges of wound. Use a ring dressing • Do not move victim unnecessarily

38. CONCUSSION MANAGEMENT

39. What is a Concussion? A concussion is a mildtraumatic brain injury (MTBI) that interferes with normal function of the brain Evolving knowledge “dings” and “bell ringers” are serious brain injuries Do not have to have loss of conciousness Young athletes are at increased risk for serious problems

40. The Problems in the Medical Field There is much variation in the knowledge of health care providers managing concussed athletes Physicians (MD/DO) Physician assistants Nurse practitioners Chiropractors Athletic trainers School nurses New and emerging research and technologies will lead to a continuing evolution of care

41. Problems for Athletes-Post-Concussion Syndrome 85-90% of concussed young athletes will recover within 1 to 2 weeks The remainder may have symptoms lasting from weeks to months interfering with school and daily life Subtle deficits may persist a lifetime

42. Extent of the Problem Professional athletes get a great deal of attention 1600 NFL players Much more common in high school than any other level- due to large number of participants HS Sports Participants Football- 1.14 million Boys Soccer- 384,000 Girls Soccer- 345,000 Boys Hoops- 545,000 Girls Hoops- 444,000 NFHS 2008-09

43. Extent of the Problem 19.3% of all FB injuries in 2009!!! Likely at least 100,000 concussions in HS athletes yearly based on CDC estimates

44. Not Just a Football Problem Injury rate per 100,000 player games in high school athletes Football 47 Girls soccer 36 Boys soccer 22 Girls basketball 21 Wrestling 18 Boys basketball 7 Softball 7 Data from HS RIO JAT, 2007

46. What has happened to make this such a big deal? • Increasing awareness and incidence • Number of high profile athletes over the past 20 years • Steve Young, Troy Aikman, Eric Lindros, etc • Bigger and faster kids, increased opportunities

47. What has happened to make this such a big deal? • High profile cases • Second Impact Syndrome • Death or devastating brain damage when having a second injury when not healed from the first • Long-term effects • Possible long-term effects- dementia, depression

48. NFL and long-term complications

49. Prevention • “Concussion prevention” has become the “holy grail” for sports equipment marketers • Soccer head gear • Girl’s Lacrosse head gear/helmets • Pole vaulting helmet • New football helmets, soccer head pads, mouth guards- NO PROVEN PROTECTION FROM CONCUSSION!! • Multiple flaws in a study looking at “Riddell Revolution” helmet • Neurosurgery, 2006

50. Prevention