Concussion

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

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

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

4. 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

5. 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

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

7. 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

8. 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

9. 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 Primary Assessment cont…

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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

16. 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

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

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

19. 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

20. 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

21. 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

22. 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

23. Glasgow Coma Scale Lowest score = 3, Highest score = 15

24. General Concussion Classification Grade VI Concussion • Death

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

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

27. Early S/S Severe head pains Dizziness Nausea Unequal pupil sizes Sleepiness Severe S/S Deteriorating consciousness Neck rigidity Slow pulse Slow respiration Convulsions Intracranial Hemorrhage

28. 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

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

30. 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

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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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