Transcript CONCUSSION ASSESSMENT - University of West Alabama

Concussion
By Brian Gober & Anedra Smith
Evaluation of Athletic Injuries I
AH 322
09/03/03
Statistics
• 10% of head injury patients die before
reaching the hospital
• 5% head injuries have spinal damage
• 25% spinal injuries have a mild head injury
• sports and recreation make up 10% of cases
Concussion
• Concussion: An
injury in which the
brain becomes
impaired or loses its
ability to perform its
duties properly.
Concussion cont.
• Traditionally characterized by immediate
and transient posttraumatic impairment of
neural functions. (Prentice 885)
• Typically caused by mild-to-moderate
impact to the skull and/or movement of the
brain within the cranial vault (Sanders 433)
Neural Functions Involved
• Consciousness
• Vision
• equilibrium
Signs and Symptoms
• Memory or Orientation Problems:
– Unaware of time, date, place
– Unaware of period, opposition, score of game
– General confusion
• Loss Of Consciousness
Symptoms
• Headache
• Dizziness
• Feeling "dinged" or
stunned
• "Having my bell rung"
• Feeling dazed
• Seeing stars or
flashing lights
Symptoms cont.
•
•
•
•
•
•
Ringing in the ears
Sleepiness
Loss of field of vision
Double vision
Feeling "slow"
Nausea
Signs
•
•
•
•
•
Poor coordination or balance
Vacant stare/glassy eyed
Vomiting
Slurred speech
Slow to answer questions or follow
directions
• Easily distracted, poor concentration
Signs Cont.
• Displaying unusual or inappropriate
emotions (e.g. laughing, crying)
• Personality changes
• Inappropriate playing behavior (e.g. skating
or running the wrong direction)
Significantly decreased playing ability from
earlier in the game/competition
Initial Assessment
• Level of Consciousness (Alert, Verbal
Stimuli, Pain Stimuli, Unresponsive)
• ABCs
• Initial C-spine precautions due to possible
neck injury from MOI
• Pupil Response
Pupil Size
Equal Pupils
Pupil Size
Dilated Pupil
Pupil Size
Constricted (Pinpoint)
Pupils
Pupil Size
Unequal Pupils
Assessment
•
•
•
•
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Consciousness
Orientation
Posttraumatic Amnesia
Retrograde Amnesia
Other S/S: Headache, dizziness, blurred
vision, and nausea
Neuropsychological Deficits
• Disturbances of new learning and memory,
planning, and the ability to switch mental
“set”
• Reduced attention and speed of information
processing, including test strategies such as
the digit symbol subtest of the Wechsler
Abbreviated Scale of Intelligence
Assessment Classification
Systems
• Robert C. Cantu, MD (1988)
• Colorado Medical Society System
• American Academy of Neurology
Guidelines
Cantu Grading System
• Grade 1 (mild): No loss of consciousness;
posttraumatic amnesia less than 30 min
• Grade 2 (moderate): Loss of consciousness
less than 5 min or posttraumatic amnesia
greater than 30 min
• Grade 3 (severe): Loss of consciousness
greater than 5 min or posttraumatic amnesia
greater than 24 hr
Colorado Medical Society
System
• Grade 1: Confusion without amnesia,
no loss of consciousness
• Grade 2: Confusion with amnesia, no
loss of consciousness
• Grade 3: Loss of consciousness
American Academy of
Neurology Guidelines
• Grade 1: Transient confusion, no loss of
consciousness, concussion symptoms
less than 15 minutes
• Grade 2: Transient confusion, no loss of
consciousness, concussion symptoms
greater than 15 minutes
• Grade 3:Any loss of consciousness
(brief or prolonged)
Concussion Classification
It is imperative to remember:
Any Loss of Consciousness greater than 30
minutes should point to a more serious
brain injury than concussion ( e.g. Subdural
Hematoma, Epidural Hematome, Basilar
Skull Fracture, etc.)
Classification of LOC
Glasgow Coma Scale (GCS)
• The GCS is scored between 3 and
15, 3 being the worst, and 15 the
best. It is composed of three
parameters : Best Eye Response,
Best Verbal Response, Best Motor
Response
Eye Response (GCS)
1.
2.
3.
4.
No eye opening.
Eye opening to pain.
Eye opening to verbal command.
Eyes open spontaneously
Verbal Response
1.
2.
3.
4.
5.
No verbal response
Incomprehensible sounds.
Inappropriate words.
Confused
Orientated
Motor Response (GCS)
1.
2.
3.
4.
5.
6.
No motor response.
Extension to pain.
Flexion to pain.
Withdrawal from pain.
Localizing pain.
Obeys Commands.
Classification with Negative
LOC
Start
Progression To
I. Confusion 
Normal consciousness without amnesia
II. Confusion  Normal consciousness with posttraumatic amnesia
III. Confusion  Normal consciousness with posttraumatic amnesia
plus retrograde amnesia
IV. Coma (paralytic)  Level III: Normal consciousness with
posttraumatic amnesia plus retrograde amnesia
V. Coma 
Vegetation state or death
VI. Death
Sideline Evaluation
Mental Status Testing
• Orientation: Time, place, person, and situation
• Concentration: Digits Backwards, Months of year
in reverse order
• Memory: Names of teams, recall 3 words or
objects, recent events, details of contest (score)
Sideline Evaluation
Exertional Provacative Tests
-
40 yard sprint
5 push-ups
5 sit-ups
5 knee-bends
Sideline Evaluation
Neurological Tests
• Strength
• Coordination and agility
• Sensation
Return to Play
Grade of
Concussion
Time
Asymptomatic
• Grade 1
• 15 min or less
• Multiple Grade 1
• 1 week
• Grade 2
• 1 week
• Multiple Grade 2
• 2 weeks
Return to Play
• Grade 3: Brief Loss of
Conciousness
• 1 week
• Grade 3: Prolonged
Loss of Consciousness
• 2 weeks
• Multiple Grade 3
• 1 month or longer,
physician decision
Racoon Eyes (Periorbital
Ecchymosis)
Battle’s Sign (Mastoid
Hematoma)
Second Impact Syndrome
• This occurs when an athlete, who has
already sustained a head injury,
sustains a second head injury before
symptoms have cleared from the first
injury. Many times this occurs because
the athlete has returned to competition
and play before his or her first injury
symptoms resolve. Coaches and
athletes do not realize that days or
weeks may be needed before
concussion symptoms resolve.
Second Impact Syndrome
• A second blow to the head, even if
it is a minor one, can result in a
loss of auto regulation of the
brain's blood supply. Loss of
autoregulation leads to brain
swelling. This results in increased
intracranial pressure and leads to
herniation of the brain.
Second Impact Syndrome
• The average time from second
impact to brainstem failure is quite
rapid, taking two to five
minutes. Once herniation and
brainstem compromise occur,
ocular movement and respiratory
failure are likely to result.
Second Impact Syndrome
Signs/Symptoms
• Within seconds or minutes of the
second impact, the athlete who is
conscious, yet stunned may:
-collapse to the ground
-semi comatose with rapidly
dilating pupils
-loss of eye movement
-evidence of respiratory failure
Conclusion
• In order for these test to effectively work, it
is best to establish a baseline during an
athletes PPE.
• Tests may be modified for use in various
field elements, however they are intended
for evaluation over a period of days.
• Used effectively, they can help decide an
athletes return to participation time frame.
Conclusion
• It is extremely important that when initially
assessing an athlete for a head injury that
you rule out sign/symptoms for more severe
Traumatic Brain Injuries (TBI)
• Serious Signs/Symptoms: Periorbital
Echymosis, “Battle” signs, Bleeding from
nose, ears, mouth, Clear Fluid (CSF) from
openings, deformity, Unequal Pupils
Questions??
• What is a concussion?
– A. A bleed within the portion of the brain just
below the dura mater
– B. An injury in which the brain becomes
impaired or loses its ability to perform its duties
properly.
– C. An occlusion on the cerebral arteries.
– D. None of the Above
Questions??
• Signs of a Concussion include?
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A. Dizziness
B. Nausea/Vomiting
C. Confusion
D. Paralysis
E. A, C, & D
F. A, B, & C
G. A, B, C, & D
Questions??
• Which of the following is a form of
Neurocognitive Assessments?
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A. Pupillary reflex
B. Sensory Organization Test
C. BESS
D. Stroop Color Word Test
E. All of the above
Questions??
• Which are errors commonly seen within the
BESS method of Assessment?
– A. Step, stumble, or fall
– B. Moving hip into more than 30 degrees of
flexion or abduction
– C. Lifting forefoot or heel
– D. All of the Above
– E. None of the Above
Questions??
• The best grading system for use with the
assessment of a concussion is:
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A. The R.T. Floyd Assessment Scale
B. The Cantu Method
C. The Colorado Medical Society Scale
D. None of the Above
References
• McCrea, M. “Standardized Mental Status Testing
on the Sideline after Sport-Related Concussion.”
Journal of Athletic Training. 36 (3): 274-279.
2001. www.journalofathletictraining.org
• Guskiewicz, K., Ross, E., &Marshall, S.: “Postural
Stability and Neuropsychological Deficits After
Concussion in Collegiate Athletes.” Journal of
Athletic Training. 36(3): 263-273, 2001:
www.journalofathletictraining.org.
References
• Roos, R. “Guidelines for Managing Concussion in
Sports: A Persistent Headache” The Physician
and Sportsmedicine. Vol. 24. No. 10. October
1996. 2/3/03. www.physsportsmed.com
•
McCrory, P., Johnston, K. “Acute Clinical
Symptoms of Concussion.” The Physician and
Sportsmedicine. Vol. 30. No. 8. August 2002.
2/3/03. www.physsportsmed.com
References
• Kelly, J. ”Loss of Consciousness: Pathophysiology
and Implications in Grading and Safe Return to
Play.” Journal of Athletic Training. 36 (3): 249252. 2001. www.journalofathletictraining.org
• Prentice, William. Arnheim’s Principles of
Athletic Training. McGraw-Hill, New York. 2003.
• Sanders, Mick. Mosby’s Paramedic Textbook.
Mosby, St. Louis. 1994.