Transcript Concussion and Sports

Closed Head Injury
Martin V. Pusic MD
Children’s & Women’s Health Centre
Division of Emergency Medicine
Outline
 Concussion
 Intracranial
Hemorrhage
 Diffuse Axonal Injury
 Brain Contusion
Concussion
Contents
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Defining concussion
Anatomy of concussion
Mechanisms of concussion
Evaluation
Management recommendations
Return to play
Richard Zednik
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.
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
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
Facts About Concussion
Concussions per every 100,000 games
and/or practices at the collegiate level
–
–
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Football:
Ice Hockey:
Men’s soccer:
Women’s soccer:
Wrestling:
Women’s basketball:
Men’s basketball:
27
25
25
24
20
15
12
(Head and Neck Injury in Sports, R.W. Dick)
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.
Anatomy of Concussion
Cervical spine -allows the head to
rotate to avoid blunt
trauma
– However, rotational
forces can be the most
damaging during
concussion
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.
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

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
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
Related Brain Tissue Injuries
 Hematoma
-- blood clot
 Contusion -- brain bruises
 Brain swelling and
diminished blood flow to
sensitive brain tissues
How is Concussion Assessed?
 AAN
guidelines for sideline evaluation
 Standardized Assessment of Concussion
(SAC) for sideline use
 Standard neuropsychological tests
 Computerized reaction time tests
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, sensation
Neurology, March 1997
Grade 1 Concussion
 Transient
confusion
 NO loss of consciousness
 Concussion symptoms or mental status
abnormalities resolve in less than 15
minutes
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
Grade 2 Concussion
 Transient
confusion
 NO loss of consciousness
 Concussion symptoms or mental status
abnormalities last more than 15 minutes
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

Grade 3 Concussion
 Any
loss of consciousness, either brief
(seconds) or prolonged (minutes)
Investigations
 CT,
MRI – rule out other conditions
 PET
Scan
Investigations
 PET
Scan
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

When to Return to Play
Grade of concussion
 Grade 1
 Multiple grade 1
 Grade 2
 Multiple grade 2
 Grade 3
 Multiple grade 3
15 minutes or less
1 week
1 week
2 weeks
2 weeks
1 month or longer
Treatment
The treating physician can utilize a variety
of treatment options including:
–
–
–
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Analgesics for pain
Sleeping medication
Muscle relaxants
Rehabilitation therapies
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

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
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
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
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)
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
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
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

Cerebral Hemorrhage
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?
Glasgow Coma Scale
Eye Opening
Verbal
Motor
Oriented
Follows
commands
Localizes
6
5
4
Spontaneous
Confused
Withdraws
3
To verbal
Inappr words
Flexion
2
To pain
Nonsp sounds
Extension
1
none
None
none
Modified GCS for Infants
Eye Opening
Verbal
Motor
6
Spontaneous
5
Coos, babbles Withdraws to
touch
4
Spontaneous
Irritable, cries Withdraws to
pain
Cries to pain Abn flexion
3
To speech
2
To pain
Moans to pain
1
none
None
Abn
extension
none
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
Classification: Minor HI
Mild
Moderate
Severe
No LOC
LOC <5 min
LOC >5 min
Normal
physical
exam
Normal physical
exam
One or more high
risk criteria
GCS 13 -15
GCS < 13
Initial GCS 15
Minor soft tissue
injuries
High Risk Criteria
1.
2.
3.
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
High Risk Criteria (cont)
4.
5.
6.
7.
8.
9.
Unexplained neurological signs
Hx previous craniotomy with shunt
Post-traumatic amnesia
Severe/worsening headache
Post-traumatic seizure
Blood dyscrasia/anticoagualants
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?
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
Case 2
Case 2 – Epidural Hematoma
• Lucent Interval?
•ABC
•Hyperventilation
•Mannitol
•Surgical Decompression
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
Case 3
Case 3
Always consider:
CHILD ABUSE
Case 4
A 9-year old suddenly
collapses while
playing pickup
football.
Case 4 – Subarachnoid
Hemorrhage
A 9-year old suddenly
collapses while
playing pickup
football.
Case 5
An 8-year old hits his
head during a highspeed motor vehicle
collision
Case 5
An 8-year old hits his
head during a highspeed motor vehicle
collision
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
Management
 Airway
 Breathing
 Circulation,
Cervical Spine Precautions
 Dextrose
 Manage
Raised ICP
The End
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