Concussion By Brian Gober & Anedra Smith Evaluation of Athletic Injuries I AH 322 09/03/03.

Concussion

By Brian Gober & Anedra SmithEvaluation of Athletic Injuries I

AH 32209/03/03

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

• 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 ClassificationSystems

• 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. No eye opening. 2. Eye opening to pain. 3. Eye opening to verbal command. 4. Eyes open spontaneously

Verbal Response

1. No verbal response 2. Incomprehensible sounds. 3. Inappropriate words. 4. Confused 5. Orientated

Motor Response (GCS)

1. No motor response. 2. Extension to pain. 3. Flexion to pain. 4. Withdrawal from pain. 5. Localizing pain. 6. 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 1

• Multiple Grade 1

• Grade 2

• Multiple Grade 2

• 15 min or less

• 1 week

• 1 week

• 2 weeks

Grade of Concussion

Time Asymptomatic

Return to Play

• Grade 3: Brief Loss of Conciousness

• Grade 3: Prolonged Loss of Consciousness

• Multiple Grade 3

• 1 week

• 2 weeks

• 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 SyndromeSigns/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?– 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?– 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:– 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): 249-252. 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.