Concussion and Sports

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					Closed Head Injury
         Martin V. Pusic MD
 Children’s & Women’s Health Centre
   Division of Emergency Medicine
Intracranial Hemorrhage
Diffuse Axonal Injury
Brain Contusion

Defining concussion
Anatomy of concussion
Mechanisms of concussion
Management recommendations
Return to play
Richard Zednik

    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
–   Football:             27
–   Ice Hockey:           25
–   Men’s soccer:         25
–   Women’s soccer:       24
–   Wrestling:            20
–   Women’s basketball:   15
–   Men’s basketball:     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

             – However, rotational
               forces can be the most
               damaging during
 Two Primary Mechanisms
      of Concussion
- 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.
- 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
 Emotional reactions out of proportion
 Memory deficits
 Any loss of consciousness
Later Signs of Concussion
 (occurring within hours to days)
  Persistent headache
  Poor attention and concentration
  Memory dysfunction
  Nausea or vomiting
  Fatigue easily
  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

– 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
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)
CT, MRI – rule out other conditions

PET Scan
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               15 minutes or less
 Multiple grade 1      1 week
 Grade 2               1 week
 Multiple grade 2      2 weeks
 Grade 3               2 weeks
 Multiple grade 3      1 month or longer
The treating physician can utilize a variety
of treatment options including:
–   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
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
6                                    Follows
5                      Oriented      Localizes
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
 4    Spontaneous   Irritable, cries Withdraws to
 3     To speech     Cries to pain Abn flexion
 2      To pain     Moans to pain      Abn
 1       none           None           none
– middle meningeal artery/vein, dural sinus
– tear of bridging veins/dura
– 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        Normal physical   One or more high
      physical          exam            risk criteria
 Initial GCS 15       GCS 13 -15         GCS < 13

Minor soft tissue
             High Risk Criteria
1.   Altered LOC: unconsciousness, GCS<13
2.   Local bony abnormalities
        Skull fracture
        FB with/without laceration
        Puncture wound
3.   Evidence of Basal Skull Fracture
        Battle sign
        Racoon’s eyes
       High Risk Criteria (cont)
4.   Unexplained neurological signs
5.   Hx previous craniotomy with shunt
6.   Post-traumatic amnesia
7.   Severe/worsening headache
8.   Post-traumatic seizure
9.   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

March 19, 2002 DONNA SPENCER,
The Canadian Press
Case 2
  Case 2 – Epidural Hematoma
• Lucent Interval?

•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:

                Case 4

A 9-year old suddenly
 collapses while
 playing pickup
      Case 4 – Subarachnoid

A 9-year old suddenly
 collapses while
 playing pickup
                 Case 5

An 8-year old hits his
 head during a high-
 speed motor vehicle
                  Case 5

An 8-year old hits his
 head during a high-
 speed motor vehicle
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
Circulation, Cervical Spine Precautions
Manage Raised ICP
The End

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