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CONCUSSIONS amnesia Powered By Docstoc
Carl W. Nissen, MD
Elite Sports Medicine
 What do these athletes have in

Troy Aikman
Steve Young
Jim Kelly
Paul Kariya
Eric Lindros

Bell Ringer
Head injury
Brain injury
Mild traumatic brain injury

Direct or indirect blow
Rapid onset of a short-lived neurologic
A traumatically induced complex
 pathophysiological process affecting
 the brain
Functional disturbance, not structural
Graded set of clinical syndromes
 Most common in young adults and males
 Risk of second concussion in football is 4-6 x
  greater than original
 Concussion per 100,000 exposures
      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

  High school – 0.59/1,000 exposures
  College – 3.5/1,000 exposures

1.5 million high school players
75,000 college players
1-in-5 will experience a concussion
300,000 concussions per fall
                  Immediate Signs

Impaired attention
  Vacant stare, delayed responsiveness,
   inability to focus
Slurred or incoherent speech
Gross incoordiantion
Emotional lability
Memory deficits
                       Delayed signs

 Dizziness, vertigo
 Persistent headache
 Poor attention and concentration
 Memory dysfunction
 Nausea/vomiting
 Photophobia
 Anxiety or depression
 Sleep disturbances
 Irritability

AAN guidelines
  Mental status testing
  Exertional provocative tests
  Neurological testing
Neuro-cognitve testing
Computerized reaction time testing
             On-field Examination

 ABC’s
 Cervical spine precautions
 Orientation
 Immediate memory
 Concentration
 Delayed recall
 Neurologic screening
                       ER Transfer?

Skull fracture
  Base of the skull
Worsening headache
Focal neurologic deficits
Sideline Evaluation of Severity

Main determiner
  Was LOC
  Now felt to be post-traumatic amnesia
                 Grading Systems

Multiple exist
Most breakdown into 3 subsets

AAN - 1997
  Grade 1 – Bell ringer, Quick
  Grade 2 – Recovery greater than 15 min
  Grade 3 – LOC
                Recent Literature

Problems with mental abilities took an
 average of 5-7 days to resolve
9% of injured players were not at
 normal function at one week
  McCrea et al – JAMA 2003
               Recent Literature

Players with a history of previous
 concussions were more likely to have
 another concussion
Previous concussion was associated
 with longer recovery
               Vienna Statement

No single grading system adequately
 addresses all of the pertinent issues
Symptomatic athletes should be
No RTP until medically evaluated,
 regardless if <15 min
Neuropsychological Testing is a
 valuable tool
                Prague Statement

Grading can only be done
 retrospectively after all symptoms
 have cleared
Abandonment of injury grading scales
  Similar to Vienna statement
                  Prague Statement
             Grading system
 Concussions all lie on a linear spectrum
   “Unitary phenomenon”
 Subtypes based on:
   Clinical manifestations
   Anatomic localization
   Biomechanical impact
   Genetic phenotype
   Neuropathological changes
                Prague Statement

Significance of loss of concussion
  Traditionally used as primary measure of
  LOC does not imply severity
               Prague Statement

Renewed interest in the role of post-
 traumatic amnesia and its role in
 determining injury severity
Nature, Burden, and Duration of post-
 concussive symptoms is more
 important than using amnesia as a
 guide to severity
             Prague Statement

Simple concussion
Complex concussion
           Simple Concussions

Resolves in 7-10 days
RTP occurs with no sequelae

Name is a misnomer
         Complex Concussions

Persistent symptoms
Prolonged LOC
Prolonged cognitive impairment
Multiple concussions over time
Concussions with progressively less
      Neuropsych Assessment

Should not be the sole basis of RTP
  Use as an aid suggested
Testing should be done after symptom
  Dizziness, photophobia, etc.
More research needed
               Prague Statement
        Acute Injury Management
1. Player should not be allowed back
   into current game or practice
2. Player should be monitored and
   observed for several hours post
3. Medical evaluation appropriate
4. RTP should be done under a
   medically supervised process
               Prague Statement

“When in doubt, sit them out”

No player should rerun to play if
                 Prague Statement
      Management Steps
1. Complete rest till asymptomatic
2. Light aerobic exercise
  Stationary bike, walking
3. Sport specific aerobic exercise
  Skating, running
4. Non-contact drills
5. Full contact after medical clearance
6. Game play
               Prague Statement

Complex concussions should follow a
 more extensive RTP process
Expertise in concussion management
 should be available for all athletes and

More common
Recovery time is longer
Bell ringers are not to be disregarded
Immature brains recover slower

     DO not return an athlete until
      he/she is completely clear

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