Concussion and Sports (PowerPoint) by mikesanye

VIEWS: 178 PAGES: 58

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

   Defining concussion
   Anatomy of concussion
   Mechanisms of concussion
   Evaluation
   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
 Centersfor 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
 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

– 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
 Transientconfusion
 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
 Transientconfusion
 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
 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        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
 Airway
 Breathing
 Circulation,   Cervical Spine Precautions
 Dextrose
 Manage   Raised ICP
The End

To top