Lecture on Concussions. Property of WESHARE Rescue Organization

1. Concussion and Traumatic BrainConcussion and Traumatic Brain
Injury in SportsInjury in Sports
Thomas A. Waters MD FACEPThomas A. Waters MD FACEP
Cleveland Browns Medical Team PhysicianCleveland Browns Medical Team Physician
Department of Emergency MedicineDepartment of Emergency Medicine
The Cleveland ClinicThe Cleveland Clinic

2. Introduction

3. Introduction
 Estimated number of
Head Injuries
(concussions, skull
fractures and intracranial
injuries) presenting to the
Emergency Department
per year per sport:
 Hockey 9,883
 Soccer 50,035
 Football
128,968

4. Introduction
 Other high risk sports include:
 MMA
 Rugby
 Basketball
 Wrestling
 Soccer
 A study done in the year 2000 looked at >1000 retired NFL
players and found that around 60% of those players sustained at
least one concussion during their career.
AmJSportsMed201240:747

5. Introduction
 Head injuries occur commonly during sports
participation.
 There are three important steps when dealing with
head injury in sports.
 Detecting Injury
 Assessing severity
 Making appropriate return to play (RTP)
recommendation.

7. Head
Injuries/Concussions

18. Helmet History

19. History of the football
helmet
 1893-First helmet was worn in the Army-Navy game
 Made by Annapolis shoemaker for Admiral Joseph
Mason Reeves
 Advised by Navy Doctor that he would be risking death
or “instant insanity” if he took another kick to the head.
 1896
 Halfback George Barclay (Lafayette College) fearing
cauliflower ear had “playing hat” made by a harness
maker-”Head Harness”

20. History of the football
helmet 1930s-Helmets became mandatory
 1948-first logo(rams horns) painted on pro leather
helmet

21. History of the football
helmet 1939-first plastic helmet
invented by John
Riddell
 1940-first chin strap
 1955-Paul Brown put
the first face mask on a
professional helmet.

22. History of the football
helmet 1971 Riddell-”microfit” air helmets with valves on the
crown to allow air to be pumped into vinyl cushions.
 1976-four point chin straps
 2002 Riddell Revolution helmet

23. Head Injury in Sports
 In general, head injuries that occur in the athletic
setting are mild in comparison to those that occur in
other settings such as MVAs and other high velocity
impacts.
 Most common injury is the Concussion
 Most common serious injuries include
 Cervical Spine spine injuries
 Vascular intracranial injuries
 Vascular catastrophes can present immediately or be
delayed by several hours

24. Mechanism of Head
Injury Any blow to the head can cause brain injury
 Injury is due to sudden head movement or cessation
of movement and shifting of the brain within the skull.
 Acceleration/Deceleration forces
 Head vs ground
 Rotational forces
 Left hook
 Impact forces
 Bean Ball

26. Direct Injuries
 Object impacts the head
 Boxing, baseball, field hockey, ice hockey
or
 Head impacts another object:
 Ground, another player-shoulder, helmet, goalpost

27. Indirect injuries
 Forces can be transferred to the cranium
 Rotational forces or compressive forces
 Fall off balance beam onto coccyx
 Rotational hit in football or hockey

28. Biomechanics
 The location and degree of head injury depends upon
the position of the head at the moment of impact, the
direction of the forces being applied to the head
combined with the structural features and integrity of
the skull

29. Head injuries in Sports
 Nonfocal
 Concussion
 Focal Injuries
 Subdural Hematoma
 Epidural Hematoma
 Cerebral contusions
 Intra-cerebral hemorrhage
 Subarachnoid hemorrhage

30. Subdural Hematoma
 Disruption of venous blood vessels causing low
pressure accumulation of blood
 Most common focal head injury in sports
 Often associated with
 LOC
 Slow deterioration of neurologic status
 Focal neurologic deficits

31. Subdural Hematoma

32. Epidural Hematoma
 Not as common as subdural
 High pressure vascular injuries
 Middle meningeal artery
 Presentation
 LOC
 Recovery (lucid interval)
 Rapid deterioration of neurologic status

33. Epidural Hematoma

34. Other Focal Injuries
 Cerebral contusions
 Intracranial hemorrhages
 Subarachnoid hemorrhages
 Skull fractures

35. Definition of Concussion
 Concussion
 Latin
 concutere-meaning to shake violently or agitate
 concussus-action of striking together.
 Definition in 1966 by the Committee on Head Injury
Nomenclature: “a clinical syndrome characterized by the
immediate and transient post-traumatic impairment of neural
function such as alteration of consciousness, disturbance of
vision or equilibrium due to mechanical forces.”

36. Definition of Concussion
 Zurich Consensus Statement on Concussion from
2008:
 “Concussion is defined as a complex pathophysiological
process affecting the brain, induced by traumatic
biomechanical forces.”

37. Concussion-Why do we
care? 44 million children/adolescents participate in
organized sports per year.
 2009 in the US there were about 1.8 million
participants in football
 Estimated 3.8 million concussions per year in US.
 Long term effects of concussions are becoming better
understood and more heavily scrutinized

38. Concussion-Presentation
 May be obvious but often subtle.
 May not have witnessed the hit
 Within the pile
 Blow was not directly to head
 Symptoms may be delayed
 Player may not recognize symptoms
 Teammates may notice “not acting right”

39. Concussion-Presentation
 Player Reported
 HA/pressure
 Nausea
 Confusion/disorientat
ion
 Equilibrium “off”
 “Don’t feel right”/”In
a fog”
 Photo/phonophobia
 Amnesia
 Observer Reported
 Dazed appearing
 Thinking/moving
slowly
 Unbalanced
 Confusion/forgetting
plays
 Irritability
 Personality changes
 “not acting right”

40. On Field Assessment
 ABC’s/C-spine then get
to sideline

41. Sideline Assessment
 Observe behavior
 Ask about Symptoms
 Sideline Assessment: questions that assess
 Orientation
 Memory
 Cognition

42. Sideline Assessment
 Maddock’s Questions
 What venue are we at
today? (Where are we?)
 What quarter/half is it?
 Who scored last?
 Who did we play last
week?
 Who won the game last
week?
 What was the play?

43. “Sideline” Assessement
 1)Sport Concussion
Assessment
Tool(SCAT2) is the
standard for “sideline”
assessment of
concussion
 2)Balance Assessment-
Balance Error Scoring
System(BESS)

44. SCAT2

46. Sideline Assessment
 NFL Sideline Concussion Assessement Tool:
 Developed by the NFL Physicians Society(NFLPS)
Head Neck and Spine Committee and implemented for
the 2011-2012 season-modified for the 2012-2013
season.
 Combination of the SCAT2, BESS.
 Takes 4-8 mins
 6 Go/No Go criteria

47. 6 Go/No Go Criteria
 LOC
 Confusion
 Amnesia
 *When in doubt-sit
them out
 New/persistent Sxs
 Abnl Neuro findings
 Progressive symptoms

48. Removal from play
 Player should be observed
for progression/development
of concerning symptoms-do
not leave them alone.
 Player may NOT return to
the field of play (Madden
Rule)
 Cognitive and physical rest
and insure appropriate
follow up with caregiver
experienced in concussion
follow up and parameters for
return to play.

49. Imaging?
 The two most commonly used evidence based clinical
decision rules for head CT in adults are:
 New Orleans Criteria
 Canadian CT head rule

52. ACEP Summary of Indications
for CT Scanning in Adults with
mTBI
 No loss of consciousness and one or more of the
following:
 GCS <15
 Focal Neuro findings
 Vomiting more than twice
 Mod to severe HA
 Age> 65
 Signs of basilar skull fx
 Coagulopathy
 Dangerous mechanism

53. ACEP Summary of Indications
for CT Scanning in Adults with
mTBI
 With loss of consciousness
 Finding from the previous slide plus:
 If one or more of the following is present:
 Drug or ETOH intox
 Persistent amnesia
 Post traumatic Sz

54. Bottom line
 Who needs to be transported from the field for head
imaging
 Prolonged LOC(>1min)
 Seizures
 Progressive neuro symptoms
 Other concerning symptoms/conditions such as
multiple episodes of vomiting.

55. Post Concussion Care
 Cognitive rest, physical rest and sleep
 Eliminate
 TV/Computer
 Video games
 Texting
 Reading
 School work
 Bright lights and sounds

56. Follow up
 It is essential that the
athlete/patient follow
up with a caregiver who
is up to date on the
latest concussion
recommendations.

57. Old Myths
 When the headache is gone, you can return to play
 Sit out 3 days then return to play
 A player who is knocked unconscious has a worse
concussion than if they were not.

58. Return to play
 Each and every individual and each and every
concussion is unique and predicting patterns of
recovery is very difficult if not impossible
 What seems to be a minor concussion may linger for
weeks
 What seems to be major at the outset may clear quickly
 What is important is that the athlete progress through
each and every step without skipping or hurrying
through any step in the process

59. Return to play
 Asymptomatic
 Normal cognitive function/balance
 Graded return to play with 24 hours between stages
 Progression in younger athletes should occur at a
slower pace than adults
 RTP decision should be more conservative in athletes
with previous history of concussion (especially if
recent)

60. Asymptomatic
 A symptom is a symptom, no matter how small.

61. Assessment Tools
 Cognitive Tools
 ImPact Test
 CogSport
 Headminder
 Balance Testing
 BESS(Balance Error Scoring System)

62. Assessment Tools
 BESS(Balance Error Scoring System

63. Return to play
 1)Asymptomatic at rest
 2)Asymptomatic with cognitive activity
 3)Asymptomatic with light aerobic activity
 4)Asymptomatic with heavy aerobic activity
 5)Asymptomatic with sport specific activity
 Baseline on any cognitive/balance testing

64. Multiple Concussions

65. Second Impact Syndrome
 Occurrence of a second head injury before an
individual has fully recovered from a first insult.
 First described and called SIS in 1984 by Saunders and
Harbaugh.
 19yo FB player had concussion, allowed to RTP died
suddenly with no major second trauma
 Autopsy showed diffuse cerebral edema but no focal
lesion or bleeding

66. Second Impact Syndrom
 The second impact can cause
 Brain swelling
 Persistent deficits
 Death
 After second impact the patient deteriorates quickly
within seconds to minutes
 SIS is rare and has only been reported in minors

67. Chronic Traumatic
Encephalopathy(CTE)
 Complication of recurrent head injury
 Premature loss of normal central nervous system function
 “punch drunk” in boxers in 1928
 Abnormalities in the cerebellar, pyramidal and
extrapyramidal systems and as well cognitive and
personality deficits
 Diagnosis made on autopsy

68. Future directions
 Genetic testing
 Apolipoprotein E
 Blood/Saliva testing
 glutamate
 New imaging techniques
 fMRI
 Post injury there is an increase need for glycolysis along
with decreased cerebral blood flow which may be able to
be detected

69. Future Directions
 Neuroprotective medications;
 Magnesium, progesterone, erythropoietin, calcium
channel blockers
 Accelerometers
 In helmets and mouth guards measure amount of g-
force sustained in an individual and cumulative hits.

70. Summary
 Early detection and recognition is a priority
 Approach in each case must be individualized
 Proper follow up is the key
 Must be baseline before returning to play

71. Questions