Concussion

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Concussion

• By Brian Gober Anedra Smith
• Evaluation of Athletic Injuries I
• AH 322
• 09/03/03

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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

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Concussion

• Concussion An injury in which the brain becomes
  impaired or loses its ability to perform its
  duties properly.

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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)

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Neural Functions Involved

• Consciousness
• Vision
• equilibrium

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Signs and Symptoms

• Memory or Orientation Problems
• Unaware of time, date, place
• Unaware of period, opposition, score of game
• General confusion
• Loss Of Consciousness

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Symptoms

• Headache
• Dizziness
• Feeling "dinged" or stunned
• "Having my bell rung"
• Feeling dazed
• Seeing stars or flashing lights

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Symptoms cont.

• Ringing in the ears
• Sleepiness
• Loss of field of vision
• Double vision
• Feeling "slow"
• Nausea

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Signs

• Poor coordination or balance
• Vacant stare/glassy eyed
• Vomiting
• Slurred speech
• Slow to answer questions or follow directions
• Easily distracted, poor concentration

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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

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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

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Pupil Size
Equal Pupils
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Pupil Size
Dilated Pupil
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Pupil Size
Constricted (Pinpoint) Pupils
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Pupil Size
Unequal Pupils
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Assessment

• Consciousness
• Orientation
• Posttraumatic Amnesia
• Retrograde Amnesia
• Other S/S Headache, dizziness, blurred vision,
  and nausea

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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

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Assessment ClassificationSystems

• Robert C. Cantu, MD (1988)
• Colorado Medical Society System
• American Academy of Neurology Guidelines

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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

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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

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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 3Any loss of consciousness (brief or
  prolonged)

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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.)

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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

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Eye Response (GCS)

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

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Verbal Response

• No verbal response
• Incomprehensible sounds.
• Inappropriate words.
• Confused
• Orientated

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Motor Response (GCS)

• No motor response.
• Extension to pain.
• Flexion to pain.
• Withdrawal from pain.
• Localizing pain.
• Obeys Commands.

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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

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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)

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Sideline Evaluation

• Exertional Provacative Tests
• 40 yard sprint
• 5 push-ups
• 5 sit-ups
• 5 knee-bends

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Sideline Evaluation

• Neurological Tests
• Strength
• Coordination and agility
• Sensation

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Return to Play
Time Asymptomatic
Grade of Concussion

• 15 min or less
• 1 week
• 1 week
• 2 weeks

• Grade 1
• Multiple Grade 1
• Grade 2
• Multiple Grade 2

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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

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Methods of Assessment

• Sensory Organization Test
• Balance Error Scoring System (BESS)
• Neurocognitive Assessment

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Sensory Organization Test (SOT)

• The SOT is designed to disrupt the athletes
  sensory selection process by altering the
  somatosensory or visual information while
  measuring the athletes ability to maintain
  postural stability.

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Sensory Organization Test

• The SOT measures how well a patient can maintain
  their postural stability under six sensory
  conditions.

Condition 1
Condition 2
Condition 3
Condition 4
Condition 5
Condition 6
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Balance Error Scoring System (BESS)

• The BESS is an accurate means of assessing an
  athletes postural stability at days 1, 3, and 5
  post injury and has also proven to be useful in
  making safe return to play decisions. The test
  consists of the following stances performed once
  on a firm surface and once on a foam surface
  Double Leg (narrow), Single Leg (non-dominant),
  and Tandem (heel?toe)

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Balance Error Scoring System Types of Errors

• Hands lifted off iliac crest
• Opening eyes
• Step, stumble, or fall
• Moving hip into more than 30 degrees of flexion
  or abduction
• Lifting forefoot or heel
• Remaining out of testing position for more than 5
  seconds

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Balance Error Scoring System
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Neurocognitive Assessment

• Trail-Making Test A
• Trail-Making Test B
• Wechsler Digit Span Test (WDST)
• Stroop Color Word Test
• Hopkins Verbal Learning Test (HVLT)

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Trail-Making Test A

• Subjects completing this test are asked to
  sequentially trace a list of 25 numbers on a
  piece of paper as fast as possible using a pen.
  This task assesses orientation, concentration,
  visual-spatial capacity and problem solving
  abilities. The time required for successful
  completion is recorded, adding one second for
  each sequential error committed.

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Trail-Making Test B

• Subjects are instructed to connect circles
  containing both numbers (113) and alphabet
  letters (AL) in alternating numeric and
  alphabetic fashion as fast as possible using a
  pen. This task assesses working memory and rapid
  visual processing.

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Wechsler Digit Span Test (WDST)

• The WDST consists of a two part protocol and is
  used to examine a patients concentration and
  immediate memory recall. During both parts of
  the test subjects are presented with a series of
  numbers and asked to repeat the digits in either
  the same order for the first part or in the
  reverse order for the second part. The number of
  successful trials for each part is recorded as
  the total score.

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Stroop Color Word Test

• Designed to assess cognitive flexibility and
  attention span by examining a subjects ability
  to separate word and color naming stimuli through
  the use of three separate subtests.

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Stroop Color Word Test cont.

• During the first subtest, subjects are asked to
  read aloud the words RED, GREEN or BLUE written
  in black ink. For the second subtest the subject
  is asked to identify aloud the colors red, green
  or blue printed in various colors. Finally, the
  third subtest involves the words on page one
  blended with the colors on page two, however in
  no case does the word match with the print color.
  Subjects are asked to read the color of print
  instead of the actual word.

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Hopkins Verbal Learning Test (HVLT)

• Consists of a twelve item word list composed of
  four words from three categories used for
  assessing verbal memory. The subject is
  instructed to listen carefully and memorize the
  word list. The subject then recalls as many
  words as possible in any order.

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Racoon Eyes (Periorbital Ecchymosis)
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Battles Sign (Mastoid Hematoma)
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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.

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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. 

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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.

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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

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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.

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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

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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

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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

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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

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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

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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

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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.
  

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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

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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. Arnheims Principles of
  Athletic Training. McGraw-Hill, New York. 2003.
• Sanders, Mick. Mosbys Paramedic Textbook. Mosby,
  St. Louis. 1994.