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Concussion. Jennifer L. Doherty, MS, LAT, ATC Management of Medical Emergencies. Concussion. Head/Brain injury Temporary impairment of brain function MOI: Direct or Indirect blow to the head. Concussion. Serious head injuries almost always represent a life-threatening situation

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Concussion

Jennifer L. Doherty, MS, LAT, ATC

Management of Medical Emergencies


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Concussion

  • Head/Brain injury

  • Temporary impairment of brain function

  • MOI: Direct or Indirect blow to the head


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Concussion

  • Serious head injuries almost always represent a life-threatening situation

  • Must get athlete to the hospital immediately

    • Within 30 minutes


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Signs and Symptoms

  • Altered level of consciousness (LOC)

  • Pain or pressure in the head

  • Tingling or loss of sensation in the extremities

  • Partial or complete loss of movement in any body part


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Signs and Symptoms cont…

  • Unusual lumps or depressions on the head

  • Blood or other fluids in the ears or nose

  • Profuse bleeding from the head

  • Seizures

  • Impaired breathing

  • Impaired vision


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Signs and Symptoms cont…

  • Nausea or vomiting

  • Persistent headache

  • Loss of balance

  • Ecchymosis

    • Especially around the eyes or behind the ears


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Signs and Symptoms cont…

  • The S/S of a head/brain injury may not be apparent until hours after the trauma occurs

  • Immediate referral to a physician is important for the proper treatment of a serious head/brain injury


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Primary Assessment

  • Must be able to recognize and interpret the S/S of a head injury

  • If an athlete is unconscious, ALWAYS assume injury to the neck as well


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Without moving the athlete, assess the airway

Athlete is breathing

Airway is obstructed

Observe for S/S of head and neck injury

Face color

Skin condition

Pulse

Breathing

Pupils

Edema

Ecchymosis

Deformity

Primary Assessment cont…


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Secondary Assessment

  • Assess mental orientation and memory

  • What is your name?

  • How old are you?

  • Where are you?

  • What game are you playing?

  • What is the score?

  • What month is it?

  • Who is president?

  • After 5-10 minutes, ask the same questions again


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Secondary Assessment cont…

  • Test for “Eye signs”

  • Dilated and/or irregular pupils

  • Blurred vision

  • Inability for eyes to accommodate rapidly to light variance

  • Inability for eyes to track smoothly

    • nystagmus


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Secondary Assessment cont…

  • Balance Testing

  • Stand with eyes closed

  • Stand on one foot

  • Stand on one foot with eyes closed

  • Finger-to-Nose test

  • Babinski Test

  • Reflex tested by running a pointed object along the bottom of the foot

  • Normal response is toe flexion


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Concussion Classification

  • There are many ways to classify concussions

  • Different Grading Scales exist

    • Cantu (1986)

    • Colorado Medical Society (1991)

    • Torg (1991)

    • American Academy of Neurology (1997)

    • Guskiewicz/University of North Carolina (1998)


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General Concussion Classification

Grade I Concussion

  • Normal consciousness

  • No memory loss

  • May elicit mild disorientation

  • S/S resolve within 5-15 minutes

  • Most common concussion sustained in sports


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General Concussion Classification

Grade II Concussion

  • Normal consciousness

  • Confusion

  • Post-traumatic amnesia

    • Inability to recall events that have occurred since the time of injury

  • Unsteadiness/Dizziness

  • Tinnitus

  • Headache


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General Concussion Classification

Grade II Concussion cont…

  • Post-concussion Syndrome

    • Difficulty concentrating

    • Recurring headaches

    • Irritability

  • S/S may last several weeks

  • Athlete may not return to play until all S/S are resolved


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General Concussion Classification

Grade III Concussion

  • Normal consciousness

  • Confusion

  • Post-traumatic amnesia

  • Retrograde amnesia

    • Inability to recall events that occurred before the injury


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General Concussion Classification

Grade III Concussion cont…

  • Unsteadiness/Dizziness

  • Tinnitus

  • Headache

  • Confusion


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General Concussion Classification

Grade III Concussion cont…

  • This athlete must be referred to a physician for a thorough examination

  • An intracranial lesion may be present

    • Results in intracranial bleeding

    • Causes a gradual increase in intracranial pressure


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General Concussion Classification

Grade IV Concussion

  • Loss of consciousness

  • Referred to as “Paralytic Coma”

    • Return to consciousness usually within a few seconds or minutes

  • Post-traumatic amnesia

  • Retrograde amnesia

  • Post-concussion Syndrome


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General Concussion Classification

Grade IV Concussion cont…

  • While returning to consciousness, the athlete will display states of:

    • Stupor

    • Confusion

    • Delirium

  • Medical Emergency

    • Suspect neck injury also

    • Spine board the athlete

    • Transport the athlete to the hospital immediately


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General Concussion Classification

Grade V Concussion

  • Paralytic Coma

  • Secondary cardio-respiratory collapse

  • The Glasgow Coma Scale is used to determine the state of the athlete


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Glasgow Coma Scale

Lowest score = 3, Highest score = 15


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General Concussion Classification

Grade VI Concussion

  • Death


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Secondary Conditions Associated with Concussions

  • Intracranial Hemorrhage

  • Skull Fracture

  • Epidural Hemorrhage

  • Subdural Hemorrhage

  • Intracerebral Hemorrhage

  • Cerebral Hyperemia

  • Cerebral Edema

  • Seizures

  • Migraine Headaches


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Intracranial Hemorrhage

  • Intracranial bleeding

  • Venous bleeding

    • Slow, insidious onset

  • Arterial bleeding

    • S/S apparent within a few hours


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Early S/S

Severe head pains

Dizziness

Nausea

Unequal pupil sizes

Sleepiness

Severe S/S

Deteriorating consciousness

Neck rigidity

Slow pulse

Slow respiration

Convulsions

Intracranial Hemorrhage


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Epidural Hemorrhage

  • A blow to the head causes a tear in one of the arteries of in the dural membrane that covers the brain

  • Hematoma forms extremely fast

    • Within 10 – 20 minutes after injury


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Epidural Hemorrhage

  • Requires surgery to relieve the pressure created by the hemotoma

  • Death or permanent disability may result


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Subdural Hemmorhage

  • A blow to the head causes a tear in one of the veins located between the dura mater and the brain

  • Hematoma forms slowly

    • S/S may not be appear until hours after injury


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Subdural Hemmorhage

  • Commonly occurs following a contrecoup injury

  • May or may not require surgery


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Intracerebral Hemorrhage

  • A blow to the head may cause bleeding within the brain itself

  • Usually results due to a compressive force applied to the brain

  • Rapid deterioration in neurological function

  • Requires immediate hospitalization


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Cerebral Hyperemia

  • Vasodilation of cerebral blood vessels following a head/brain injury

  • Causes an increase in intracranial blood pressure

  • Develops within minutes after the injury

  • S/S: headache, vomiting, sleepiness

  • S/S usually resolve within 12 hours after the injury


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Cerebral Edema

  • Localized swelling of the brain at the injury site

  • Develops within 12 hours after the injury

  • S/S: headache, seizures (occasionally)

  • Cerebral edema may remain for as long as 2 weeks following the injury


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Criteria to Return to Play

  • Normal neurological function

  • Normal vasomotor functions

  • Normal balance

  • Free of headaches

  • Free of lightheadedness

  • Free of dizziness

  • Free of seizures


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Criteria to Return to Play: Mild Concussion

  • First Concussion

    • Return to play if asymptomatic

  • Second Concussion

    • Must be asymptomatic for 1 week

  • Third Concussion

    • Terminate season

    • May play next year if asymptomatic


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Criteria to Return to Play: Moderate Concussion

  • First Concussion

    • Must be asymptomatic for 1 week

  • Second Concussion

    • Must be asymptomatic for 1 month

  • Third Concussion

    • Terminate season

    • May play next year if asymptomatic


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Criteria to Return to Play: Severe Concussion

  • First Concussion

    • Must be asymptomatic for 1 month

  • Third Concussion

    • Terminate season

    • May play next year if asymptomatic


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