Head Injuries & Concussion Management

1. Head Injuries & Concussion Management • The Facts • Definition • Assessment • MOI • S/S • Grading/Testing • Management • Return to Participation • Second Impact/Post-Concussion Syndrome • Other Related Injuries

2. The Facts • Concussions can Occur in Any Sport • Concussions can be Life Threatening • 2-4 million Concussions/Year • 10% of all contact sport athletes get concussed each season • After 1st Concussion, Chance of 2nd is 4X Greater***

3. Definition of Concussion • A clinical syndrome characterized by immediate and transient post-traumatic impairment of neural functions. • In English = Brain trauma that messes up your normal brain function. • MTBI: Mild Traumatic Brain Injury • Sports Concussion

4. More Concussion Facts • Injury appears to be metabolic not structural which is why CT scan is almost always normal • Headache probably caused by increased glucose demand following injury • Magnitude of force not predictor of outcome/severity of injury • Seems to be an increased risk from force on top of head? • Recovery time • Professional < College < Youth • NFL vs. Youth FB • Concussion Rate (1 /5650) • Sport with highest risk during games?

5. Where to get the best info on Concussions? • NATA.org • CDC.gov • Consensus Statement 3rd Int’l Conference on Concussion in Sport- Zurich 2008 • Clin J Sport Med 19(3), p.185-195

6. Mechanism of Injury (MOI) • Direct (Coup) • Simple Physics • Indirect • Blow to Chin • Fall in Sitting Position • Contrecoup Injury • Brain Damaged on Opposite Side of Trauma • Head Moving into Stationary Object I think he has a concussion!

7. Disorientation Dizziness Headache*** Loss of Consciousness* Nausea Tinnitus Movement/Balance Problems Blurred Vision Nystagmus (Involuntary Eye Movement) Pupil Discrepancies Post-Traumatic (Anterograde) Amnesia (PTA)* Retrograde Amnesia* Signs and Symptoms(S/S)

8. IC Concussion Management Policy • All concussions will be treated and managed on an individual basis • If an athlete describes concussion-like S/S, it will be treated as though a concussion has taken place • Once concussed, an athlete will not return to the current game or practice • The athlete should be given an on-the-field SCAT, and a follow-up IMPACT test once symptom-free

9. Pre-Participation/Baseline Testing • All athletes are asked about concussion hx during PPE • Any athlete with hx of concussion, along with athletes from the following sports will be baseline tested using IMPACT • Football, Soccer (MW), Field Hockey, Lacrosse (MW), Baseball, Softball, Gymnastics, Wrestling, Basketball(MW)

10. What is IMPACT? • A computer based neuropsychological test • Assesses memory, reaction time, and cognition • Test can be taken on any computer (with a mouse) and takes about 25-30 minutes to complete • Demo may be taken at www.impacttestonline.com/impactdemo

11. Immediate Concussion Management • On-the-field SCAT (Sport Concussion Assessment Tool) • Gross Neural Exam, Other evaluation as needed • Athlete is given Sports Concussion information sheet • Given follow-up appt with ATC or team MD • Advised to have complete mental and physical rest • Discuss do’s and don’ts • Alcohol, Meds

12. Other Special Tests • Four C’s • Cognitive • Anterograde vs. Retrograde • Counting • Cranial Nerves (12) • Eye Tests (PEARL, Vision, Tracking) • Facial Movements • Coordination • Rhomberg, Finger to Nose, Heel to Toe, Past Pointing • Consciousness • Reflex (Babinski) • Sensory (Dermatomes)

13. Criteria to Assess for RTP • Normal Neurological • Four C’s • Consciousness, Cranial Nerves, Cognition, Coordination • Myotomes/Dermatomes • Normal Vasomotor • Free of S/S (Headaches, Balance Problems) • “If you Sway, you don’t Play” • Increase in Activity doesn’t Cause S/S to Return

14. Return to Play Progression • Athletes should be asymptomatic and at/better than baseline on IMPACT before RTP • Progressive system of return • Level 1- Rest • Level 2- Light Exercise • Level 3- Sport Specific Exercise • Level 4- Non-Contact Drills • Level 5- Full Contact • Level 6- Game • Each level should take approximately 24 hours • If s/s resume, drop back to previous level once asymptomatic • Some concussions will be progressed much slower, MD controlled

15. Team Physician Decision CT Scan, Other Testing? Possible Consultation with Neuropsychologist SUNY Upstate Returning after Multiple Concussions

16. SecondImpactSyndrome • Second Impact Syndrome (SIS) • Athlete returns to play while still experiencing S/S of previous concussion, then receives another blow, causing serious injury/possible death • Typically seen in adolescent athletes • Concussions are Cumulative!! • DON’T Push for Early Return to Play. • Problems: • Little or no research on youth, parents think – CT scan means OK, youth athletes not as honest

17. Post-Concussion Syndrome • Continued disability due to one or more concussions. Examples with Professional Athletes: • Al Toon, Meryl Hoge, Chris Miller, Brett/EricLindros, Pat LaFontaine, Stan Humphries, Steve Young, Troy Aikman • Three Categories of S/S • Physical: Headache, Dizziness, Light Sensitive • Emotional: Anxiety, Depression, Anger • Cognitive: Attention, Memory

18. Possible Related Injuries • Subdural Hematoma • Epidural Hematoma • Skull Fracture • Cervical Spine Injury

19. Subdural Hematoma • Slow Venous Bleeding (Subdural Space) • Symptoms Progressively get Worse – Hours to Days • Increased BP, Decreased Pulse, One Pupil Dilated, Muscle Weakness on Opposite Side of Injury

20. Epidural Hematoma • Arterial Bleeding – High Pressure (between Skull and Brain) • Rapid Deterioration – Minutes to Hours • Similar S/S to Subdural, also Sleepiness, Convulsions

21. Skull/C-Spine Trauma • Skull Fracture • R/O Fx at Trauma Site or Away from Site • General S/S: Skin Cool and Moist, Decreased BP/Increased Pulse, and Pupil Discrepancies • Specific S/S: ‘Raccoon Eyes’, ‘Battle’s Sign’, Goose Egg, Cerebrospinal Fluid (CSF), Otorrhea/Rhinorrhea • Testing for CSF Discharge • Bull’s Eye Test/Halo Sign • Pale Yellow CSF Encircles Blood Sample • Cervical Spine Injury • Point Tender, Numbness/Tingling, Inability to Move Limbs

22. Summary • Monitor ABC’s, Recognize Concussion • History • What happened?, Previous Hx, Neck Pain, LOC?, Who are you? Where are you? • Observation • Focus, Balance, Pupils, Bleeding/CSF (Halo Sign), Trauma Signs, Verbal Ability • Palpation • Skull, Cervical Spine, Mandible, Eye Socket • Special Tests, SCAT, IMPACT • Refer, Information Sheet, F/U