Head Injuries &
Concussion Management
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The Facts
Definition
Assessment
– MOI
– S/S
– Grading/Testing
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Management
– Return to Participation
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Second Impact/Post-Concussion Syndrome
Other Related Injuries
The Facts
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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***
Definition of Concussion
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A clinical syndrome characterized by immediate
and transient post-traumatic impairment of neural
functions.
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In English = Brain trauma that messes up your
normal brain function.
MTBI: Mild Traumatic Brain Injury
Sports Concussion
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More Concussion Facts
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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?
Where to get the best info on
Concussions?
NATA.org
 CDC.gov
 Consensus Statement 3rd Int’l Conference
on Concussion in Sport- Zurich 2008
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– Clin J Sport Med 19(3), p.185-195
Mechanism of Injury (MOI)
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Direct (Coup)
– Simple Physics
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Indirect
– Blow to Chin
– Fall in Sitting Position
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Contrecoup Injury
– Brain Damaged on Opposite Side of Trauma
– Head Moving into Stationary Object
I think he has a concussion!
Signs and Symptoms(S/S)
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Disorientation
Dizziness
Headache***
Loss of
Consciousness*
Nausea
Tinnitus
Movement/Balance
Problems
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Blurred Vision
Nystagmus
(Involuntary Eye
Movement)
Pupil Discrepancies
Post-Traumatic
(Anterograde)
Amnesia (PTA)*
Retrograde Amnesia*
IC Concussion Management
Policy
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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
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
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– Football, Soccer (MW), Field Hockey,
Lacrosse (MW), Baseball, Softball,
Gymnastics, Wrestling, Basketball(MW)
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
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Immediate Concussion
Management
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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
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Alcohol, Meds
Other Special Tests
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Four C’s
– Cognitive
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Anterograde vs. Retrograde
Counting
– Cranial Nerves (12)
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Eye Tests (PEARL, Vision,
Tracking)
Facial Movements
– Coordination
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Rhomberg, Finger to Nose, Heel to
Toe, Past Pointing
– Consciousness
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Reflex (Babinski)
Sensory (Dermatomes)
Criteria to Assess for RTP
1) Normal Neurological
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Four C’s
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Consciousness, Cranial Nerves, Cognition, Coordination
Myotomes/Dermatomes
2) Normal Vasomotor
3) Free of S/S (Headaches, Balance Problems)
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“If you Sway, you don’t Play”
4) Increase in Activity doesn’t Cause S/S to Return
Return to Play Progression
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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
Returning after Multiple Concussions
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Team Physician Decision
CT Scan, Other Testing?
Possible Consultation with Neuropsychologist
– SUNY Upstate
Second Impact Syndrome
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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:
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Little or no research on youth, parents think – CT
scan means OK, youth athletes not as honest
Post-Concussion Syndrome
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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
Possible Related Injuries
Subdural Hematoma
 Epidural Hematoma
 Skull Fracture
 Cervical Spine Injury
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Subdural Hematoma
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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
Epidural Hematoma
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Arterial Bleeding – High
Pressure (between Skull
and Brain)
Rapid Deterioration –
Minutes to Hours
Similar S/S to Subdural,
also Sleepiness,
Convulsions
Skull/C-Spine Trauma
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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
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Cervical Spine Injury
– Point Tender, Numbness/Tingling, Inability to Move
Limbs
Summary
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Monitor ABC’s, Recognize Concussion
History
– What happened?, Previous Hx, Neck Pain, LOC?, Who
are you? Where are you?
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Observation
– Focus, Balance, Pupils, Bleeding/CSF (Halo Sign),
Trauma Signs, Verbal Ability
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Palpation
– Skull, Cervical Spine, Mandible, Eye Socket
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Special Tests, SCAT, IMPACT
Refer, Information Sheet, F/U