Authors: Mark T. Bamman, MD (EM Resident Physician, Advocate Christ Medical Center), Kelly Williamson, MD (EM Attending Physician, Advocate Christ Medical Center), and Andrej Urumov, MD (EM Attending Physician, Advocate Christ Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)
Washington, 2006 – The whistle blew and 13 year-old Zach Lystedt lay clutching his helmet with both hands; he had just made a tackle in his junior high school football game. He was able to make it to the sideline, where he sat out the next three plays and the game went to halftime. Zach was back in the game for the start of the third quarter, and after several more hits throughout the second half, he collapsed on the field. He was suffering from significant cerebral edema requiring emergent craniectomy as a result of premature return to play following a concussion, which ultimately resulted in devastating neurologic damage. Zach’s life following these injuries has consisted of a tireless battle to not only regain basic neurologic functions, but also to raise awareness about the dangers of concussions. He and his family spearheaded a campaign, which, in 2009 in the state of Washington, resulted in the passage of the first comprehensive concussion safety law for youth sports, aptly named the Zachary Lystedt Law. Since 2009, all 50 states have adopted similar legislation regarding concussions in sports and return to play protocols in conjunction with the Center for Disease Control and Prevention’s Heads Up campaign. The American Medical Society for Sports Medicine, the American Academy of Neurology, and the 4th International Conference on Concussion in Sport have each published consensus statements on concussion in sport.
Sports-related concussions are serious, widely prevalent, and often underreported traumatic brain injuries with potential for significant long-term deleterious effects on the athlete and beyond. A systematic approach for both sideline and emergency department evaluation is recommended to ensure proper recognition and management of concussions to mitigate impact.
Concussion is broadly defined as any disturbance of normal brain function resulting from head trauma, and it is commonly considered to be a mild traumatic brain injury (TBI). Sports related concussion (SRC) is that which occurs during participation in a sporting event.
Clinical features of SRC are numerous and diverse. Signs and symptoms may be best thought of in categories of physical, cognitive, and emotional disturbances.
Loss of consciousness, gross motor incoordination, vacant stare, vomiting, slurred speech, motor weakness, delayed cognitive response
Physical – numbness, tingling, blurred vision, headache, dizziness, nausea, fatigue, photophobia, phonophobia, drowsiness, insomnia
Cognitive – amnesia, attention difficulty, disorientation, word finding difficulty
Emotional – emotional lability or inappropriate emotionality, anxiety
Annual incidence of SRC is estimated between 1.6-3.8 million cases per year. This likely represents an underestimation, however, as many athletes who suffer mild concussions do not seek medical attention. The highest incidence of SRC occurs with college football for males (3.02/1000 games) and college soccer for females (1.8/1000 games). The financial impact of SRC may be best illustrated by the 2013 legal settlement in which the National Football League (NFL) agreed to pay $765 million to an estimated 18,000 former players as compensation for those who suffered concussions and secondary sequelae while playing in the NFL.
An athlete who demonstrates any signs or symptoms of concussion should be immediately removed from play and evaluated by a physician or other licensed healthcare provider using a validated sideline assessment tool. Recommended tools include the Sport Concussion Assessment Tool 3rd Edition (SCAT3) and the Standardized Assessment of Concussion (SAC). There are also several validated tools that are specific to pediatrics, such as the Child-SCAT3. These tools are best interpreted in context of a baseline score; therefore all athletes should have baseline testing performed prior to the beginning of an athletic season. If the athlete is suspected to have a concussion based on these assessment tools, then he or she should not be allowed to return to play on the day of the injury.
Indications for emergency department (ED) evaluation:
-Prolonged loss of consciousness (>1 minute)
-Concern for cervical spine injury
-High-risk mechanism for intracranial hemorrhage
Including but not limited to: high velocity impact, fall from significant height
-Findings suggestive of skull fracture
-Any significant worsening of the athlete’s condition
Emergency department evaluation
Patients in the ED should be assessed with a complete history and physical exam, with particular attention paid to neurologic and neuropsychological evaluation. Physicians can again utilize the SCAT3 and SAC tools.
Advanced imaging, such as CT-head/brain, should be performed for any patient at increased risk of intracranial hemorrhage. There are several validated decision rules available, including the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC), that should be used to risk stratify patients with SRC and determine whether or not to perform imaging. Comparisons of these decision tools demonstrate that the CCHR and NOC are equally highly sensitive for significant brain injuries and injuries needing neurosurgical intervention, but the CCHR has higher specificity. Any patient who demonstrates an acute change in neurologic status while in the ED should have CT-head/brain performed.
The mainstay of concussion management is rest, both physical and cognitive. The athlete should abstain from any strenuous physical or cognitive activity for a minimum of 24 hours and should not resume activities until the acute concussive symptoms have resolved. Following the resolution of acute concussive symptoms and the minimum rest period, the athlete can begin the stepwise return to play (RTP) protocol outlined below. Cognitive rest is less strictly defined, and may include restriction of computers, cell phones, video games, music, and advanced mental activities depending on severity of symptoms.
Pharmacologic management of acute concussive symptoms is not extensively studied, but it is generally recommended to avoid any substance, prescription or otherwise, that can potentially alter the patient’s neurologic status (e.g. opioids, benzodiazepines, alcohol, illicit drugs). Medications that are likely safe in the treatment of acute concussive symptoms, such as headache, include acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs). Post-concussive nausea is unlikely to require pharmacologic therapy, but if symptoms are severe, then administration of low dose ondansetron is reasonable and likely safe.
Patient disposition is determined by CT-head findings and presence or absence of high risk factors. If the CT-head is abnormal, then the patient should be admitted, with neurosurgical consultation as appropriate. If the CT-head is normal, then the patient can be safely observed as an outpatient if there is an absence of any high risk factors (i.e. GCS < 15, bleeding diathesis, anticoagulant use, seizures, no responsible caregiver at home). If any of these high risk factors are present, then the patient should be admitted and observed on an inpatient basis, even in the presence of a normal CT-head. Patients who do not meet criteria for performance of CT-head based on CCHR or NOC can be safely observed at home.
Outpatient observation instructions:
- There must be a responsible party available for observation for 24 hours
- The observer should seek prompt medical attention if the patient develops any of the following signs or symptoms:
– Inability to awaken the patient
– Severe or worsening headaches
– Somnolence or confusion
– Restlessness, unsteadiness, or seizures
– Difficulties with vision
– Vomiting, fever, or stiff neck
– Urinary or bowel incontinence
– Weakness or numbness involving any part of the body
- The patient should be re-evaluated within the next 1-2 days by a physician
Note: It is neither necessary nor recommended to wake the patient during sleep for repeated evaluation. Rather, the responsible party should simply observe the patient’s sleep behavior for signs of distress. If no evidence of distress, then the patient should be allowed to sleep.
Return to play
A graduated RTP protocol is recommended, as endorsed by the 2012 International Conference on Concussion in Sport. With the following stepwise protocol, each stage should last at least 24 hours, and the athlete can advance to the next stage provided that he or she is asymptomatic. If any concussive or post-concussive symptoms are present, then the athlete should regress to the previous stage following a 24-hour period of rest.
Table 1: Graduated return to play protocol
|Rehabilitation stage||Functional exercises||Objective|
|1. No activity||Symptom limited physical and cognitive rest||Recovery|
|2. Light aerobic exercise||Walking, swimming, or stationary cycling keeping intensity <70% maximum permitted heart rateNo resistance training||Increase HR|
|3. Sport-specific exercise||Skating drills in ice hockey, running drills in soccer.No head impact activities||Add movement|
|4. Non-contact training drills||Progression to more complex training drills, e.g. passing drills in football and ice hockeyMay start progressive resistance training||Exercise, coordination, and cognitive load|
|5. Full-contact practice||Following medical clearance, participate in normal training activities||Restore confidence and assess functional skills by coaching staff|
|6. Return to play||Normal game play|
Post-concussive syndrome (PCS) – Loosely defined and somewhat controversial, PCS is estimated to occur in up to 80% of patients who experience mild TBI. Clinical features include headaches, dizziness, vertigo, cognitive difficulties, and emotional/psychological changes.
Second impact syndrome (SIS) – A rare and potentially fatal complication of concussion, SIS is a condition thought to involve diffuse cerebral edema secondary to a recurrent or second concussion while the patient is still symptomatic from the first insult.
Post-traumatic epilepsy (PTE) – The incidence of seizures following TBI is increased compared to the general population and is largely dependent on the severity of the injury, with more severe injuries more likely to be associated with PTE. Of note, routine pharmacologic prophylaxis with antiepileptic medications is not recommended, as it has not been shown to effectively prevent seizures.
Chronic traumatic encephalopathy (CTE) – Suspected to be secondary to the cumulative effects of multiple, repeated concussions and TBI in general, CTE involves degenerative cognitive, neurologic, and neuropsychological changes that result in increased rates of behavior and personality changes, depression, suicidality, parkinsonism, dementia, Alzheimer’s dementia, speech and gait abnormalities, and cognitive impairment. While the likelihood of CTE increases with increased frequency of concussion, there is no established threshold number of concussions that has been shown to result in CTE.
With the current body of knowledge regarding the significant adverse effects of SRC, the most impactful intervention to reduce morbidity and mortality is prevention. Advances in helmet technology and sport specific rule changes are aimed at SRC prevention, while RTP protocols are aimed at reducing secondary effects from premature return to competition following an existing concussion. Furthermore, the Heads Up campaign and state legislation are aimed at early recognition of concussions with proper initiation of RTP protocols.
References / Further Reading
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Boutis, Kathy, Kirstin Weerdenburg, Ellen Koo, Suzan Schneeweiss, and Roger Zemek. “The Diagnosis of Concussion in a Pediatric Emergency Department.” The Journal of Pediatrics 166.5 (2015).
Brolinson, P. Gunnar. “Management of Sport-Related Concussion.” Clinical Journal of Sport Medicine 24.1 (2014): 89-90.
CDC. The Zack Lystadt Law: A Concussion Survivor’s Return to Play (n.d.): n. pag. The Lystedt Law: A Concussion Survivor’s Journey. Center for Disease Control and Prevention. Web. 25 July 2015.
Chen, Yenting. “Comparison of the Canadian CT Head Rule and the New Orleans Criteria in Patients with Minor Head Injury.” The Journal of Emergency Medicine 30.4 (2006): 478.
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