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Head Injuries & Concussions

We are well into football season and I have already seen my fair share of sports related head injuries with and without concussions in the Emergency Department. As I have also had family, friends, and aquaintances ask me from time to time what constitutes a concussion or if their child needs a cat scan of their head, I figured this would be a good time to do an article on the topic of head injuries, concussions, and who typically needs a cat scan.

Disclaimer: This article is not intended to be used as a substitute for medical advice or in place of a medical evaluation in the event of a head injury. It is intended for informational / educational purposes only. Always seek medical attention/advice from your primary doctor in the event of a head injury. If there is any doubt to the severity of the injury, you cannot get in contact with your primary care doctor, or your primary advises you, call 911 and/or proceed to the nearest Emergency Department. Please read this site’s full disclaimer on the main page.

CONCUSSIONS

While concussions do not occur with every head injury, they are invariably a concern. In addition, while sports are not the only mechanism by which head injuries occur (i.e. Motor Vehicle Accidents, falls from a significant height), their incidence does tend to increase during football and hockey seasons where the number of people participating in contact sports increases. The information below will concentrate on sports related concussions, most of the information, with the exception of pre-season screening, can apply to concussions due to any mechanism.

So what is a concussion? The medical definition of a concussion is a head injury with a temporary loss of brain function. Concussions cause a variety of physical, cognitive, and emotional symptoms, which may not be recognized if subtle. Anatomically, the brain floats in cerebrospinal fluid within the skull, so when head injury occurs, the brain will slosh back and forth. This can cause the brain to actually impact the inside of the skull causing blunt injuries to the opposite side of initial impact (medically know as a coup contra-coup injury) as well as rotational forces on the brain. One of the most important aspects is that a concussion is a clinical diagnosis. This means that a concussion is diagnosed base on the history / mechanism of injury and the physical exam. It is not based on imaging which we will get into later. The general guidelines for concussions can be divided into three areas; Prevention, Recognition, and Recovery. It is also important to note that concussion guidelines may differ state to state. It is important to be familiar with your state’s guidelines. The New Jersey guidelines for sports related concussions can be found here:

http://www.nj.gov/education/aps/cccs/chpe/concussions/policy.pdf

Prevention

Prevention of concussions consists of:

1. Pre-season baseline testing: This gives each athlete a picture of their baseline mental status which can then be compared to repeat tests following a head injury during the season

2. Education of student athletes on concussion prevention

3. Reinforcement of early identification and treatment of concussions to improve recovery

4. Immediate removal of any student athlete who exhibits signs and symptoms of a concussion and they may not return to play that day

Recognition

Recognizing a concussion further consists of two parts, signs and symptoms.

Signs are issues observed by the coach, trainer, team physician, or school nurse and may include:

1. Appearing dazed, stunned, or disoriented

2. Forgets plays, or demonstrates short term memory difficulty

3. Exhibits difficulties with balance or coordination

4. Answers questions slowly or inaccurately

5. Loses consciousness

Symptoms are issues reported by the athlete and may include:

1. Headache

2. Nausea/Vomiting

3. Balance problems or dizziness

4. Double vision or changes in vision

5. Sensitivity to light or sound/noise

6. Feeling sluggish or foggy

7. Difficulty with concentration and short term memory

8. Sleep disturbance

9. Irritability

In the event of a head injury associated with the above signs and symptoms the athlete…

1. Should be immediately removed from competition or practice

2. Should be evaluated immediately by a physician or school’s licensed health care provider

3. Should have 911 called and be taken to the nearest Emergency Department for evaluation if symptoms worsen, patient experiences a loss of consciousness, patient complains of neck pain, there is not physician / health care provider on scene, or if recommended by on scene physician / health care provider

Recovery

Recovery from a concussion is a slow, graduated process that involves input from everyone involved in the student athletes care including but not limited to a physician trained in the treatment of concussions, school nurse, athletic trainer, and coaches. It includes a slow re-introduction to not only athletics but also day to day school activities, as mental and cognitive stress are just as important to limit as physical stress. Both mental and physical stressors can adversely affect the athlete and delay recovery.

In general, any student must remain symptom free for at least a week since their last symptom before returning to competition. For example, if the last concussion symptom an athlete experiences is vomiting and only three days pass before vomiting returns, the one week clock starts again. The athlete must wait a week from the resolution of the second episode of vomiting. This is because the greatest risk of long term brain injury occurs if an athlete sustains a second head injury while still recovering from a concussion. The basic tenants of recovery include:

1. The athlete is advised, while experiencing symptoms and signs of a sports-related concussion or other head injury, to have complete physical, cognitive, emotional, and social rest (Minimize mental exertion, limiting overstimulation, multi-tasking etc.)

2. Upon resolution of signs/symptoms and re-evaluation by a physician trained in the treatment of concussions, the athlete requires written clearance that the athlete is without symptoms at rest and may start the graduated return to play protocol. This protocol should also include changes in daily school activities to lessen any mental / cognitive stressors

3. If any concussion symptoms return during the graduated return to play protocol, the athlete is to return to the previous level of activity that did not cause symptoms

4. If any concussion symptoms return after being cleared for normal physical activity, the athlete is to be removed from any further exertional activities and re-evaluated by their physician

5. Medical clearance to return to normal training activities is done by consultation between the athlete’s physician, athletic trainer, team physician, and school nurse

While research into concussions is always ongoing, we know a great deal more than we did even twenty years ago. Adherence to these guidelines is vital to protect student athletes and allow them the chance to make a full recovery and prevent / minimize long term cognitive issues.

CAT SCANS

It’s difficult to talk about head injuries and concussions without also discussing Cat Scans of the brain. While many head injuries, sports related and otherwise, will get a Cat Scan of the brain it is important to know that a much smaller percentage of head injuries actually need one. As mentioned earlier, a concussion is a clinical diagnosis which means to diagnosis a concussion, a Cat Scan is not required. There is no abnormality seen on a Cat Scan that a physician or health care provider will point to and say “there is the concussion”. However, there are times when a Cat Scan is needed to rule out other, more worrisome, conditions associated with head injuries. Like concussions, the need for CT scans of the brain has been well studied and as a result there is an excellent understanding for when they are needed, and also medical guidelines for them as well. As you will see, the red flags we associate with other more serious traumatic brain injuries have overlap with concussion symptoms. This is why in the setting of concussions, sometimes CT scans are needed, and sometimes they are not.

In keeping with our talk on concussions, the guidelines for head CT’s we will be reviewing will be specific to children and teenagers. These guidelines cannot be used for the elderly, patient’s on blood thinners, or patient’s with these symptoms in the absence of a head injury. The signs and symptoms that parents, coaches, team physicians, school nurses, and teachers should be aware are divided into two age groups, under 2 years old and over 2 years old. While young children and toddlers are not participating in contact sports, they are still prone to head injuries via other mechanisms that require evaluation.

Head Injury Over 2 Years Old

Requires a CT Scan of the brain:

1. Bruising around both eyes (raccoon eyes) or behind the ears (Battle Signs)

2. Altered Mental Status: Agitation, slow response, repetitive questions, amnesia, excessive sleepiness

CT Scan of brain vs. Observation:

1. Vomiting

2. Loss of Consciousness

3. Severe Headache

4. Severe Mechanism Of Injury: Fall from more than 5ft, MVA with ejection from vehicle / roll over / fatality, bike/pedestrian MVA w/o helmet, struck by high impact object

In these cases, the decision to do a CT scan vs observing is shared between the health care provider and parent/patient. The factors involved are multiple vs. isolated mechanisms, worsening findings during observation, abnormal neurological exam, physician experience, and parental preference.

Head Injury Under 2 Years Old

Requires a CT Scan of the brain:

1. Palpable skull fracture or obvious deformity to skull

2. Altered Mental Status: Agitation, slow response, repetitive questions, excessive sleepiness

CT Scan of brain vs. Observation:

1. Vomiting

2. Loss of Consciousness greater than 5 seconds

3. Scalp hematoma (except frontal)

4. Not acting normally per parent

5. Severe Mechanism Of Injury: Fall from more than 3ft, MVA with ejection from vehicle / roll over / fatality, bike/pedestrian MVA w/o helmet, struck by high impact object

In these cases, the decision to do a CT scan vs observing is shared between the health care provider and parent/patient. The factors involved are multiple vs. isolated mechanisms, worsening findings during observation, abnormal neurological exam, physician experience, parental preference, or patient less than 3 months old.

Again, this information is not to take the place of medical advice or examination by a health care provider. In the absence of these findings a phone consultation to your pediatrician should at least be done. Keep in mind your pediatrician may still ask that you have your child evaluated in the ER as they cannot do a full evaluation by phone. The material presented here is for informational purposes only and intended to educate and help those understand the factors that go into medical evaluation of concussions and deciding whether a patient needs a CT scan. As a parent, if there is ever any doubt, call 911 or bring you child to the Emergency Department. As health care providers, we would prefer to take the time to reassure patients and parents or observe them in the ER rather than have someone stress over whether or not to come to the ER.

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The balance of medicine

While the linked article centers around Emergency Medicine clinicians, the gist of the article is applicable to any field of medicine. Not every symptom / condition requires the most expensive test or any test at all for that matter. The point being, just as one should be weary of clinicians who prescribe a pill for every issue, one should be weary of clinicians who refer patients for tests with every issue. Tests are not always necessary and in the case of multiple radiological studies, they can be dangerous down the line. Multiple and frequent tests can certainly increase healthcare costs as well. In my own practice, I’m very conscious in trying to minimize the use Cat Scans and X-Rays when not necessary while not withholding them in cases where they are indicated. For instance, x-rays for fractures to the nose and tailbone are almost never needed. Likewise, back x-rays in the setting of most injuries almost never yield useful findings. Even Cat Scans, especially in children, need to be carefully considered. With a good history and use of an accepted screening tool like the Canadian Head CT Rule, many head injuries do not require a CT scan. And in cases of suspected appendicitis in children, an ultrasound can sometimes make the diagnosis and spare the radiation exposure (though it can’t rule out the diagnosis, so a CT scan may still be needed). Sometimes, even a period of observation or having a patient come back for a second examination is an acceptable alternative. So, if your primary care provider is alway ordering tests, remember you have the right to take an active part in your care. Ask why that particular test, what will it diagnose, what can it rule out, and are there any alternatives that can utilized. A confident and competent clinician should not object or take offense to such questions.

http://online.wsj.com/news/articles/SB10001424052702303519404579354813030233586?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702303519404579354813030233586.html

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