Embed Size (px)
Citation preview
Closed Head Injury
Martin V. Pusic MD
Children’s & Women’s Health Centre
Division of Emergency Medicine
Outline
Concussion Intracranial Hemorrhage Diffuse Axonal Injury Brain Contusion
Concussion
Contents
Defining concussion Anatomy of concussion Mechanisms of concussion Evaluation Management recommendations Return to play
Richard Zednik
Concussion
Definition
A concussion is an alteration of mental status due to biomechanical forces affectingthe brain. A concussion may or may not cause loss of consciousness.
Facts About Concussion Centers for Disease Control and Prevention
(CDC) estimates 300,000 sports-related concussions occur per year– 100,000 in football alone
An estimated 900 sports-related traumatic brain injury deaths occur per year
Facts About Concussion
Concussion occurs most often in males and children, adolescents and young adults
Risk of concussion in football is 4-6 times higher in players with a previous concussion
Facts About Concussion Concussions per every 100,000 games and/or
practices at the collegiate level– Football: 27– Ice Hockey: 25– Men’s soccer: 25 – Women’s soccer: 24– Wrestling: 20– Women’s basketball: 15– Men’s basketball: 12
(Head and Neck Injury in Sports, R.W. Dick)
Anatomy of Concussion
The brain is a jello-like substance vulnerable to outside trauma.
Skull protects the brain against trauma, but does not absorb impact forces.
Anatomy of Concussion
Cervical spine -- allows the head to rotate to avoid blunt trauma
– However, rotational forces can be the most damaging during concussion
Two Primary Mechanisms of Concussion
Linear - Example: A quarterback falls to the ground and hits the back of his head. The falling motion propels the brain in a straight line downward.
Rotational- Example: When a football player is tackled, his head may strike an opponent’s knee; this contact to the head can cause arotational motion.
Immediate Signs of Concussion(occurring within seconds to minutes)
Impaired attention -- vacant stare, delayed responses, inability to focus
Slurred or incoherent speech Gross incoordination Disorientation Emotional reactions out of proportion Memory deficits Any loss of consciousness
Later Signs of Concussion(occurring within hours to days) Persistent headache Dizziness/vertigo Poor attention and concentration Memory dysfunction Nausea or vomiting Fatigue easily Irritability Intolerance of bright lights Intolerance of loud noises Anxiety and/or depression Sleep disturbances
Post Concussion Syndrome
Lingering symptoms and continuing cognitive deficit following a concussion injury
– May occur for weeks or months after injury– Associated with concussion Grades 2 & 3
Related Brain Tissue Injuries
Hematoma -- blood clot Contusion -- brain bruises Brain swelling and
diminished blood flow to sensitive brain tissues
How is Concussion Assessed?
AAN guidelines for sideline evaluation Standardized Assessment of Concussion
(SAC) for sideline use Standard neuropsychological tests Computerized reaction time tests
AAN Sideline Evaluation Mental status testing
- Orientation, concentration, memory
Exertional provocative tests - 40-yd. dash, push-ups, sit-ups, knee-bends
Neurological tests - Strength, coordination/agility, sensation
Neurology, March 1997
Grade 1 Concussion
Transient confusion NO loss of consciousness Concussion symptoms or mental status
abnormalities resolve in less than 15 minutes
Management RecommendationsGrade 1
Remove from contest Examine immediately and at 5-minute
intervals for the development of mental status abnormalities or post-concussive syndrome at rest and with exertion
May return to contest if mental status abnormalities or post-concussive symptoms clear within 15 minutes
Grade 2 Concussion
Transient confusion NO loss of consciousness Concussion symptoms or mental status
abnormalities last more than 15 minutes
Management RecommendationsGrade 2
Remove from contest; disallow return that day Examine on-site frequently for signs of evolving
intracranial pathology A trained person should reexamine the athlete
the following day A physician should perform a neurologic exam to
clear the athlete for return to play after 1 full asymptomatic week at rest and with exertion
Grade 3 Concussion
Any loss of consciousness, either brief (seconds) or prolonged (minutes)
Investigations
CT, MRI – rule out other conditions
PET Scan
Investigations
PET Scan
Management RecommendationsGrade 3
Transport from the field to the nearest emergency department by ambulance if still unconscious or worrisome signs are detected (with cervical spine immobilization, if indicated)
A thorough neurologic evaluation should be performed emergently, including neuroimaging procedures when indicated
Admit to hospital if any signs of pathology are detected or if the mental status remains abnormal
When to Return to Play
Grade of concussion Grade 1 15 minutes or less Multiple grade 1 1 week Grade 2 1 week Multiple grade 2 2 weeks Grade 3 2 weeks Multiple grade 3 1 month or longer
Treatment
The treating physician can utilize a variety of treatment options including:– Analgesics for pain – Sleeping medication – Muscle relaxants– Rehabilitation therapies
Second Impact Syndrome Second concussion occurs while still
symptomatic & healing from previous injury days or weeks earlier
Loss of consciousness not required Second impact more likely to cause brain
swelling and other widespread damage Can be fatal -- 50% mortality rate in most
severe cases Higher risk of long-term cognitive dysfunction
Case Study
17-year-old high school football player Suffered concussion without loss of
consciousness during a varsity game Complained of headache throughout the
next week Received no further injuries and did not
seek medical attention
Case Study
Next game– A week after first concussion
While carrying the ball, he was struck on the left side of his helmet by the helmet of his tackler
He was stunned, but mental functions appeared to clear quickly during a brief time out on the field
Case Study
He was given the ball during the next play His helmet made only slight contact with
one of several tacklers during the play He arose from the pile of players under his
own power then fell unconscious into the arms of a teammate
Case Study
He arrived at the local hospital unresponsive, pupils fixed and dilated
All treatment efforts were unsuccessful Brain pressure rose stopping blood flow to the
brain 15 hours after his loss of consciousness he
was pronounced dead (Kelly, et al, JAMA, November 27, 1991)
Prevention Goals Identification and education
It’s important to educate others about ways to prevent concussion before it happens
Implementing sideline evaluations & treatment recommendations– Recognize and treat post concussion syndrome– Prevent second impact syndrome– Prevent further morbidity– Prevent fatal injury
Prevention Tools
Rule changes– Play smart, keep the head safe by making
penalties tougher Use helmets and other protective equipment Design changes for protective equipment Ongoing research
– education, risk factors, early detection of concussion using SAC
Goals for the Future
Eliminate fatalities -- second impact syndrome Prevent morbidity -- post concussion syndrome Preserve brain function -- enable young players to
reach their full potential in life! Make sports safer Increase awareness about sports-related
concussions
Cerebral Hemorrhage
Case 1
4 yo male struck by a car when he ran across street. Thrown 10 feet. In ER, he opens his eyes when you ask him, he is not moving much but he pulls his arm away from the nurse as she starts an IV. He is moaning on the ER table.
What is his GCS?
Glasgow Coma ScaleEye Opening Verbal Motor
6 Follows commands
5 Oriented Localizes
4 Spontaneous Confused Withdraws
3 To verbal Inappr words Flexion
2 To pain Nonsp sounds Extension
1 none None none
Modified GCS for InfantsEye Opening Verbal Motor
6 Spontaneous
5 Coos, babbles Withdraws to touch
4 Spontaneous Irritable, cries Withdraws to pain
3 To speech Cries to pain Abn flexion
2 To pain Moans to pain Abn extension
1 none None none
Pathophysiology
Epidural– middle meningeal artery/vein, dural sinus
Subdural– tear of bridging veins/dura
Subarachnoid– blood enters CSF
Axonal injury– disruption of axons/blood vesselsbrain edema
Classification: Minor HI
Mild Moderate Severe
No LOC LOC <5 min LOC >5 min
Normal physical
exam
Normal physical exam
One or more high risk criteria
Initial GCS 15 GCS 13 -15 GCS < 13
Minor soft tissue injuries
High Risk Criteria
1. Altered LOC: unconsciousness, GCS<13
2. Local bony abnormalities
Skull fracture
FB with/without laceration
Puncture wound
3. Evidence of Basal Skull Fracture
Hemotympanum
Battle sign
Racoon’s eyes
High Risk Criteria (cont)
4. Unexplained neurological signs
5. Hx previous craniotomy with shunt
6. Post-traumatic amnesia
7. Severe/worsening headache
8. Post-traumatic seizure
9. Blood dyscrasia/anticoagualants
Case 1
4 yo male struck by a car when he ran across street. Thrown 10 feet. In ER, he opens his eyes when you ask him, he is not moving much but he pulls his arm away from the nurse as she starts an IV. He is moaning on the ER table.
What is his GCS?
Case 2
Death of young girl by flying puck leads to calls for safety standards By DONNA SPENCER
March 19, 2002 DONNA SPENCER,
The Canadian Press
Case 2
Case 2 – Epidural Hematoma
• Lucent Interval?
•ABC
•Hyperventilation
•Mannitol
•Surgical Decompression
Case 3 – Subdural Hematoma
Afebrile one-year old presents with irritability, lethargy for two days.
At the outset had sustained a 3-foot fall onto his head
Case 3
Case 3
Always consider:
CHILD ABUSE
Case 4
A 9-year old suddenly collapses while playing pickup football.
Case 4 – Subarachnoid Hemorrhage
A 9-year old suddenly collapses while playing pickup football.
Case 5
An 8-year old hits his head during a high-speed motor vehicle collision
An 8-year old hits his head during a high-speed motor vehicle collision
Case 5
Case 5 – Diffuse Axonal Injury White Matter
of the Brain– Nerve cells are
connected by axons (long projections of nerve cells resembling insulated wiring) which connect neurons to other neurons
Management
Airway Breathing Circulation, Cervical Spine Precautions Dextrose Manage Raised ICP
