A concussion itself may seem mild, but the potential consequences and sequelae of a concussion can be dangerous and even deadly.
The incidence of concussions has been rising. Estimates put the annual incidence in the United States at 1.6 to 3.8 million.1 The actual incidence may be much higher because of the propensity of athletes to underreport their injuries, either because they do not understand the severity of the injury or they fear they will be forced out of the game by referees and coaches.2
The potentially deadly consequences of concussions and the lack of public knowledge about them mandate that clinicians be able to properly diagnose a concussion and that they be up to date on current management and return-to-play guidelines.
RECOGNIZING A CONCUSSION
Signs and symptoms of concussion may not appear until several hours after the initial insult.3 These symptoms can be short-lived or persist for many weeks.2 Common complaints include headaches, drowsiness, irritability, cognitive impairments, emotional lability, amnesia, and/or ataxia.3 One common misconception is that loss of consciousness (LOC) almost always follows a concussion. In fact, LOC occurs in less than 9% of concussed patients.4
The Pocket Sports Concussion Assessment Tool 2 (SCAT2) is easy to use for early evaluation of any patient older than 10 years.2,3 SCAT2 includes a symptom scale, a mental status test, and a balance assessment and can be administered to players on the sidelines.2 The checklist can be used both to quantify symptoms as they resolve and to flag symptoms that require direct treatment. Having a baseline symptom checklist is ideal because many symptoms, such as lack of concentration, can predate an injury.1
SECOND IMPACT SYNDROME
The most significant danger of concussions arises when the brain suffers a secondary trauma before fully recovering from the primary insult. The most feared and deadly result of such potential secondary injuries is second impact syndrome.5 When a patient suffers an initial blow to the head, even a minor one, cerebral arterial tone can be lost and, with it, the ability to control cerebral BP.5 The primary insult does not cause any serious or prolonged effects unless there is a subsequent and severe increase or decrease in BP.5 If a patient returns to activities before fully recovering and is hit again, the surge of catecholamines that occurs with any traumatic event will produce a rapid and profound increase in BP.5 The cerebral arteries will be unable to compensate for the pressure change, and the patient is at risk of either cerebral hypoperfusion or cerebral engorgement. Cardiac and respiratory collapse and even death may follow.5
ASSESSMENT AND
MANAGEMENT
Concussion management requires physical and cognitive rest until symptoms resolve, followed by progression through an individualized program of step-by-step increases in physical exertion before achieving medical clearance and return to play.3 In addition, patients should undergo computer-based neurocognitive assessment within 72 hours of concussion and then again in 5 to 7 days.6 Neurocognitive assessment tools, such as ImPACT, CogSport, or HeadMinder, test memory, processing speed, visuomotor and visuospatial abilities, executive planning, and attention. These tests can accurately identify neurocognitive deficits in someone who is otherwise asymptomatic but still not ready to return to play.6
Standard structural brain imaging
techniques usually show nothing remarkable following concussions.6
CT and MRI contribute little to the
evaluation because the injury is functional, not structural.6 These techniques should be used only if there is suspicion of an intracerebral bleed. Examples of situations in which a CT or MRI may be required include a prolonged disturbance of consciousness, focal neurologic deficits, or progressively worsening symptoms.3
BOTTOM LINE
Concussions must be treated appropriately. Allowing for adequate recovery time is crucial to avoid the detrimental effects of second impact syndrome. JAAPA
Mary L. Hewitt, PA-C, MS, department editor
REFERENCES
1. d'Hemecourt P. Subacute symptoms of sports-related concussion: outpatient management and return to play. Clin Sports Med. 2011;30(1):63-72.
2. Ferullo SM, Green A. Update on concussion: here's what the experts say. J Fam Pract. 2010;59(8):428-433.
3. McCrory P, Meeuwise W, Johnston K, et al. Consensus statement on concussion in sport—the 3rd International Conference on concussion in sport, held in Zurich, November 2008. J Clin Neurosci. 2009;16(6):755-763.
4. Piebes SK, Gourley M, Valovic McLeod TC. Caring for student-athletes following a concussion. J Sch Nurs. 2009;
25(4):270-281.
5. Wetjen NM, Pichelmann MA, Atkinson JL. Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg. 2010;211(4):553-557.
6. Johnson EW, Kegel NE, Collins MW. Neuropsychological assessment of sport-related concussion. Clin Sports Med. 2011;30(1):73-88.
A concussion is a type of mild traumatic brain injury that may be caused by either a fall; a direct blow to the head, face, or neck; or a blow elsewhere on the body that transmits force to the head. The injury shakes the brain inside the skull. Concussions are common among sports participants, especially people who play high-contact sports like football, boxing, wrestling, or lacrosse.
Click NEXT for Patient Information.