Concussion Management

Over the years we’ve learned a lot about concussion in athletics. Concussion has been linked to numerous chronic problems, including depression, dementia and Parkinson’s disease.1 Substantial increases have been demonstrated in morbidity among victims who suffer multiple concussions in a short time.2 As a result, a number of sports organizations have created or revised programs aimed at increasing awareness of what has proven a significant problem. The research has prompted several medical organizations, including the National Athletic Trainers’ Association (NATA) and American Academy of Neurology (AAN), to issue position statements and work toward developing guidelines regarding concussions in athletes.3,4 This focus is one of which health professionals in the field of sports medicine are well aware. Unfortunately, EMS providers may not be as familiar with current research and practices, even though such understanding would be a great benefit to our practice.

Concussion Essentials
Concussion is classified as a mild traumatic brain injury that interrupts normal brain function.5 Though concussed patients may present with loss of consciousness, the majority do not.6 More patients will just appear dazed, and symptoms may resolve rapidly. It is this subtle neurological presentation that makes recognition of concussion a challenge. While specially trained physicians and athletic trainers are likely to be present at higher-profile professional, collegiate and even high school athletic contests, EMS providers will often be the first healthcare provider an injured athlete encounters in many other situations (e.g., youth sports events).

Further, although sports and recreation-related activities account for a substantial number of concussions, falls, motor-vehicle collisions and other mechanisms of injury commonly cause them too. As such, EMS professionals must be familiar with the recognition, treatment and disposition of at-risk patients.

Assessment of Head Injuries
As always, assessment of any head-injured patient begins with consideration of the mechanism of injury. Did your patient sustain a blow to the head? If so, how exactly did it happen, and where was the impact? Was the patient using protective equipment? Keep in mind that the use of safety equipment does not preclude significant injury.
Next direct your attention to airway, breathing, circulation and level of consciousness.5 Consider c-spine immobilization, especially in the unconscious patient, as forces that injure the head will often jeopardize the neck as well.7 Early and aggressive airway management may be indicated, particularly with serious head injuries.
Patients who experience a prolonged loss of consciousness should be transported for evaluation without delay,5 as it is impossible to differentiate concussions from more severe injuries in these patients. Aim physical examination at discovering associated injures, which should be managed promptly. Assess gross neurologic function and document the findings. Once immediate threats to life have been ruled out, the conscious patient may be thoroughly assessed for concussion, primarily by evaluating their cognitive function.

Concussion Recognition
Assessing cognition in head-injured patients need not be a difficult task. A typical patient interview will tell the clinician a great deal. Can the patient tell you their name? Can they describe the events that led up to their injury? Use specific questions to query your patient.5 Ask a young football player what team he’s playing against, or a motor vehicle crash victim where they were driving. Coaches, friends and family members on scene should be enlisted to verify the patient’s answers.5 Pay careful attention to your patient’s responses. Do they hesitate or seem to have trouble recalling? Is your patient easily frustrated? Even the most subtle change in cognition or personality may indicate concussion.
An injured patient may be assessed for antegrade amnesia by reading a simple series of words or numbers and having them repeat the series back. What physical symptoms is your patient experiencing? Headache, dizziness, nausea, confusion and tinnitus are common symptoms,7 but may not be obvious, so thorough assessment is warranted. Does the patient have a prior history of concussion? If so, apply a much higher index of suspicion for current injury. Patients who have suffered a recent concussion, particularly if symptoms remain, are at great risk for substantial complications from injury, a condition known as second-impact syndrome.2,5,6

Second-Impact Syndrome
Second-impact syndrome (SIS) is thought to occur when the brain suffers new injury before it has completely healed from a previous one. Through a complex series of autoregulatory processes, the injured brain alters its metabolic functions and blood flow to compensate for insult. These protective measures may continue for several weeks. Research suggests that injury suffered during this healing period can disrupt the brain’s ability to continue compensation, leading to unchecked cerebral edema, rapid increases in ICP, herniation and ultimately death or profound disability.2 It is important to note that neither injury needs to be particularly serious to precipitate SIS. Though the incidence of SIS is difficult to estimate, experts do not believe it’s a common condition.5 It is, however, devastating to victims and easily avoided—thereby warranting attention from EMS providers.

Education and Disposition
If a concussion is suspected, physician evaluation is indicated. As stated earlier, many concussion symptoms mimic those of more serious injuries, such as cerebral contusion and intracranial hemorrhage. Under no circumstances should a concussed patient be allowed to resume activity that involves risk of further head injury—the risk of second-impact syndrome is too great.2 Athletes should sit out until asymptomatic.4 Many sports organizations, including the NCAA, Pop Warner and numerous high school athletic associations, require that participants who suffer concussions be completely symptom-free and receive physician clearance before being allowed to return to play.8,9 A similar approach should be applied to those who suffer concussion outside the realm of sports. Patients who have suffered concussion should be monitored continuously for signs of more serious injury as discussed above. Above all, patients must be made aware of the serious nature of their injury and the very real potential for death or disability from further injury.

Conclusion
Proficiency at the assessment and management of concussion is an important skill for EMS providers at all levels. Whether the patient is an injured athlete, an elderly fall victim or a driver hurt in an MVC, concussion is a common and potentially deadly condition. Fortunately, awareness and thorough assessment techniques can help responders provide treatment and patient education, substantially mitigating the danger.

References
1. Guskiewicz KM, Marshall SW, et al. Recurrent concussion and risk of depression in retired professional football players. Medicine & Science in Sports & Exercise 39(6): 903–09, 2007.
2. Bey T, Ostick B. Second impact syndrome. Western J Emerg Med 10(1): 6–10, Feb 2009.
3. Guskiewicz K, Bruce SL, et al. National Athletic Trainers’ Association position statement: Management of sport-related concussion. J Athletic Training 39(3): 280–97, 2004.
4. American Academy of Neurology. Position Statement on Sports Concussion, www.aan.com/globals/axon/assets/7913.pdf.
5. Harmon KG. Assessment and management of concussion in sports. Am Fam Physician 60(3): 887–92, Sep 1, 1999.
6. Cantu RC. Head injuries in sport. Br J Sports Med 30(4): 289–96, Dec 1996.
7. Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care, 2nd Edition. Prentice Hall, 2002.
8. Runkle D. National Collegiate Athletic Association. Concussion Management Plan, www.ncaa.org.
9. Pop Warner Little Scholars. 2010 In Season Safety Rule Amendment Re: Concussions, www.popwarner.com/admin/pdf/2010%20Concussion%20Rule%20Change.pdf.
10. Gioia G, Collins M. Acute Concussion Evaluation, www.cdc.gov/concussion/headsup/pdf/ACE-a.pdf.
11. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guidelines for Management of Concussion/Mild Traumatic Brain Injury (mTBI), www.healthquality.va.gov/mtbi/concussion_mtbi_full_1_0.pdf.

Doug Edenburn is a paramedic from North Carolina. He works full-time for Cabarrus County EMS and part-time for the Department of Special Events and Sports Medicine at Carolina’s Medical Center-Northeast. He also teaches various EMS classes for Rowan-Cabarrus Community College in Salisbury, NC. Contact him at dedenburn@gmail.com.