Transcript Joint Section of Neurotrauma & Critical Care

Joint Section on
Neurotrauma and Critical
Care on Traumatic Brain
Injury in Sports
Joint Section of Neurotrauma & Critical Care
Joint Section of
Neurotrauma &
Critical Care
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Objective
1. What is mild Traumatic Brain Injury?
2. Recognition & response to mild TBI
3. Understanding of potential long-term effects
4. Return to play decisions
5. Prevention of Sports-Related TBI
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Neurotrauma &
Critical Care
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About TBI
 In the United States
 one person incurs a traumatic brain injury
 every 21 seconds.
 Every 5 minutes
 one person will die and another will become
permanently disabled due to a brain injury.
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Neurotrauma &
Critical Care
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About TBI
 TBI accounts for 1/3 of all injury-related deaths in the
United States.
 About 75% of TBI’s that occur each year are
concussions or other forms of mild TBI.
 The number of people with TBI who are not seen in an
emergency department or who receive no care is
unknown.
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Neurotrauma &
Critical Care
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About TBI
 TBI can be categorized by severity
 Mild – concussion, confused
 Moderate – consciousness is more impaired
 Severe – patient is in a coma
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Neurotrauma &
Critical Care
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“Traumatic Brain Injury in the United States: Emergency Department
Visits, Hospitalizations and Deaths 2002-2006”
www.cdc.gov/TraumaticBrainInjury
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Neurotrauma &
Critical Care
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Age and TBI
“Traumatic Brain Injury in the United States: Emergency Department
Visits, Hospitalizations and Deaths 2002-2006”
www.cdc.gov/TraumaticBrainInjury
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Neurotrauma &
Critical Care
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What is a concussion?
 A concussion is a brain injury, and all are serious.
 Most concussions occur without loss of consciousness.
 Recognition and proper response to concussions when
they first occur can help prevent further injury or even
death.
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Neurotrauma &
Critical Care
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What is a concussion?
 Most prevalent form of Traumatic Brain Injury
 Often missed at time of initial injury
 MRI and CT scans are normal
 15% have symptoms for more than one year
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Critical Care
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 Defined as the result of the forceful motion of the head
causing a brief change in mental status.
Ropper et al. N Engl J Med 2007;356:166-72
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Neurotrauma &
Critical Care
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What causes a concussion?
 A concussion is caused by a bump, blow, or jolt to the
head that can change the way your brain normally
works.
 Concussions can occur in any sport or recreational
activity.
 Everybody needs to learn concussion signs and
symptoms and what to do if a concussion occurs.
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Neurotrauma &
Critical Care
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Recognizing Symptoms
of Concussion . . .
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Neurotrauma &
Critical Care
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Observations Reported by Others
 Appears dazed or stunned
 Is confused about assignment or position
 Forgets an instruction
 Is unsure of game, score, or opponent
 Moves clumsily
 Answers questions slowly
 Loses consciousness (even briefly)
 Shows mood, behavior, or personality changes
 Can’t recall events prior to hit or fall
 Can’t recall events after hit or fall
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Neurotrauma &
Critical Care
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Observations Reported by Athlete
 Headache or “pressure” in head
 Nausea or vomiting
 Balance problems or dizziness
 Double or blurry vision
 Sensitivity to light
 Sensitivity to noise
 Feeling sluggish, hazy, foggy, or groggy
 Concentration or memory problems
 Confusion
 Does not “feel right” or is “feeling down”
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Neurotrauma &
Critical Care
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Response
 Remove the athlete from play
 Obtain an evaluation by a trained professional
 Inform the athlete’s parents or guardians
 Keep the athlete out of play the day of the injury
 Continue to keep the athlete out of play until a trained
professional says they are symptom free
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Neurotrauma &
Critical Care
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Response
 Cornerstone of concussion management is physical and
cognitive rest
 Majority of injuries will recover spontaneously over
several days
 The consensus panel on concussion in sport agreed that
there are modifying factors that can influence
management and outcome1
1 Consensus Statement on Concussion in Sport: the 3rd International
Conference on Concussion in Sport held in Zurich, November 2008
McCrory et al.Br J Sports Med 2009
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Neurotrauma &
Critical Care
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Concussion Modifiers
Consensus Statement on Concussion in Sport: the 3rd International
Conference on Concussion in Sport held in Zurich, November 2008
McCrory et al.Br J Sports Med 2009
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Neurotrauma &
Critical Care
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Care after Concussion
 Normal neurological exams are observed for 2 hours,
and athlete is discharged to home to care of responsible
person
 Return to normal activity should be postponed until
symptoms like dizziness and headaches subside
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Neurotrauma &
Critical Care
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Care after Concussion
 Balanced nutrition
 Avoid alcohol, tobacco and other non-prescribed drugs
 Good exercise routine
 Avoid over-exertion
 Lots of rest
 Fatigue common; short naps and rest periods ; do not
sleep excessive lengths during the daytime that then keep
you awake at night
 Get a full nights sleep
 Avoid stimulants or sedatives at night
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Neurotrauma &
Critical Care
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Head CT Rules for Concussion
Ropper et al. N Engl J Med 2007;356:166-72
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Neurotrauma &
Critical Care
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Return to Hospital
 Increasing headaches
 Repeated vomiting
 Weakness or numbness (concern of delayed bleeding)
 Speech disturbance
 Drowsiness
 Increasing confusion, irritability, or behavioral change
 Signs of a seizure
 Fluid from the nose or ear (CSF leak)
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Neurotrauma &
Critical Care
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Second Impact Syndrome
 Concern that a second impact within a short period could
lead to catastrophic neurological damage
 Rare second mild TBI caused massive brain swelling
 Case reports
Snoek et al. Brain 1984;107: 15-36.
McCrory et al. Neurology 1998;50:677-83.
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Neurotrauma &
Critical Care
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Post-Concussion Syndrome
 25 out of 100 patients still suffer symptoms one year
after concussion
 Sometimes disabling
 Treatment: pain medication, medications for dizziness
and depression, and balance exercise
Evans et al. Oxford University Press. 1992:97-107.
Mittenberg et al. J Clin Exp Neuropsychol 2001;23:829-36.
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Neurotrauma &
Critical Care
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Criteria for Post-Concussion
Syndrome
Ropper et al. N Engl J Med 2007;356:166-72
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Neurotrauma &
Critical Care
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Understanding long-term effects
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Neurotrauma &
Critical Care
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Long-Term Effects of TBI

 Repeat concussion that occurs before the brain recovers
from a previous one can slow recovery and increase the
likelihood of having long-term problems.
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Neurotrauma &
Critical Care
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Long-Term Effects of TBI
 Occurrence of neurological decline after repeated
concussions is best seen in boxers
 Preventing second concussion during recovery period is
important in preventing permanent damage
 Athletes with one concussion are at greater risk for a
second brain injury during the same season
Guskiewicz et al. 2003;290:2549-55.
Handratta et at 2010 Apr;16(2):125-34.
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Neurotrauma &
Critical Care
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Lack of
Underst
anding
Depres
sion
Memor
y
Proble
m
Aggres
sion
Faulty
Reason
ing
Person
ality
change
s
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Neurotrauma &
Critical Care
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Return to Play Decisions
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Neurotrauma &
Critical Care
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Return to Play After TBI
 Guidelines exist
 Not routinely enforced in more junior or amateur settings
 Coaches, trainers, athletes, and parents of minor
athletes need to be advocates for the strict use of these
guidelines
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Neurotrauma &
Critical Care
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Graduated Return to Play
Protocol
Consensus Statement on Concussion in Sport: the 3rd International
Conference on Concussion in Sport held in Zurich, November 2008
McCrory et al.Br J Sports Med 2009
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Neurotrauma &
Critical Care
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Prevention
 Coach or parent, you play a key role in preventing
concussions and responding properly when they occur.
 Currently the culture is to downplay concussion to
remain in the game!
 RECOGNIZE—RESPOND—PREVENT
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Neurotrauma &
Critical Care
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Prevention
 Insist that safety comes first!
 Teach and practice safe playing techniques
 Encourage athletes to follow the rules of play
 Make sure athletes wear the right protective equipment
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Neurotrauma &
Critical Care
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Prevention
 Check with league and school about concussion policy
 Develop action plan in case of concussion
 Teach athletes it is not smart to continue to play with a
concussion
 Give time to heal after concussion to prevent long-term
problems
 Monitor concussion in athletes
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Neurotrauma &
Critical Care
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Information & Resources
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Neurotrauma &
Critical Care
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Neurotrauma &
Critical Care
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