Concussion

1. See Also
   1. Head Trauma
2. Definition: Concussion
   1. Acute trauma-induced mental function alteration
   2. Duration under 24 hours
   3. Loss of consciousness may be present
3. Pathophysiology: Second Impact Syndrome
   1. Repeated Concussions over short period of time
   2. Results in progressive cerebral edema
4. Epidemiology: Incidence Concussion in football per year
   1. High School athletes: 20%
   2. College athletes: 10%
5. Risk Factors
   1. Contact Sports Participation
      1. Football
      2. Ice Hockey
      3. Soccer
      4. Boxing
      5. Lacrosse
      6. Wrestling
      7. Basketball
   2. Non-Contact Sports Participation
      1. Gymnastics
      2. Skiing
      3. Sledding
      4. Ice Skating
      5. Inline Skating
      6. Horseback riding
6. Symptoms
   1. Headache
   2. Dizziness
   3. Nausea or Vomiting
   4. Slurred speech
   5. Imbalance
   6. Incoordination
7. Signs
   1. Amnesia
   2. Disorientation
   3. Confusion
      1. Vacant stare
      2. Disorientation
      3. Delayed answers to questions
      4. Poor concentration
      5. Inattention
8. Grading
   1. Grade 1 Concussion ("Ding" Concussion)
      1. Confusion
      2. Concussion symptoms resolve within 15 minutes
      3. No Loss of Consciousness
   2. Grade 2 Concussion
      1. Confusion
      2. Concussion symptoms persist beyond 15 minutes
      3. No Loss of Consciousness
   3. Grade 3 Concussion
      1. Confusion
      2. Concussion symptoms persist beyond 15 minutes
      3. Any Loss of Consciousness
9. Evaluation: Stabilization
   1. See Primary Survey
   2. See Secondary Trauma Survey
   3. See Head Injury
   4. See Cervical Spine Injury
10. Evaluation: Sideline Evaluation for return to play
    1. Orientation and memory
       1. At which field are we playing?
       2. What team are we playing today?
       3. What is the current period or half of the game?
       4. How much of the current period or half has elapsed?
       5. What team was the last to score?
       6. Who did we play in our last game and did we win?
       7. References
          1. Maddocks (1995) Clin J Sports Med 5:32-5
    2. Evaluate for postural instability
       1. See Balance Error Scoring System
11. Management: Gerenal Guidelines
    1. See Management of Mild Head Injury
    2. Based on three separate and conflicting guidelines
       1. Cantu Guidelines (1986)
       2. Colorado Medical Society (1991)
       3. American Academy of Neurology (1997)
    3. Definition of Asymptomatic (guidelines below)
       1. No somatic symptoms
       2. No behavioral symptoms
       3. No cognitive symptoms
12. Management: Guidelines for Grade 1 Concussion
    1. Background
       1. Grade 1 Concussion memory deficits persist 1-6 days
       2. Return to play in 15 minutes may be too soon
       3. Lovell (2004) Am J Sports Med 32:47-54
    2. First Grade 1 Concussion
       1. Return to play if asymptomatic for 15-20 minutes
    3. Second Grade 1 Concussion
       1. Requires formal examination by physician
       2. Return to play if asymptomatic for 1 week
    4. Third Grade I Concussion
       1. Terminate season
       2. Requires formal examination by physician
13. Management: Guidelines for Grade 2 Concussion
    1. First Grade 2 Concussion
       1. Requires formal examination by physician
       2. Return to play if asymptomatic for 1 week
    2. Second Grade 2 Concussion
       1. Return to play if asymptomatic for 1 month
    3. Third Grade 2 Concussion
       1. Terminate Season
14. Management: Guidelines for Grade 3 Concussion
    1. First Grade 3 Concussion
       1. Urgent Neurologic Exam at hospital ER
       2. Consider Head CT
       3. Return to play guidelines
          1. No participation for one month minimum
          2. May return to play if asymptomatic for 1-2 weeks
    2. Second Grade 3 Concussion
       1. Terminate Season
    3. Third Grade 3 Concussion
       1. Terminate Sport
15. Patient Instructions: Criteria for immediate follow-up
    1. See Head Injury Precautions
16. Complications
    1. Cerebral edema (Second Impact Syndrome)
    2. Cumulative neuropsychologic deficits
    3. Intracranial bleeding
    4. Postconcussion Syndrome
17. Reference
    1. (1997) Neurology 48:581-5
    2. (1999) Pediatrics 104:1407-15
    3. Cantu (1986) Phys Sportsmed 14(10):75-83
    4. Kushner (2001) Am Fam Physician 64:1007-14
    5. Whiteside (2006) Am Fam Physician 74(8):1357-62