Friday, October 16, 2009

Guidelines for Head injuries in contact sports

In lieu of the recent tragedy that happened to the young football player in Simi Valley I have felt compelled to put this article together. Please share it with all your friends who participate in high action and contact sports. I have been associated with high action and contact sports for over 20 years and it saddens me when I hear of accidents such as this. Most of these accidents are just that, they are rare accidents. However, understanding brain injuries and knowing what to do is an important part of the “recovery” phase.

I recall an article that addressed head injuries in youth sports. On March 14, 1997, an Issue of MMWR of the Centers for Disease Control and Prevention describes two cases of second-impact syndrome that resulted in deaths. One case involved a high school football player in 1991 and the other a college football player. In each case, the player did not require hospitalization, and each player was sent home for close monitoring with no follow up guidelines. The American Academy of Neurology has developed guidelines for preventing second-impact syndrome and reducing the frequency of other cumulative brain injuries. These are different than the “Famed” Colorado guidelines and air on the side of being conservative.

Summary of Recommendations for Management of Concussions in Sports

The most common head injury is the concussion. Concussions are a form of brain injury that should not be taken lightly. The after effects of a concussion, post-concussion syndrome, can linger for days or weeks. Concussions are an unfortunate side effect of collision sports such as football, hockey, lacrosse, motorcycle and bicycle riding. They range in severity from the minor (“I just had my bell rung") to major, life threatening brain contusions ("he was knocked out cold”).

A concussion is defined as a clinical syndrome characterized by immediate and transient post-traumatic impairment of neural function owing to mechanical forces. A concussion occurs when the body is moving rapidly through space and suddenly stops. Keep in mind that the brain is traveling at the same velocity as the rest of the body. When the body suddenly stops, the brain continues to move at the same velocity in the same direction. The brain then hits the skull and bounces back, hitting the opposite side of the skull until it loses momentum. This occurs due to the fact that the brain is floating in the cerebral spinal fluid, and does not actually touch the skull.

When the brain strikes the skull, a portion of it is damaged. When enough damage is done, it begins to operate improperly. This is when the outsider notices the symptoms of the concussion. The effects of these repeated blows to the brain are cumulative, that is, one blow intensifies the effects of the previous. Because of this, an athlete may take what appears to be a slight blow to the head or body and then show the symptoms of the concussion.

There is no standard classification system for concussions. Four of the leading researchers in head injuries maintain their own classification system. The symptoms of each degree of concussion are often very similar, and it is easy to be confused when assessing a head injury. However, the latest protocol that is recognized as the leader is the information by the ANA (American Neurological Association).

Definitions from the ANA and treatment recommendations for each category are presented below.

Grade 1 Concussion

Definition: Transient confusion, no loss of consciousness, and a duration of mental status abnormalities under 15 minutes.

Management: The athlete should be removed from sports activity, examined immediately and at 5 minute Intervals, and allowed to return that day to the sports activity only if post concussive symptoms resolve within 15 minutes. Any athlete who incurs a second Grade 1 concussion on the same day should be removed from sports activities until asymptomatic for 1 week.

Grade 2 Concussion

Definition: Transient confusion, no loss of consciousness, and a duration of mental status abnormalities15 minutes or longer.

Management: The athlete should be removed from sports activity and examined frequently to assess the evolution of symptoms, with more extensive diagnostic evaluation if the symptoms worsen or persist longer than 1 week. The athlete should return to sports activity only after being asymptomatic for 1 full week. Any athlete who incurs a Grade 2 concussion subsequent to a Grade 1 concussion on the same day should be removed sports activities until asymptomatic for 2 weeks.

Grade 3 Concussion

Definition: Loss of consciousness either brief (seconds) or prolonged (minutes or longer).

Management: The athlete should be removed from sports activity for I full week without symptoms if the loss of consciousness is brief or for 2 full weeks without symptoms if the loss of consciousness is prolonged. If still unconscious or if abnormal neurologic signs are present at the time of initial evaluation, the athlete should be transported by ambulance to the nearest trauma hospital. An athlete that has suffered a second grade 3 concussion should be removed from sports activity until asymptomatic for 1 month. Any athlete with an abnormality on CT or MRI brain scan consistent with brain swelling, contusion, or other intracranial pathology should be removed from sports activities for the season and discouraged from future return to participation in contact sports. Source: New standards for head trauma subcommittee, American Academy of neurology 1997

With any head injury the patient needs to be monitored (no matter what the patient says, does or thinks) by a parent, mature teammate or friend. Since a head injury can alter mental function, personality and the ability to make clear and well thought out decisions, sometimes the decisions are left up to the “significant other”. Following any head injury a comprehensive exam should follow to insure the athletes safety. Also, knowing what to do if any injury occurs can mean the difference, at times, between life and death.

Patient instructions following a head injury

Before I tell you what not to do if you SUSTAIN an injury, I need to address a common problem that many athletes do prior to “game time”. Since a concussion is essentially a “bruise to the brain” anything you take prior to participation that could thin the blood is not recommended. If you participate in any high impact sport DO NOT take aspirin, advil, alleve or any other supplement or medication prior to participation due to the fact that this could thin the blood and make ANY bleed worse.

Common symptoms of a head injury include: headaches, nausea and slight dizziness. There may be swelling and pain at the site of impact. A head injury can cause slow bleeding or other problems inside the head that may not be detected at the initial exam. Make sure you consult any health care provider if any symptoms change or worsen.

Home treatment:

• Do not take any sedatives or sleeping pills
• Do not take aspirin, ibuprofen, motrin, advil, alleve, nuprin or any other medication that can thin the blood
• If needed, the use of acetaminophen (Tylenol) is recommended for pain only
• Do not drink alcohol or tea
• Do not exert yourself or participate in PE (follow guidelines above)
• Do not eat or drink much for the first 24 hours (clear liquids are the best)
• Sleep with head slightly elevated
• Avoid hot tubs and Jacuzzis for the first 48 hours

I hope this information is helpful to anyone involved with high action or contact sports. Be safe so you can play another day! Please pass this on to anyone you may know and have them sign up for our newsletter for more upcoming tips.

No comments: