Wednesday, October 14, 2015

Concussions…Ding dong…Not as simple as getting “your bell rung”….

Concussions…Ding dong…Not as simple as getting “your bell rung”….
Part 2 – Signs, Symptoms and Diagnosis

By Ann L. Contrucci, MD, Director, Risk and Patient Safety, MagMutual Patient Safety Institute

In part one of this article, we discussed the pathophysiology of head concussion, as well as the incidence of head injury in children and adolescents, emphasizing that the evaluation and treatment of concussions is not as simple as previously thought. In this article we will address the signs, symptoms and diagnosis of concussion; the complexity of the clinical picture can be a diagnostic challenge and a clinician must maintain a low threshold of suspicion for further evaluation, and be able to identify and respond immediately to life-threatening signs.

Signs, Symptoms and Diagnosis of Concussion

A thorough head injury assessment includes three diagnostic areas:

1) Characteristics of the injury itself

• the exact mechanism of the injury

• the direction of the “hit”

• type and location of the force

Even an apparently “mild” blow can cause significant injury. Rotational force can be a vital characteristic as it has been shown that angular acceleration may increase the actual risk of sustaining a concussion from 25% to 80%. It is important to ask if there was a loss of consciousness, although loss of consciousness only occurs in sports- related concussions approximately 10% of the time.

2) Symptom type and severity

Signs and symptoms of concussion are divided into four categories: somatic, cognitive, affective, and sleep. Somatic symptoms include what one would expect: headache, dizziness, vertigo, nausea/vomiting, photophobia and/or blurry vision, as well as phonophobia, a persistent, abnormal, and unwarranted fear of sound. Phonophobia is an anxiety disorder, not a hearing disorder. Cognitive symptoms include anterograde or retrograde amnesia, confusion or disorientation, loss of consciousness, and feeling “fuzzy” or “foggy”. Other cognitive manifestations include “staring into space”, focusing issues, delay in verbal or motor response, slurred or incoherent speech, and excessive sleepiness. Affective evidence of concussion includes labile emotions, irritability or fatigue, anxiety and sadness. Sleep may be affected by either sleeping too much or not enough. One of the diagnostic challenges with concussion is that it is an evolving injury in which an athlete may feel different immediately afterwards and then develop further symptomatology within 30 minutes to an hour. Monitor for signs of more serious injury or neurological deterioration during the first 24-48 hours. Red flags indicating the need for immediate evaluation and transport include loss of consciousness greater than 30 seconds, worsening headaches, repeated emesis, slurred speech, increasing confusion or disorientation, any unusual behavior; other worrisome symptoms include seizures or signs of cervical spine injury, such as weakness or numbness of the extremities, severe cervical tenderness, irritability, or loss in range of motion.

3. The risk of sustaining a concussion

The risk of diffuse cerebral edema is greater in children and adolescents which makes a second impact even more dangerous. Don’t feel pressured to allow the athlete to continue playing. Emphasize that playing with a concussion is dangerous! Monitoring should occur at least one to two hours after the immediate injury, and for at least 24 hours, as life-threatening signs can develop at any time during this time frame. Document the injury and discuss it with the child’s caregivers or parents. Specifically discuss with them signs of deterioration, when and how to seek medical treatment. This incident creates a teachable moment; time to provide coaches and parents some head injury education.

Handling an “on the field response”

Responding to an “on the field” event requires a three-step evaluation and an assertive management response:

1. The on field exam. A systematic review at the time of injury is crucial; perform the ABC’s initially, a mental status assessment, a brief neurological exam and a cervical spine status assessment.

2. Sideline evaluation. If an emergent disposition is not needed, the next step should be a sideline evaluation. At this point, conduct a more detailed exam, and obtain a past medical history, including but not limited to questions concerning whether the patient has a history of any known previous concussions. Ensure cognitive, somatic and affective symptoms are assessed. The number and duration of symptoms seems to be predictive of severity of the concussion. Evaluate the child’s orientation, memory, concentration, and balance.

A number of effective checklists and tools are available. The SCAT2 – the Sports Concussion Assessment Tool, developed by a consensus of sports medicine professionals, and recommended for athletes ages 10 years and older is commonly used 4 , 5

  3. Remove the athlete from the field. The third step is to remove the athlete from the field with no same day return to play. This is crucial. If a second hit is sustained, there is an increased chance of “second impact syndrome” which in its extreme form, can result in permanent brain damage or even death.

Whether diagnosis of concussion occurs in the office, ED or on the sideline, the exam should focus on cognition, neurologic exam, balance and any deteriorating neurological function. Neuroimaging studies should be reserved for suspicion of intracranial hemorrhage, skull fractures or other structural injury and be based on neurological exam, symptom assessment, and mechanism of injury. Practices vary, and currently there is no clear cut evidence on when to perform neuroimaging studies. Hospital admission should be considered if repeat serial exams may be required due to signs of intracranial injury or fluctuating or deteriorating symptoms are occurring. When dealing with children, if there is any question of inadequate supervision or follow up, then hospital observation may be warranted. 6

In summary, the clinical picture of concussions can be an evolving and fluid process. Clinical judgement plays a critical role in diagnosis and medical decision making for further evaluation. The importance of educating those caring for the child or adolescent cannot be overemphasized as deterioration can occur in the first 24 hours after the initial injury. 

In Article (3) we will discuss concussion complications, treatment options, and recommendations for follow up care.

Published October 2015


3 Consensus statement on Concussion in Sport – the 4th international conference on concussion in sport held in Zurich, November 2012. Journal of Science and Medicine in Sport 16(2013) 178-189
4 Consensus statement on Concussion in Sport – the 4th international conference on concussion in sport held in Zurich, November 2012. Journal of Science and Medicine in Sport 16(2013) 178-189

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