Don't lose your head! Recommendations for the management of concussion.

RECOMMENDATIONS FOR THE MANAGEMENT OF CONCUSSION

One of the unhappier statistics in contact sports is the 300,000 annual traumatic brain injuries of mild to moderate severity.

Most of these can be classified as concussions. Repeated mild brain injuries occurring over an extended period (months or years) can result in cumulative neurologic and cognitive deficits.

When these mild brain injuries occur within a short period (hours, days, or weeks), they can be catastrophic or fatal. This has been reported more frequently since it was first characterized in 1984.

CASE REPORT 1 (OCTOBER 1991):

A 17-year-old high school football player was tackled on the last play of the first half and struck his head on the ground. During halftime intermission, he told a teammate that he felt ill and had a headache; he did not tell his coach. He played again during the third quarter and received several routine blows to his helmet. He then collapsed on the field and was taken to a local hospital in a coma.

A brain scan revealed diffuse swelling of the brain and a small subdural hematoma. He was transferred to a regional trauma center, where he was pronounced brain dead four days later. Autopsy revealed diffuse brain swelling, focal areas of subcortical ischemia, and a small subdural hematoma.

CASE REPORT 2 (AUGUST 1993):

A 19-year-old college football player reported headache to family members after a full-contact practice in summer training. In practice the following day, he collapsed approximately two minutes after engaging in a tackle. He was transported to a nearby trauma center, where a CT scan showed diffuse brain swelling and a thin subdural hematoma. Attempts to control the elevated intracranial pressure failed, and he was pronounced brain dead three days later. Autopsy revealed the brain to be diffusely swollen with evidence of cerebrovascular congestion and features of temporal lobe herniation.

These two cases involved repeated head trauma with probably concussions that separately might have been considered mild, but in additive effect were fatal.

The risk for catastrophic effects from successive, seemingly mild concussions sustained within a short period of time is not yet widely recognized. Second-impact syndrome results from acute, usually fatal, brain swelling that occurs whenever the athlete sustains a second concussion before he has completely recovered from a previous concussion.

The risk of second-impact syndrome is prevalent in contact sports such as football, ice or roller hockey, soccer, baseball, basketball, and snow skiing, and boxing.

The American Academy of Neurology has prepared a series of recommendations designed to prevent second-impact syndrome and to reduce the frequency of other cumulative brain injuries related to sports.

The recommendations define the symptoms of concussions and specify layoffs following a concussion. Whenever a head blow produces an alteration of mental status, including transient confusion or amnesia with or without loss of consciousness, the athlete should be taken out of the activity until examined by a health-care provider familiar with these guidelines.

The popularity of contact sports puts a large number of participants at risk for brain injury. Recurrent brain injuries can be serious and non-responsive to medical treatment. But recurrent brain injuries and second-impact syndrome are highly preventable.

Physicians, p.e. instructors, coaches, trainers, athletes, their parents, and the general public should be familiarized with these recommendations.

Summary of Recommendations for Management of Concussion in Sports:

A concussion is defined as a trauma-induced alteration in mental status that may or may not involve loss of consciousness. It can be categorized as follows:

GRADE 1 CONCUSSION

* Definition: Transient confusion, no loss of consciousness, and a duration of mental status abnormalities of 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 postconcussive symptoms resolve within 15 minutes. Any athlete who incurs a second Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 1 week.

GRADE 2 CONCUSSION

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

* 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 for 1 week. The athlete should return to sports activity only after 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 from sports activity until asymptomatic for 2 weeks.

GRADE 3 CONCUSSION

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

* Management: If the loss of consciousness is brief, without symptoms, the athlete should be removed from sports activity for 1 full week. If the loss of consciousness is prolonged, without symptoms, the athlete should be removed from activity for 2 full weeks. 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 hospital emergency department.

An athlete who suffers a second Grade 3 concussion should be removed from sports activity until asymptomatic for 1 month. Any athlete with an abnormality on computed tomography 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.