Concussions and Environmental Considerations

Concussion Definition

• A traumatically induced transient disturbance of brain function due to a complex pathological process.

• A clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation; may involve loss of consciousness.

• A TBI caused by a direct blow to the head, neck, or body, resulting in an impulsive force transmitted to the brain, initiating a neurotransmitter and metabolic cascade.

• NATA: trauma-induced alteration of mental status that may or may not involve loss of consciousness.

• Minimize layman's terms like "ding," "getting one's bell rung," and "clearing the cobwebs."

Mild Traumatic Brain Injury (mTBI)

• The diagnostic label ‘concussion‘ may be used interchangeably with ‘mild TBI‘ when neuroimaging is normal or not clinically indicated."

• "Mild" qualifier not used if:

  • LOC > 30 minutes

  • After 30 minutes, Glasgow Coma Scale (GCS) < 13

  • Post-traumatic amnesia > 24 hours

Concussion Characteristics

• Not a “clear cut” injury with objective diagnostic evidence—relies on a clinical diagnosis by trained professional

• Disruption in brain function at a cellular level---doesn’t necessarily result in anatomical changes that you can see

• Makes diagnosis difficult to explain and understand

• No physical bandage.

• Described as a functional injury, rather than a structural injury (McCrory, 2017)

Concussion Evaluation

• Clinical exam and impression (MOST IMPORTANT!)

• Symptom assessment

• Neurocognitive function

• Mental status assessment

• Coordination and balance assessment

• Visual acuity/eye tracking

• Mood or emotional assessments

• Sleep disturbances

Symptom Evaluation

• Instructions differ for baseline vs. suspected/post-injury evaluations.

• Baseline: "Please rate your symptoms below based on how you typically feel with "1" representing a very mild symp- tom and "6" representing a severe symptom."

• Suspected/Post-injury: "Please rate your symptoms below based on how you feel now with "1" representing a very mild symptom and "6" representing a severe symptom."

Cognitive Screening

• Orientation questions: What month is it? What is the date today? What is the day of the week? What year is it? What time is it right now? (within 1 hour)

• Immediate Memory: Repeat list of words (Trials 1, 2, 3).

• Concentration: Digits Backward (repeat numbers in reverse order), Months in Reverse Order.

Coordination and Balance Assessments

• Timed tandem gait

• Dual task gait

• Static balance (Romberg Sign, BESS)

• Dynamic balance

• Sensory Organization Test

Sensory Organization Test

• Sensory Organization Test- Gold Standard

Balance Error Scoring System (BESS)

• Quantifiable clinical battery test utilizing different stances on firm and foam surfaces.

• Eyes are closed.

• Errors include:

  • Patient opens eyes

  • Takes hands off hips

  • Steps/stumbles or falls

Tandem Gait Test

• 3m line, hands on hips, <14 seconds, no errors.

Visual Acuity and Vestibular/Ocular-Motor Screening (VOMS)

• Smooth pursuits.

• Horizontal saccades.

• Vertical saccades.

• Convergence.

• Horizontal VOR.

• Vertical VOR.

• VMS.

Mood or Emotional Assessments

• Anxiety Screen (scores of 0, 1, 2, and 3 for "not at all," "several days," "more than half the days," and "nearly every day")

• Depression Screen (screen for depression in a "first-step" approach).

Sleep Assessments

• SCOAT6™ Sleep Screen: questions about hours of sleep, satisfaction with sleep quality, time to fall asleep, trouble staying asleep, and use of medicine to help sleep.

Head Anatomy

• Bones – 22 bones connected by immovable joints called sutures

• Scalp – Loose connective tissue and skin

Brain and Meninges

• Brain

• Cerebrospinal Fluid (CSF) – Surrounds and suspends brain within skull cavity and acts as a cushion

• Meninges- 3 membranes surrounding brain/spinal cord

  • Dura Mater- outermost dense layer

  • Arachnoid- weblike delicate layer

  • Pia Mater- innermost, thin layer that is highly vascularized and adheres closely to brain/cord

Assessing Head Injuries

• History

  • Previous hx of head trauma

  • MOI

    • Direct blow

    • Deceleration of head (whiplash)

    • Shear forces

    • Rotational forces

• Observation – What is normal for them?

• Palpation

  • Cervical Spine

  • Skull

    • Crepitus, FX

    • Point tenderness or Deformity

Skull Fracture

• MOI – Most common cause is direct blow

• Si/Sx

  • Severe headache and nausea

  • Palpation may reveal deformity in skull, crepitus

  • May be blood in the middle ear, ear canal, nose, ecchymosis around the eyes (raccoon eyes) or behind the ear (Battle’s sign)

  • Cerebrospinal fluid may also appear in ear and nose

• Management – Immediate hospitalization and referral to neurosurgeon

Brain Bleeds

• Two Types: Epidural Hematoma, Subdural Hematoma

• Both are medical emergencies.

• Generally speaking, brain/head injuries are medical emergencies.

Epidural Hematoma

• Etiology

  • Blow to head or skull fracture which tear meningeal arteries

  • Blood pressure, blood accumulation and creation of hematoma occur rapidly (minutes to hours)

• Signs and Symptoms

  • LOC followed by period of lucidity, showing few signs and symptoms of serious head injury

  • Gradual progression of S&S

    • Head pains, dizziness, nausea, dilation of one pupil (same side as injury), deterioration of consciousness, neck rigidity, depression of pulse and respiration, and convulsion

• Management

  • Requires urgent neurosurgical care; CT may be necessary for diagnosis

  • Must relieve pressure to avoid disability or death

Subdural Hematoma

• Etiology

  • Result of acceleration/deceleration forces that tear vessels that bridge dura mater and brain

  • May be:

    • Acute (rapidly progressing)

    • In association with other brain/skull injury

    • Chronic (Due to venous bleeding – slow bleed, w/out serious intracranial pressure)

• Signs and Symptoms

  • With a simple subdural hematoma LOC generally does not occur

  • headache, dizziness, nausea or sleepiness

  • Generally a SLOWER onset and progression

• Management

  • Immediate medical attention

  • CT or MRI is necessary to determine extent of injury

  • Beware blood thinners!

Red Flag Symptoms:

• Deteriorating Level of Consciousness

• Severe and Persistent Headache

• Repeated Vomiting

• Pupil Changes

• Weakness or Numbness on One Side

• Speech Difficulties

• Vision Changes

• Seizures

• Balance Problems or Difficulty Walking

• Changes in Behavior or Personality

• Lucid Interval Followed by Rapid Deterioration

• Gradual Onset of Worsening Symptoms

• New Neurological Symptoms After Head Injury (Even Minor)

Scalp Injuries

• Etiology – Blunt trauma or penetrating trauma tends to be the cause.

• Si/Sx – Patient complains of blow to the head. Bleeding is often extensive.

• Management

  • PPE

  • Manage bleeding with dressings, pressure, hemostatic gauze

  • Refer for suturing depending on location and size of wound

Facial Anatomy

• Bony Landmarks: Temporomandibular Joint (TMJ), Supraorbital ridge, Zygomatic Arch, Nasal bone, Mandible

Mandible Fracture/Dislocation

• Fracture

  • Etiology – Direct blow

  • Si/Sx – Deformity, loss of occlusion, pain with biting, bleeding around teeth, lower lip anesthesia

  • Management – Temporary immobilization w/ elastic wrap followed by reduction and fixation

• Dislocation

  • Etiology – Involves TMJ joint. MOI is generally a blow to an open mouth from the side

  • Si/Sx – Dislocated jaw presents in locked-open position with poor ROM

  • Management – Follow-up w/ soft diet, NSAIDs and analgesics w/ a gradual return to activity 7-10 days following acute period

Facial Fractures

• Zygomatic

  • MOI = direct blow

  • Si/Sx – Deformity, nosebleed, diplopia, and numbness in cheek

  • Management – Control swelling and referral to a physician. Healing will take 6-8 weeks

• Maxillary

  • MOI = blow to upper jaw

  • Si/Sx – Pain with chewing, malocclusion, nosebleed, diplopia, numbness of lip and cheek region

  • Management – Maintain airway. Be aware of possible brain injury. Transport to hospital immediately.

Nasal Fractures

• Etiology – MOI = direct blow

• Si/Sx – Bleeding, Deformity

• Management

  • Control bleeding and refer to a physician for X-ray, examination and reduction

  • Uncomplicated and simple fractures will pose little problem for the athlete’s quick return

  • Splinting may be necessary

Tooth Injuries

• Etiology: Blow to the jaw, direct trauma

• S/S: Fragments, possible bleeding, pain, deformity

• Management: Xray to determine root fracture/damage. Subluxed/dislocated teeth should be preserved. Referral to dentist!

Auricular Hematoma (Cauliflower Ear)

• Occurs either from compression or shear injury to the ear (single or repeated). Causes subcutaneous bleeding.

Tympanic Membrane Rupture

• Etiology

  • Fall or slap to the unprotected ear or sudden underwater pressure variation can result in a rupture

• S/S

  • Hearing loss, visible rupture (seen through otoscope)

  • Complaint of loud pop, followed by pain in ear, nausea, vomiting, and dizziness

• Management

  • Small to moderate perforations usually heal spontaneously in 1-2 weeks

  • Infection can occur and must be continually monitored

Eye Injuries

• Orbital Hematoma

  • Etiology: Blow to the area surrounding the eye which results in capillary bleeding

  • Si/Sx: Swelling and discoloration

  • Management: Manage swelling. Do not blow nose after acute eye injury

• Orbital Fx (“Blowout Fx”)

  • Diplopia, restricted eye movement, downward displacement of the eye, soft-tissue swelling and hemorrhaging

  • X-ray will be necessary to confirm fracture

Eye Injuries (continued)

• Corneal Abrasion

  • Etiology: Foreign object produces considerable pain, and disability. No attempt should be made to remove.

  • Si/Sx: Severe pain, watering of the eye, photophobia

  • Management: Patch eye and refer to a physician. Diagnosis will require use of fluorescein strip

• Hyphema

  • Blunt blow to the eye. Blood pooling in eye

• Globe Rupture

  • Blow to the eye by an object smaller than the eye

• Retinal Detachment

  • Blow to the eye or strong shear force can partially or completely separate the retina from the back of the eye

Throat Injuries

• Contusion

  • Etiology

    • Direct blow (clothes-lining)

    • Could result in trauma to the carotid artery (clotting), impacting blood flow to the brain

  • Si/Sx

    • Severe pain w/ coughing, speaking w/ a hoarse voice, and complaining of difficulty with swallowing

  • Management

    • Airway integrity - first

    • Manage swelling and pain

    • Severe neck contusion may require stabilization w/ a well-padded collar

Management of Concussions

• The decision to return a patient to competition following a brain injury is a difficult one that takes a great deal of consideration

• If any loss of consciousness occurs the athletic trainer must assume C-spine injury and remove the patient from participation for further evaluation

• NOT all concussions include loss of consciousness

• If a concussion is suspected, no same day return to play allowed

• Objective measures should be used to determine readiness to play (as best as able)

• Return to Play Guidelines

  • CDC Heads Up

  • National Athletic Trainers Association Bridge Statement: Management of Sports Related Concussion

  • National Federation of State High School Associations- NFHS

Persisting Concussion Symptoms

• Condition which occurs following a concussion

• Signs and Symptoms (range of post-concussion problems)

  • Persistent headaches, impaired memory, lack of concentration, anxiety and irritability, fatigue, depression, visual disturbances

  • May begin immediately following injury and may last for weeks to months

Second Impact Syndrome

• Result of rapid swelling and herniation of brain after a second head injury before symptoms of the initial injury have resolved

  • Second impact may be relatively minimal and not involve contact w/ the cranium

• Impact disrupts the brain’s blood autoregulatory system leading to swelling, increasing intracranial pressure - NOT WELL UNDERSTOOD AND OFTEN DISPUTED

• Often patient does not have Loss of Consciousness (LOC)

• Management - prevention

Chronic Traumatic Encephalopathy (CTE)

• Neurodegenerative disease associated with a history of repetitive head impacts, including concussions and sub-concussive trauma.

• Characterized by abundance of an abnormal form of tau protein.

• Brain degeneration is associated with:

  • memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, progressive dementia

Traumatic Encephalopathy Syndrome (TES)

• Describes the clinical presentation of CTE as well as other possible long-term consequences of repetitive head impacts

• Based on:

  • Exposure to Brain Trauma

  • Clinical Features

  • Course

  • Biomarkers

Environmental Considerations

• Environmental stress can adversely impact performance and pose serious health threats

• Areas of concern:

  • Hyperthermia

  • Hypothermia

  • Altitude

  • Lightning storms

Hyperthermia

• Condition where body temperature is elevated

• AT must understand heat/humidity factors to manage and plan accordingly with coaching staffs

• AT must also be able to recognize clinical signs/symptoms of heat illnesses

Heat Stress

• Extreme caution should be used when training in the heat

• Underlying medical conditions may put some athletes at risk

• Not limited to hot/humid weather conditions – Dehydration, equipment

Heat Stress - 5 factors affect body temperature (heat gain/loss)

• Metabolic Heat Production – “running temperature” of body

• Conductive Heat Exchange – Physical contact with objects

• Convective Heat Exchange – circulation of medium (air/water)

• Evaporative Heat Loss - Sweat must evaporate to dissipate heat

• Radiant Heat Exchange – Sun vs shade

Preventing Heat Illness - Hydration

• Should begin activity well hydrated (24 hrs prior)

  • Monitoring urine color

• Small amounts of fluid at regular intervals prior to activity as opposed to a large quantity immediately before

• Mild dehydration is 2% of body weight lost in fluid. Even this small amount can cause symptoms and problems

• Dehydration symptoms can mimic concussion symptoms. Athlete should be removed from heat and monitored if in doubt.

Preventing Heat Illness. Fluid and Electrolyte Replacement

• Monitoring fluid loss through weight tracking

• Body requires 2.5L of water daily when engaged in minimal activity

• Adult will typically lose ~1.5L per hour during intense activity. Up to 2.5L/ hr

• 2% drop in body weight will trigger a thirst response

• Human thirst reflex is late and weak

• Unlimited access to fluids is essential

Preventing Heat Illness. Using Sports Drinks

• More effective than just water

• Flavoring results in increased desire to consume

• Replaces fluids and electrolytes

• Small amounts of sodium help in retention of water

• Optimal CHO level is 14g per 8 ounces of water

Preventing Heat Illness - Acclimatization

• Most effective method of avoiding heat stress

• Graded intensity changes are recommended with progressive exposure over 7-10 day period

• 80% of acclimatization can be achieved during first 5-6 days

• 2 hour morning and afternoon practice sessions

Preventing Heat Illness. Identifying Susceptible Individuals

• Large muscle mass

• Overweight (increased metabolic rate)

• Death from heat stroke increase 4:1 as body weight increases

• Others: poor fitness, history of heat illness, or febrile condition, the young and the elderly

• Medications

Monitoring Heat Index

• Heat, sunshine and humidity must be monitored closely

• Wet bulb globe temperature index (WBGT) is an objective measure – incorporates 3 different thermometer readings

  • Dry bulb (standard mercury temperature)

  • Wet bulb (thermometer with wet gauze that is swung around in air)

  • Black bulb (black casing that measures radiant heat)

• Formula yields WBGT index

Types of Heat Illness

• Heat Syncope

  • Associated with rapid fatigue and overexposure

  • Peripheral vasodilation🡪 pooling of blood in extremities 🡪dizziness and fainting

  • Treat by placing athlete in cool environment, consuming fluids and laying down

• Heat Cramps

  • Two working theories

    • Electrolyte Depletion and Dehydration

    • Altered Neuromuscular Control

Types of Heat Illness. Exertional Heat Exhaustion

• Inadequate fluid replacement; Unable to sustain adequate cardiac output

• profuse sweating, pale skin, mildly elevated temperature, dizziness, nausea, vomiting or diarrhea, hyperventilation, persistent muscle cramps, and loss of coordination

• Core temperature will be <104o.

• Management: Immediate fluid ingestion, Place in cool environment, Remove excess clothing

Types of Heat Illness. Exertional Heat Stroke

• Life-threatening condition; Breakdown of thermoregulatory mechanism

• Characterized by sudden onset - sudden collapse, LOC, CNS dysfunction, flushed hot skin, minimal sweating, shallow breathing, strong rapid pulse, and core temperature of > 104o F

• Cool first, transport second

Types of Heat Illness. Acute Exertional Rhabdomyolysis

• Sudden catabolic destruction and degeneration of skeletal muscle

  • Occurs during intense exercise in heat and humidity resulting in: gradual muscle weakness, swelling, pain, dark urine, renal dysfunction severe case = sudden collapse, renal failure and death

• Associated with individuals that have sickle cell trait

Types of Heat Illness. Exertional Hyponatremia

• Fluid/electrolyte disorder 🡪 abnormally low concentration of sodium in blood

• Caused by ingesting too much fluid before, during, and after exercise.

Hypothermia

• Defined as abnormally low body temperature; Temperature/wind chill/ dampness or wetness increases risk

• Heat loss > heat production via metabolism: impairment of neuromuscular function

• Core temp drop stimulates shivering but stops after temp drops below 85-90oF

• Death is imminent when temp falls below 77-85oF

• Prevention is mostly in terms of appropriate apparel and monitoring athletes and conditions

Common Cold Injuries

• Localized cooling can result in tissue damage

  • Formation of ice crystals between cells, destroys cells, disrupts blood flow, clotting may occur

• Frostnip

  • Involves, ears, nose, chin, fingers, and toes; Occurs with high wind and/or severe cold

  • Skin appears firm with cold painless areas that may peel and blister (24-72 hours)

Common Cold Injuries. Frostbite

• Due to poor peripheral circulation

• Superficial Frostbite involves only skin and subcutaneous tissue

  • Appears pale, hard, cold and waxy

• Deep Frostbite indicates frozen tissues requiring hospitalization

Altitude

• Maximum oxygen uptake decrease in performance

• Body compensates through tachycardia and hyperventilation

Altitude Illnesses

• Acute Mountain Sickness

  • 1 out of 3 will experience when making the jump 7000-8000 feet.

  • Experience headache, nausea, vomiting, sleep disturbance, and dyspnea

Altitude and Medical Conditions

• Sickle Cell Trait Reaction

  • 8-10% of African Americans have sickle cell trait (Common in Mediterranean descent also)
    Abnormality in red blood cell hemoglobin structure. Causes enlarged spleen and could rupture at high altitudes

Lightning Safety

• Emergency action plans must be set for this type of event

  • Chain of command, monitoring of weather service, decision making regarding removal and return to field

• Flash to Bang count estimates distance away for the storm

  • Count from time lightning is sighted to the clap of thunder count, divide by 5 to calculate the number of mile away

• Suspend play if you can see lightning or hear thunder

• NATA and National Weather Service recommend returning to the field 30 minutes following the last clap of thunder or lightning strike

Liability and Negligence

• Liability

  • Legal responsibility to provide a certain standard or quality of care

• Negligence

  • Failure to provide the standard of care that a reasonably prudent person would have provided.

Negligence

• Failure to use ordinary or reasonable care

• Care that one would normally exercise to avoid injury to themselves or to others under similar circumstances

• Four basic elements

  • Duty of Care, Breach of Duty (Torts), Causation, Harm

4 Elements of Negligence. Duty of Care

• A specific obligation to not harm others or their property (job description)

4 Elements of Negligence. Breach of Duty (Torts):

• “Act as a reasonable and prudent person would with the same education, background and experience”

• Act of Omission

  • Nonfeasance: When an individual fails to perform a legal duty.

• Act of Commission

  • Malfeasance: You commit an act that is not legally yours to perform.

  • Misfeasance: You do something improperly that you have a legal right to do.

4 Elements of Negligence. Causation

*Proving negligence Injury or harm

Standard of Care

• A duty to provide a certain level, or standard of care

• Who establishes the Standard of Care?

  • BOC, State Licensure

• Federal/State Law (RTP after head injury)

• Position/consensus statements of medical organizations (NATA, AMSSM, American Academy of Neurology)

• Job description

Practicing Risk Management. Reducing the Risk

• Work to establish good working relationships with athletes, parents and coworkers

• Effective communication is key

• Establish policies and procedures regarding athletic training facility and coverage (Develop emergency action plan)

• Know the medical history of athletes

• Work within scope of practice

• Annual checks and maintenance of equipment

• Follow direction of physician

• Purchase professional liability issuance

• Know state regulations

• Use common sense

Emergency Action Plan (EAP)

• Minimal criteria; All venues

Practicing Risk Management

• Policies and Procedures

  • Policies: Basic rules and principles, Procedures: Step by step processes
    Specific to the site and institution; Reduces risk by ensuring safe practices

OSHA. Occupational Safety and Health Administration

• US Department of Labor

• Guidelines for workers who will likely have exposure to blood / body fluids / pathogens

• Employer must: Train employees; Provide PPE; Offer HBV vaccinations

Bloodborne Pathogens: Universal Precautions

• Treat all blood & body fluids as if infected; Personal Protective Equipment

When bleeding occurs

• Use universal precautions (i.e. glove-up)

• Control bleeding, clean and cover wound

• Clean or change uniform if soiled

• Clean any equipment or facilities (1:10 bleach:water solution)

• WASH HANDS

Use of Gloves

• Avoid touching personal items; Avoid touching face

• Discard used or torn gloves

• Change gloves between patients

• Wash hands immediately after glove removal