What Are Concussions and Why They Matter

Submitted by TraumaRN on

I'm cognizant that this information is a day late but it is still important and still worth educating everyone about. When people ask why I'm so mad, as a medical provider, this is why. 

 

What is a concussion?

A Concussion is a mild traumatic brain injury that interferes with normal function of the brain. You cannot “see” a concussion on a CT or MRI scan and it is a clinical diagnosis based on patient history and symptoms, you do not have to have loss of consciousness (LOC) to have a concussion. Car crashes and sports injury are the leading causes of concussions  Concussions occur as a result of imparted linear and rotational accelerations of the brain that causes neurons to potentially twist or shear causing cell damage or cell death. Headache is the most common sign of a concussion, along with confusion, difficulty sleeping, amnesia(retrograde or anterograde), dizziness, fatigue, loss of consciousness, nausea, vomiting, anxiety, visual disturbances, feeling "in a fog," sensitivity to light or sound, lack of focus, delayed motor responses, loss of balance, slurred speech, and vacant or glazed over stare.

 

Concussion Grading

From the American Academy of Neurology

•Grade I –Mild

–Short term confusion, post event amnesia, symptoms resolve in < 15 minutes

–NO LOC.

This is most likely what Shane had.

 

•Grade 2 –Moderate

–Symptoms last > 15 minutes

–Again NO LOC

 

•Grade 3 –Severe

–ANY Loss of Consciousness, plus above symptoms

 

Return to Play

Grade 1 Mild

–Remove from contest

–Examine every 5 minutes for amnesia or post concussive symptoms.

–Return to activity after 1 full week without symptoms

 

Grade 2 Moderate (symptoms last longer than 15 minutes)

–Remove from contest

–Cannot return to play that day

–Examine on site on a frequent basis for signs of evolving intracranial problems

–Medical re-examination the next day

–CT or MRI if symptoms last more than one week

–Return to activity after 1 full week without symptoms

 

Grade 3 Severe

–Ambulance transport from field

–Emergent medical full neurological exam to include brain and spine, with possible CT and/or MRI

–May go home that day with head injury instructions if otherwise stable

–Hospital admission if symptomatic

–For LOC < 1 minute, return to play only after asymptomatic for 1 week

–For LOC > 1 minute, return to play only after asymptomatic for 2 weeks

 

So why are concussions so dangerous in football??

Second Impact Syndrome

Second Impact Syndrome is a condition in which the brain swells rapidly and potentially fatally after a person suffers a second concussion before symptoms from an earlier one have subsided. It is often times fatal, and if not fatal then it leaves the person permanently disabled. It is caused by blood vessels in the brain losing the ability to regulate their own diameter and results in massive overload of blood to the brain causing rapid swelling as the skull is a fixed space. This usually leads to brain herniation and then death.

 

The 6 ‘No Go’ signs

•Loss of Consciousness

•Confusion

•Amnesia

•New and/or persistent symptoms, such as headache and nausea

•Abnormal neurological findings, such as balance issues, (remember Shane stumbling?)

•Progressive, persistent, or worsening symptoms

I was surprised no one mentioned or at least I haven’t seen anyone mention the 2012 Steelers/Browns game where James Harrison hit Colt McCoy.

McCoy sent back into the game 2 plays later and less than 5 minutes after being hit. The hit was a near mirror image of what happened to Shane. http://www.youtube.com/watch?v=IfFW-Yezv0k

 

What can we do about it?

The biggest thing is to increase awareness of the general public. Encourage the public to demand player safety. Unfortunately, this incident with Shane is not how you’d like to increase awareness. Rather it needs to start with education of parents, coaches and players as soon as they begin playing football(or other high impact sport) and continue throughout their career. The macho rub some dirt on it culture needs to stop right now. Eventually it will lead to a player being killed or disabled on the field. The push for helmets with impact sensors needs to continue. And if I am being frank, they should be mandatory across all levels of football and if they detect a hit with an impact that could cause potential brain injury pull that player from the game.

Mandatory coach education is a must, and I realize many places it is already the standard but it still is clearly is not enough as we have seen. Once you get to the major college and pro level certified athletic trainers and neurologists need to be on the sidelines or in the booth and preferably both. They need the power to override coaches and refs. Period. If we're to be serious about player safety this needs to happen on the college level immediately as the NFL is getting to this point already. 

Moreover, all high impact sport governing bodies need to be absolutely punitive when it comes to head injuries, if you directly target someone with a head or neck shot you are gone immediately from that game and from the next. No exceptions, even if it is accidental. It may sound harsh and I admit it is, but at this point it is necessary.   

If there is any doubt about a head injury sit the player out, start cognitive testing and no return to play on that same day even if the symptoms resolve or aren’t readily apparent. Brain injuries can take time before symptoms become readily apparent. 

Because really how important is a game compared to being alive?

 

 

Comments

ST3

October 1st, 2014 at 4:16 PM ^

Some of the comments I've seen say that they don't grade concussions anymore, so Brandon must've stuck that language in the press release. Your post seems to contradict that.

P. S. Can a mod front page this please?

TraumaRN

October 1st, 2014 at 4:40 PM ^

Yeah there are lots of grading scales out there, the one I used is one of the more common ones in use and it is easy for the layperson to understand hence why I used it. 

And you are correct in 2008 it was recommended grading be dropped and to just use the term "concussion" for all concussions, which is fine if you are well versed in medical language but can be confusing for laypeople. Again I choose to use it because it does help clarify things, especially when we're talking severity. 

As far as the wording in the press release, I don't mind that they used mild concussion, I do have a problem with them saying "probable." You either have one, or you don't. It's like saying you probably had a heart attack, well you either had one or you didn't. It was at least from my opinion an attempt to downplay it. It didn't work because none of us are blind and we all saw the hit....moreover, it is exactly that kind of attitude we need to educate and stop because it literally is destroying the future lives of players when we downplay head injuries.  

pdxblue

October 1st, 2014 at 8:03 PM ^

Great work!   As a practicing emergency physician, I agree with your overall message and strongly support your effort to inform.

I will, however, disagree on you continued use of a concussion grading scale.   Both the American Academy of Neurology and the Concussion in Sports Group have dropped grading of concussion from their recommendations.  When I talk to patients and their families, I do not use the grading scale for a number of reasons:

1)  The scale had no prognostic value.  A person who graded as "mild" could have cognitive effects that are more significant and longer in duration than someone graded as "severe."   As you point out, recurrence of concussion, especially soon after a previous concussion is the most important factor.

 

2)  When a concussion is termed "mild," it just serves to downplay the severity.  Families always want me to tell them its "mild" and their future scholarship athlete can go to practice tomorrow.  They get bummed when I tell them "no."  

 

3)  Its not an accepted diagnosis anymore.

I have a huge problem with Brandon using the term "mild" in his press release because no medical staff person, especially a neurologist who is a world expert in concussion, would use that term.  I agree with you on the "probable" piece.   You either have on or you don't.

Overall, great work!  Just had to nitpick on a nursing colleague a little.  ;-)

TraumaRN

October 1st, 2014 at 9:52 PM ^

Oh I get it that you have to jazz me, and I realize what you're saying and I don't disagree. In my current role it is just concussion and no grading. I'm just trying to help the general public but aware and I know it's outdated information but if it at least helps people understand then I've succeeded. 

Thanks for the input regardless. I just felt like the medical/nursing side of things was missing from this whole situation. 

remdog

October 1st, 2014 at 11:27 PM ^

I generally agree but not entirely.

#1. There is some prognostic value to the degree of concussion according to some studies.  But as you point out, a "mild" concussion may have more significant long term effects than a "severe" discussion.  So yes, it's not of practical use in individual cases.  

#2. I think it can be valuable to reassure someone or their family that they do not appear to have had a "severe" brain injury in some cases but at the same time, emphasizing the difficulty in predicting the degree or duration of symptoms, the serious risk of recurrent concussions (the high prevalance within 10 days of a recent concussion and the higher risk of long term sequelae with such a recurrence), the need to avoid the risk of a recurrent concussion and the need to have close follow up and clearance by trained medical personnel before returning to higher risk activities.  Patient and family anxiety regarding these injuries can be extremely problematic since they often literally fear the absolute worst.  I strongly suspect allaying some of this anxiety can be beneficial for their overall mental and physical health.  Acceptable physician practice may vary.

#3. I disagree with you on the use of the word "probable."  Although the word is not acceptable in "codable" diagnoses anymore, there are many clinical situations where there is not diagnostic certainty and this may have been one such case.

I think our knowledge about and management of brain injuries is constantly evolving and it's important to realize this and follow conservative guidelines.

remdog

October 1st, 2014 at 11:42 PM ^

As an emergency physician, I appreciate your thoughtful insights and comments.

I agree with your feelings about the use of grading.  It can be useful in some cases to allay patient and family anxiety by communicating to them that the brain injury does not appear "severe."  Lay people often fear the absolute worst.  Alleviating some of their fears is likely very beneficial to their mental and physical health.

I also suspect the use of grading systems may possibly be more useful in time with greater research and modification.

As for the use of the word "probable," I do think it's different from a heart attack.  Unlike a heart attack, there is no laboratory or imaging study to determine whether you have had a concussion so it's purely a clinical diagnosis based on the history and exam.  In some cases, there can be clinical uncertainty so the use of the word "probable" may be appropriate.  And even in the case of a heart attack, our tests are not always definitive in some rare cases. 

El Jeffe

October 1st, 2014 at 4:16 PM ^

Thank you for this. Very educational and passionately-written.

I agree that tackling with the helmet, especially if there is targeting to the head or neck, need to be and can be drummed out of football if it starts early enough. This would require all football governing bodies to agree that leading with the helmet and especially targeting ball carriers' heads and necks would result in the kind of penalties the OP suggests--ejection and further suspension.

jshclhn

October 1st, 2014 at 4:32 PM ^

Love the comment about the need for medical staff to have override power.

For that matter, teammates should have override power.  As part of their onboarding and at least annual team meetings, as a major college football player you should explicitly be given the charge to have the courage to intervene.  If you are an OL, and you see your quarterback a few yards away stumbling around you with symptoms - man up, tell him to sit down and let the medical staff take a look at him.

bronxblue

October 1st, 2014 at 7:12 PM ^

Great stuff.  Thanks for sharing.  I agree that Brandon's claim of "probable" felt more like CYA than anything he received from the medical staff, though obviously I wasn't there so I don't know.  

Honest question - given the fact that the concussion tests were clearly not administered until sometime later, how easy is it to diagnose a "mild" concussion?  I know the test takes some time, but given the short duration of the symptoms I wonder how what they could still determine from his current state and how much was based on a review of the hit and the video evidence.

GoBLUinTX

October 1st, 2014 at 10:31 PM ^

What do you think of this one, also from 2012, but far closer to home.  I should add that this player, though removed from this series, returned the very next defensive series.

 

UMgradMSUdad

October 1st, 2014 at 11:16 PM ^

The medical personnel already have the power to determine whether a player gets held out or not. People are understandably upset at Hoke and Brandon, especially for their handling of communicating to the public after the game, but why is there no criticism of the medical staff?  Aren't they the ones who are supposed to evaluate the players and advise the coaches on when players are good to go or must be held out of the game due to medical concerns?

GoBLUinTX

October 2nd, 2014 at 12:04 AM ^

aren't the ones with the poor W-L record.  But I hear you, when Paul Schmidt saw Morris stumble and lean on Braden, which reportedly he did see, why didn't he go to him immediately? 

Furthermore, the unnamed neurologist on the sideline who allegedly was making his way to Morris to examine him, why didn't he conduct the examine immediately after Morris returned to the sideline? 

Why won't the media exhibit some intellectual curiousity about what the UM medical staff were/weren't doing?

wolfman81

October 2nd, 2014 at 1:26 PM ^

Where WAS the neurologist?  From what I can gather, he wasn't on the sideline.  Why doesn't HE have a headset if he's not there.  Morris came off, had doctors looking at his ankle, and then went back in despite the neurologist wanting to do an exam.  How about that failure of communication?

I may not buy the whole, "I didn't see the hit" garbage we've been hearing from the coaches. But this seems to be squarely on the medical staff too. Coaches aren't supposed to question the med staff, if they say "No go" player must sit.  This is obviously the converse situation.  But the number of people who didn't see the hit is incredulous:  Hoke, Nussmeier, other field coaches, medical staff,...Morris comes off after having stumbled around and they look at his ankle, but nobody in the viscinity of Shane was like, "Hey, dude just got his bell rung, we might want to look into that.  He can't play yet."

DrewGOBLUE

October 2nd, 2014 at 6:48 AM ^

Out of curiosity, I was just reading a bit on some of the more detailed aspects of concussion pathology. What caught my attention though was the recommendation that after a concussion occurs, the affected individual should avoid both physical and cognitive exertion, given that both can worsen the prognosis.



I certainly wonder if Morris was instructed to take these precautions. Does anyone have insight on whether or not the avoidance of such activities for several days is widely recognized as part of the recovery process?



Side note: this information is from a 2012 publication - http://www.healio.com/pediatrics/journals/pedann/2012-9-41-9/%7Bc125fe5…

TraumaRN

October 2nd, 2014 at 8:32 AM ^

I haven't looked it up but just going off my knowledge base the recommedation for no physical exertion is to limit further damage probably on the idea of physical exertion raises intracranial pressure which can then be highly problematic....it is a fairly complex answer and don't lambast me for doing this but the Wikipedia article on the topic does a fairly decent job answering why physical exertion might worsen a concussion outcomes. http://en.wikipedia.org/wiki/Intracranial_pressure

Read up on the Monro-Kellie hypothesis and then the pathophysiology section.