October 3, 2019
Focus | Sports-Related Concussions
Special thanks to John Kiel, DO, MPH, Assistant Professor of Emergency Medicine and Sports Medicine, UF College of Medicine–Jacksonville for providing content. 
Football season is in full swing, so get PEDReady for concussion management!

Over the last several decades, reported sport-related concussions (SRCs) have been increasing for several reasons:
  • exposure to contact sports at younger ages  
  • long-term exposure to repetitive head trauma
  • increased reporting and overall awareness
  • improved lay public education

Did You Know?

  • 1.9 million SRRCs (sports- or recreation-related concussions) occur annually in children under 18 years or younger in the U.S. (Coronado, 2015).

  • 329,000 children were treated in the ED for SRRCs. That number has increased from 2001 to 2012 (MMWR, 2011).

  • SRRC is frequently missed in the ED. Only 200/443 pediatric patients who met criteria were diagnosed by emergency physicians (Boutis, 2015).

  • The #1 predictor of a patient’s recovery from SRRC is the severity of a person’s symptoms in first day or two (McCrory, 2017).
What is a Sports-Related Concussion (SRC)?
There is currently no universally accepted definition of SRC. Debate still exists as to whether the term 'concussion' or 'mild traumatic brain injury (mTBI)' should be used to describe the injury. Concussion is often considered a subset of mTBI.

Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 ( source ):
Sport-related concussion is a traumatic brain injury induced by biomechanical forces.
  • SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
  • SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
  • SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  • SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness.
  • Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged. The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc.) or other comorbidities (eg, psychological factors or coexisting medical conditions).

American Congress of Rehabilitation Medicine definition of concussion:
Traumatically-induced physiological disruption of brain function, as manifested by at least one of the following:
  • Any period of loss of consciousness
  • Any loss of memory for events immediately before or after the accident
  • Any alteration in mental state at the time of the accident
  • Focal neurological deficit(s) that may or may not be transient
  • But where the severity of the injury does not exceed the following:
  • LOC of 30 minutes or less
  • After 30 min an initial Glasgow Coma Scale (GCS) of 13–15
  • Posttraumatic amnesia (PTA) not greater than 24 h
Sequelae of Missed Concussion Diagnosis:
  • Prolonged recovery
  • Delayed RTP (return to play)
  • Repeat concussion
  • Post-concussive syndrome
  • Symptoms of concussion persist for weeks or months
  • Psychosocial consequences (depression, anxiety, behavioral change, suicide)
  • “Second impact syndrome”
  • autonomic dysfunction, cerebral edema, herniation and even death
  • Chronic Traumatic Encephalopathy (CTE)
Risk Factors:
  • History of previous concussion
  • Younger age
  • Certain sports positions
  • Past medical history:
  • Learning disorder
  • ADD
  • Migraines
  • Mood disorder (anxiety, depression, other)
Key ED and EMS Evaluation Questions:
  • Mechanism of injury
  • Who witnessed the event?
  • Duration of symptoms
  • Was patient removed from play or returned to play?
  • Subsequent activity?
  • LOC? (occurs in a small percentage of concussions)
  • Previous concussions? If yes, then may have more symptoms and prolonged recovery
Signs & Symptoms:
There are four categories: physical, cognitive, emotional and sleep:
  • Younger athletes have challenges reporting symptoms (e.g. balance, vision, fatigue, emotional changes, irritability, memory and concentration)
  • Headache and dizziness are very common
  • Seizures are uncommon—do not confuse with fencing (abnormal posturing due to brainstem reflexes). Watch this video for an example
Concussion Tools:
SCAT5

SCAT5 is a standardized tool for evaluating concussions designed for use by physicians and licensed healthcare professionals.* The SCAT5 cannot be performed correctly in less than 10 minutes .

SCAT5 includes 6 steps: immediate or on-field assessment, symptom evaluation, cognitive screening, neurological screening, delayed recall and decision.

Use the SCAT5 Sport Concussion Assessment Tool to evaluate athletes ages 13 years and older .

For children ages 5-12 years of age, please use the Child SCAT5 Sport Concussion Assessment Tool .

*If you are not a physician or licensed healthcare professional, please use the Concussion Recognition Tool 5 (CRT5) .

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)

ImPACT is an FDA-cleared medical device purchased and used by healthcare, educational and sports organizations to assess and manage concussions.
Managing Concussions:
Management:
  • Primary management: removal from all high-risk activity
  • Requires re-evaluation by a physician/licensed healthcare provider with concussion training (state legislation varies)
  • Typical 24-48 hours before increasing activity to sub-symptom exacerbation threshold
  • Avoid: excessive or prolonged physical, visual, auditory of cognitive stimulation during the first few days following initial injury, especially if these activities are provoking or exacerbating symptoms
  • Headaches
  • Acetaminophen
  • NSAIDS
  • 3% NS, 10 ml/kg improved HA for 2-3 days following presentation (Lumba-Brown, 2014)

Disposition:
  • Need follow up with physician familiar with concussion management
  • Until re-evaluated, avoid
  • All physical or high-risk activity including participating in sports
  • Physical education
  • Any other recreational activity

Typical Progression:
  • Most athletes take 10-14 days to recover
  • Longer in younger children
  • Close monitoring of symptoms
  • Graded return to activities
  • School (1/2), full day, jog at practice, non-contact practice, contact, game
  • If premature return to sport
  • High risk of recurrent or prolonged symptoms
  • Persistent post-concussive symptoms
  • Failure of symptoms to resolve in 2 weeks in adults, 4 weeks in children
  • Severe symptoms may require specialized physical therapy, cervical, vestibular or ocular therapy, cognitive behavioral therapy
  • Potentially a discontinuation of the offending sport
Take Home Points:
  • Transport!
  • Beware of teens minimizing symptoms to continue play
  • Younger patients are harder to evaluate
  • Strongly consider using validated concussion tool (SCAT5)
  • Limited role for imaging in SRRC unless positive PECARN and MRI is the neuroimaging modality of choice in patients with prolonged concussion
  • Know your local concussion policies, resources and state laws:
  • FL requires clearing health professional to be a licensed physician or trained in TBI management, training for coaches, athlete education and parent education (learn more)
  • To review concussion legislation by state, click here
  • Stay tuned for concussion biomarkers in the future
Resources:
References:
  • McCrory, Paul, et al. “Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016.” Br J Sports Med (2017): bjsports-2017.
  • Taylor CA, Bell JM, et al. Traumatic Brain Injury–Related Emergency Department Visits, Hospitalizations, and Deaths — United States, 2007 and 2013. MMWR Surveill Summ 2017;66(No. SS-9):1–16.
  • Coronado VG, Haileyesus T, et al. Trends in sports- and recreation-related traumatic brain injuries treated in US emergency departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012. J Head Trauma Rehabil 2015; 30 (3): 185–197.
  • Centers for Disease Control and Prevention. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged ≤19 years–United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2011;60(39):1337–1342 pmid:21976115
  • Boutis K, Weerdenburg K, Koo E, Schneeweiss S, Zemek R. The diagnosis of concussion in a pediatric emergency department. J Pediatr. 2015 May;166(5):1214-1220.e1. doi: 10.1016/j.jpeds.2015.02.013. PubMed PMID: 25919731.
  • O’Connor, K., et al. “History of diagnosed and undiagnosed concussions at baseline had differential impact on neurocognitive performance and symptom scores.” Journal of the Neurological Sciences 381 (2017): 758.
  • Bey T, Ostick B. Second impact syndrome. West J Emerg Med. 2009;10(1):6-10.
  • Harmon, Kimberly G., et al. “American Medical Society for Sports Medicine position statement: concussion in sport.” Br J Sports Med 47.1 (2013): 15-26.
  • Currie DW, Comstock RD, Fields SK, Cantu RC. A Paired Comparison of Initial and Recurrent Concussions Sustained by US High School Athletes Within a Single Athletic Season. J Head Trauma Rehabil. 2017 Mar/Apr;32(2):90-97.
  • Wennberg, Richard, et al. “Is concussion a risk factor for epilepsy?” Canadian journal of neurological sciences 45.3 (2018): 275-282.
  • Currie, Dustin W., et al. “A paired comparison of initial and recurrent concussions sustained by US high school athletes within a single athletic season.” Journal of head trauma rehabilitation 32.2 (2017): 90-97.
  • Mastrangelo M, Midulla F. Minor Head Trauma in the Pediatric Emergency Department: Decision Making Nodes. Current pediatric reviews. 2017;13(2):92-9.
  • Amyot F, Arciniegas DB, Brazaitis MP, Curley KC, Diaz-Arrastia R, Gandjbakhche A, et al. A Review of the Effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury. Journal of neurotrauma. 2015;32(22):1693-721.
  • McCrea M, Meier T, Huber D, Ptito A, Bigler E, Debert CT, et al. Role of advanced neuroimaging, fluid biomarkers and genetic testing in the assessment of sport-related concussion: a systematic review. British journal of sports medicine. 2017;51(12):919-29.
  • Lewis LM, Schloemann DT, Papa L, Fucetola RP, Bazarian J, Lindburg M, et al. Utility of Serum Biomarkers in the Diagnosis and Stratification of Mild Traumatic Brain Injury. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine. 2017;24(6):710-20.
  • Lumba-Brown A, Harley J, Lucio S, Vaida F, Hilfiker M. Hypertonic saline as a therapy for pediatric concussive pain: a randomized controlled trial of symptom treatment in the emergency department. Pediatr Emerg Care. 2014 Mar;30(3):139-45.
  • Bryan, Mersine A., et al. “Sports-and recreation-related concussions in US youth.” Pediatrics 138.1 (2016): e20154635.
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Children's Disaster Services Workshop
October 11-12, 2019 | Tampa, FL
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This is a specialized training for Certified Child Life Professionals only. Certified child life specialists are invited to register. Ten PDU’s are available.
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October 29-30, 2019 | St. Petersburg, FL
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Experts in pediatric and adult trauma will discuss a range of current issues. Day 1 will cover pediatric trauma; day 2 will cover adult trauma. Registration fee is $25/day.

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November 6-7, 2019 | 8:30-4:30 pm | St. Augustine, FL
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This 2-day (16-hour) course provides EMS and Mobile Healthcare (MHC) practitioners with the skills to effectively interact with patients and their families, other medical personnel, co-workers, supervisors and community residents. This course is appropriate for EMTs, paramedics, other MHC practitioners and emergency responders. Upon successful completion, students receive a certificate, wallet card
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Pediatric Care After Resuscitation (PCAR) Course
Dec 2-3, 2019 | Jacksonville, FL

The mission of TCAR (Trauma Care After Resuscitation) Education Programs is to expand the knowledge base and clinical reasoning skills of nurses who work with injured patients anywhere along the trauma continuum of care, particularly in the post-resuscitation phase. 
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