S3E8: Concussion - Sports
We’ve something new! Leah is entering the world of Sports and Exercise Medicine with Dr Carl Byrne, Emergency Medicine SpR and sports med fanatic. Aoife joins them from behind the scenes of TCR to discuss all things concussion.
Professor John Ryan, Head of Medicine in Leinster Rugby and Consultant in Emergency Medicine in St. Vincent’s University Hospital is our Adult in the Room this month and helps us along our way.
On balance, we’ve decided to start splitting our cases to give you even more content to look forward to throughout the month. Our bonus Sports Medicine segment will be released in two weeks time so don’t worry, you can have even more TCR to listen to.
AND… We’re introducing some fun new show notes which can be used as infographics and posters for teaching cases within your department. Catch the start of them below and watch our Twitter space where we will start to release ones for old cases.
The Case
A 19 year-old female presents to the Emergency Department with her parent after sustaining a head injury during a rugby match.
History
Drill down into the mechanism as much as you can
Direct contact with the head/ neck?
What hit the patient?
Loss of consciousness
Vomiting/ dysphasia
Retrograde/ anterograde amnesia
Confusion
Subsequent weakness/ going back down onto knees after injury/ slow to get up
Change in play/ change in performance
Any knocks earlier on or history of head injuries/ concussions in the past?
Videos/ recordings of the game and the injury occurring can be very helpful
Rigidity/ tonic posturing. The classic “fencing response”
Seizure
Establish their pre-game form
Examination
Vital signs
Evidence of a head injury/ basal skull injury
Full neurological examination
Vestibular system
Cervical spine
Secondary survey- possible to miss other injuries sustained during the game
Differential Diagnosis
Intracranial: ICH/ underlying neurological condition, idiopathic intracranial hypertension, malignancy
Electrolyte: Dehydration, electrolyte imbalance e.g. hyponatraemia
?Collapse work-up
Cardiovascular conditions
Keep your thinking cap on, particularly in patients that re-present with ongoing symptoms
Mental health complaints such as depression or anxiety may be triggered by head injury
Could this be a viral illness, ENT condition or even an endocrinological pathology such as diabetes or thyroid dysfunction?
Investigations
Remember that there’s often very little indication for lab work unless you have a high suspicion for an alternative cause or if the history isn’t quite fitting the way that you’d like. In terms of radiological investigations, aim to follow guidelines locally or using NICE Guidelines for CT Brain in head injury. You can use the Canadian C-Spine rules to assist on deciding on the imaging the neck. In many cases, these patients do not require any imaging and provided on their social circumstances, may be discharged home with strict safety net advice as outlined below.
Patient Education
This is the really important bit. In all cases, we should feel comfortable and proficient in explaining to the patient and whoever may be in attendance with them what the diagnosis of concussion means, what they should expect in coming days to weeks, return to play strategies if applicable and the all important red flags to return for. Ideally, written leaflets are also very helpful if they are available in your department or you can direct patients’ families to certain websites which we’ve outlined below. The reality is they will Google so help them get it from the right places!
What is concussion?
Ultimately, concussion is a form of traumatic brain injury. This is not a benign condition. The chronic consequences of this can be very serious for patients. It is caused by a direct trauma to the head which causes the brain to shift rapidly backwards and forwards within an enclosed space. This is thought to cause stretching of neurones and a chemical imbalance.
What supports the diagnosis of concussion?
It’s mostly signs and symptoms. Less emphasis on investigations. Patients complain of headaches and may have a single episode of vomiting. Photophobia, audiophobia, irritability and change in personality are all possible and again, should be interpreted in the context of the overall presentation. Actually, friends, family and teammates will all tell you more about some of the symptoms faster than the patient. They will point out slowed speech, objective confusion or slightly odd behaviour. Neurological examination is usually normal. It’s important to explain to patients and that a CT scan will not assist us in diagnosing this and we use evidence-based medicine and international guidelines to help us avoid performing unnecessary scans which are not indicated.
What’s next?
Symptoms can take up to 24-48 hours to fully manifest themselves. Usually most have then resolved by about 1-2 weeks but can last for a number of weeks after this. Sleep can be affected but encouraging good sleep hygiene is important. Triggers for concussive symptoms in the acute period include bright lights, screens, loud music, stress, alcohol and strenuous mental work requiring high levels of concentration. If a patient is still complaining of symptoms past the 2 week mark, they’re usually vestibular related or will be complaining of cervicogenic headaches. Difficult concentrating, balance problems, nausea, dizziness and visual disturbance can all occur at this stage. Physiotherapists with an interest in vestibular retraining can be helpful for these patients. Their recovery can be increased quite rapidly as a result of this.
Can they play the next big game?
A tricky conversation to have with anyone who is passionate about sports! However, counselling patients on why it is important to avoid further injuries and why you are telling them to stay out of matches does help. If they think you’re just being difficult, that isn’t going to help their irritability! Keep them future focused and give them local guidelines or guidelines from their sporting body to follow. We reference the IRFU Return to Play Protocol frequently in the case. Remind the patient that this applies to all sports if they are playing anything else. There is a discrepancy between amateur and professional players but 21 days is usually quoted as an approximate guide. However, that goes with the caveat that the patient must be symptom free before returning to play. Ideally, a patient should have a medical review with their GP or sports medicine physician before returning to play.
A ticket out of the mock exams?
Cognitive rest is quite important. The average return to full education is considered 8 days but there may need to be some adjustments made to this. In the acute 24-48h, this is particularly important and then a gradual return to full education can be implemented depending on the patient and their symptoms. Shorter days and adjustment in lessons is better than pulling a patient entirely from school. Writing a detail medical cert on discharge outlining what the patient can and can’t engage in and what you advise is more important than a “blanket ban for a week”. There actually aren’t great guidelines in Ireland on the return to education formally- a little nudge to all you research enthusiasts!
Symptom Management
Simple analgesia for headaches only. Avoid opiates and codeine-based medications in particular which can cause a medication-induced headache and worsen symptoms. Prevention is always better than cure so advise them to avoid triggers as much as possible in the acute phase. Caffeine-based analgesia has been suggested colloquially but this is more user dependent and how much caffeine they are usually already taking. It’s more useful in patients with low ICP rather than concussion.
Red Flag Advice
They don’t need a scan… yet! Give written information including criteria that they may start meeting NICE Guidelines for a CT. Behaviour that is erratic or out of proportion. Seizures, multiple episodes of vomiting, CSF rhinorrhoea or otorrhoea should all be bringing this patient back. We always give the caveat that if they just aren’t happy and there might be something that their family or friends are concerned about, they’re better bringing the patient back for a second review.
Second Impact Syndrome
Second impact syndrome has been mentioned in some research. A review carried out in 2016, noted that there have only been 36 cases reported globally. It usually relates to patients that return to play early (usually within the same game) while remaining symptomatic and sustain a second head injury. Even if the second hit is minor, it can lead to rapid, fatal brain oedema. It’s thought to be due to loss of autoregulation. When you have concussion and the neurones stretch, there is some chemical and neurotransmitter leakage around the brain. This increases glucose demand in the recovery phase which alters blood flow. A second impact is thought to cause dysautoregulation, oedema and raised intracranial pressure. An alternative theory suggests that in a more severe head initial head injury, there may be a very small subdural or pathology which may recover spontaneously but if a second impact occurs, this clot can be disrupted and cause raised ICP. It is, thankfully, a very rare phenomenon.
SCAT-5
The Sport Concussion Assessment Tool (5th Edition) or “SCAT-5” is a well-renowned tool used in the assessment of patients with concussion in sport at the pitch-side. Usually, in elite sports, a baseline SCAT-5 is completed by the player with their medical team at the beginning of the season and this can be subsequently compared to a result during a HIA (Head Injury Assessment). Patients with concussion usually rate their symptoms as mild to moderate and score approximately a 20-40 points out of 132. There is also guidance for a neurological examination to complete for the evaluating clinician. In the Emergency Department, try find a quiet place if possible to perform this as there will be a concentration and memory assessment. In a busy environment, this can create a false reading for the patient.
Follow Up
Ideally, patients should have a medical check from a GP or sports medicine physician prior to returning to play. We speak about concussion or sports medicine review clinics but we recognise that these aren’t widely available in Emergency Departments in Ireland currently and capacity issues limit accessibility to these. As a result, this can fall to the general practitioner to assess the patient in follow up. There are not a huge amount of clinicians that are specialists in complex concussions. Emergency physicians, sports and exercise and rehab consultants sometimes have training in managing them.
What’s Coming in the World of Concussion?
Most of our current concussion guidance comes from the Berlin Conference which was held in 2016. The subsequent British Journal and Sports and Exercise Medicine edition published the outcomes from these discussions which created the groundwork for our current evidence for concussion investigation and management. We link the consensus statement below but the edition can be accessed online. This was due to be revised in 2020 but due to the pandemic, was postponed. It was held in Amsterdam in November 2022. The findings from that will likely be published in the coming months in the BJSEM.
References
O’Sullivan, I. (2021) ‘Concussion and Sport.’ Available on: https://emed.ie/Trauma/Head_Neck/TBI_Sport.php.
Cantu, R. (2016) ‘Dysautoregulation/ Second Impact Syndrome with Recurrent Athletic Head Injury,’ World Neurosurgery 95: Available at: http://dx.doi.org/10.1016/j.wneu.2016.04.056601-602.
Concussion in Sport Group (2017). ‘Sport Concussion Assessment Tool- 5th Edition. British Journal of Sports Medicine.’ Available at: https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf
Irish Rugby Football Union (2018) ‘Return to Play Protocol and Concussion Guidelines.’ Available online at: https://d19fc3vd0ojo3m.cloudfront.net/irfu/wp-content/uploads/2019/01/30172053/IRFU-Concussion-Brochure-2018.pdf.
Concussion in Sport Group (2017) ‘Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016.’
NICE Guidelines for Performing a CT Head in Head Injury. Available online: https://www.nice.org.uk/guidance/cg176/chapter/Recommendations.
Bovard, J (2019) ABC Assessment of Concussion’. British Journal of Sports and Exercise Medicine. Available at: https://blogs.bmj.com/bjsm/2019/05/13/assessing-concussion-as-easy-as-abc-dr-jim-bovard-episode-380/
