Heads up on teen athlete concussions

When legislators pass laws mandating health care practices, it usually means we've missed an opportunity to protect vulnerable citizens. 

Thirty-two states have recently legislated management of student-athlete concussions; others have laws pending. ⁽¹⁾Quite obviously, EMS, coaches, and the medical community have dropped the ball on teen athlete concussions. Alarm bells first sounded in 2006 when several high profile head injuries left teen-aged athletes with debilitating brain damage. Most died; those who survived require lifelong care.

The cause of these head injuries were often not major blows to the head, but rather an anomaly called, "Second Impact Syndrome" where a player sustains a second blow to the head before fully recovering from an earlier head trauma. This poorly understood cascade of events leads to diffuse brain swelling and in most cases, death. Every reported case has involved an athlete under 20 years old. The mechanism is repetitive head trauma, especially in children and adolescents who take considerably longer than adults to fully recover from any blow to the head.

The first step in reducing concussions is appreciating the risks. An estimated 3.8 million sports-related concussions occur annually in the United States, accounting for 8.9 percent of all high school athletic injuries with a higher reported incidence in girls than in boys in similar sports. In rank order, football has the highest concussion incidence, followed by girl's soccer, boy's lacrosse, boy's soccer, girl's basketball, wrestling, girl's lacrosse, softball, boy’s basketball, boys and girl's volleyball, and baseball. Rugby and ice hockey also have high concussion rates, but good data are lacking as are meaningful data on skateboarding, skiing and snowboarding, or mountain biking. Twenty percent of high school and 40 percent of college football players will suffer at least one concussion. Clearly, the incidence is high and the risk significant.⁽²⁾

Prevention is good medicine. Helmets have clearly demonstrated benefits in bicycling, motor sports, horseback riding, skiing and snowboarding. In football, hockey, and other high-energy contact sports, helmets reduce impact forces to the face, head, and brain but have not consistently lowered player concussion rates.

This is important for coaches and EMS providers who may be lulled into a false sense of security, believing that a properly fitted helmet protected an injured athlete from significant head injury. Beware! Nonetheless, in sports and recreational activities where protective headgear or helmets are available, they should be used. Injury prevention is part of emergency medical services. If you see unsafe play, consider it your role to intervene.

Treatment protocols for EMS
Treatment is where we've all dropped the ball, and the reason why elected officials have taken it upon themselves to mandate better assessment and care for teens and kids with concussions.  Most adults (80 to 90 percent) will fully recover from a concussion within seven to ten days.⁽³⁾

Children and adolescents take considerably longer to achieve full recovery, often several weeks.  In 92 percent of repeat concussions, the second injury happens within 10 days of the first. For younger athletes, that’s a perfect setup for a lethal Second Impact Syndrome. 

Let's start with the definition of a concussion, which has changed considerably over time.  Today, concussion is defined as a trauma-induced, short-lived disruption of brain function.  Since a concussion is physiologic and not structural, it cannot be seen on imaging studies like x-ray or CT scan. Loss of consciousness (LOC) may occur with concussions, but is rare (seen in less than 10 percent).

Like LOC, amnesia indicates a more serious injury. A player should be assessed for retrograde (before the injury) and antegrade (after injury) amnesia by inquiring about details of events. Symptoms of retrograde amnesia may improve over time, although it is more likely that an injured athlete hears others talking about the event and falsely reports return of memory. Mental fogginess predicts a slower recovery from concussion.

Field exam for concussion in an injured athlete can be challenging. Beyond the issues of obvious injury, there are two key questions the EMS provider will be asked to resolve: has the athlete experienced a concussion and can they return to play? There have been at least 25 different concussion grading scales published over the years. While three of these are still commonly used in North America, expert consensus strongly suggests shifting to a symptom based approach for concussion assessment and determination of return to play.

The American Academy of Pediatrics recommends that physicians use the consensus based SCAT2 (Sport Concussion Assessment Tool 2) for evaluation of a head injured athlete aged 10 or older. While not appropriate for prehospital EMS use, the tool does provide an excellent source of criteria for an EMS provider to suspect a concussion.  If any one or more of these are present, suspect a concussion:

1. Symptoms – headache (most common), nausea, dizziness, visual problems, light sensitivity, noise sensitivity, excessive fatigue, or feeling mentally "foggy."

2. Physical signs – unsteady gait, balance or coordination problems, or vomiting.

3. Impaired brain function – confusion, amnesia, mental fogginess, difficulty concentrating, answers questions slowly, repeats questions, sleepy, dazed, or stunned.

4. Abnormal behavior – irritability, nervousness, aggressiveness, more emotional, sad, or different from baseline.

Any athlete with a suspected concussion must be removed from play and medically assessed (which means transported to a medical facility or seen by their personal physician). Additionally, they should not be allowed to return to play on the same day as the initial injury, even if the signs and symptoms resolve. Ensure that they are monitored for deterioration (i.e., not left alone) and advise them not to operate a motor vehicle.

Return-to-play guidelines vary. Your state may have legislated specific guidelines. Your school district or sports club may have specific return to play guidelines. If none of these exist, your department should have a return to play SOG. The American Academy of Pediatrics recommends a stepped progression of physical activity, beginning with complete rest until all symptoms totally resolve and then slowly increasing levels of exertion while monitoring for any return of symptoms.

Once medically cleared and able to participate in sports practice without symptoms, the athlete can return to play. Any return of symptoms during activity suggests incomplete recovery from the concussion and requires at least 24 hours of rest. A minimum of five days is required to progress towards full return to play. Most players with a minor concussion will recover in seven to ten days.

The Centers for Disease Control and Prevention (CDC) recognize the need to raise awareness of the serious consequences of sports related concussions in younger players. They have created a web site (www.cdc.gov/concussion/HeadsUp/youth.html) for parents, coaches, and athletes on prevention, recognition, and treatment of sports head injuries. For medical professionals like yourself, a consortium of organizations and experts have developed a web site (http://preventingconcussions.org/) with a wide variety of training materials and resources on recognizing, preventing, and treating concussions in young athletes.

Our elected officials are telling us loudly and clearly that we've dropped the ball on protecting and properly treating younger athletes with concussions. It's time for EMS to join with the rest of the medical community and adopt a heads up approach to making sure that every sports related head injury gets a thorough assessment and proper follow up. Catastrophic consequences come more often from repeated injuries within hours or days of the initial insult than they do from major blows. EMS can put the brakes on this life altering event. The future life and well being of a child is priceless.

References 

1.) National Conference of State Legislatures (http://www.ncsl.org/default.aspx?tabid=18687)

2.) Halstead ME, Walter KD, and the Council on Sports Medicine and Fitness.  Clinical Report – Sport-Related Concussion in Children and Adolescents.  Pediatrics. 2010;126(3):597-615.

3.) McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M and Cantu R.  Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med 2009;43(Suppl I):i76–i84.

Mueller FO. Catastrophic Head Injuries in High School and Collegiate Sports. J Athl Train. 2001;36(3):312-315.