By Laurence Degelsmith, MD
November 9, 2007
I can always tell when football season starts because we see one head injury after another in the emergency department.
Some head injuries are mild and require no more than reassurance to the patient and family members. Other injuries are clearly more severe on initial presentation and require more aggressive evaluation including a CT scan and occasional overnight observation. A few patients present with serious trauma to the head requiring neurosurgical evaluation and sometimes surgery for bleeding or swelling.
The majority of head injuries that we see in the emergency department fall somewhere between minor and moderate and require a thorough neurological evaluation by the emergency physician and sometimes a CT scan of the head. An MRI is almost never indicated during acute management of a head injury, but it is sometimes ordered to evaluate a suspected neck injury.
I order CT scans on about half of the patients I see with head injuries. The factors I use when deciding when to order a CT scan are loss of consciousness for several minutes (not a few seconds); severe headache; dizziness; vomiting more than once; not acting “right;” age of more than 60 years depending on the mechanism of injury; and the presence of Coumadin, a blood thinner. People on aspirin have not been shown to have higher incidences of bleeding in the brain than those who are not. Keep in mind that most of the very mild injuries don’t come for medical evaluation and the severe injuries usually go directly to Westchester Medical Center in Valhalla by ambulance where a trauma service is available twenty-four hours a day.
Concussions
A concussion is defined as a temporary loss of normal brain function, usually following a blow to the head. Contrary to popular belief, concussions can occur without a loss of consciousness. The majority of people who have a concussion do not experience any loss of consciousness, but will have other typical concussive symptoms including dizziness, prolonged headache, vision disturbances, nausea or vomiting, impaired balance, confusion, difficulty concentrating, sensitivity to light and amnesia of the event.
A concussion occurs when a blow to the head is strong enough to cause the brain to be shaken within the skull cavity, usually in a rotational manner, which transiently affects transmission of electrical impulses within the brain. Depending on the severity of the forces exerted on the brain, a person may be dazed for an instant or may remain unconscious for periods exceeding ten minutes. The length of time a person remains unconscious usually correlates with the severity of the concussion and the risk of prolonged symptoms known as post-concussive syndrome.
A person with a concussion often cannot remember events immediately before or after the event. Besides memory, a concussion can affect judgment, reflexes, speech, balance and muscle coordination. Typically, a patient continues to ask what happened to him even after being told repeatedly. Concussions are very common among high school, college and professional athletes, especially football and soccer players. They are also caused by bicycle and automobile accidents. Football players who do suffer a concussion are four to six times more likely to suffer a second concussion.
Grading concussions
Concussions are often graded into one of three types. Grading a concussion is helpful in determining the management of the patient, which often includes deciding when an injured player can participate in sports again. There are a few published guidelines used by coaches and trainers which set limits on returning a player to active participation in sports but these guidelines often vary.
The key point is to prevent a player from suffering a second concussion before the first one has completely healed. This phenomenon, called “second-impact syndrome,” refers to acute and sometimes fatal brain swelling, which can occur when a second concussion occurs before the complete healing of the first. Following post-concussive guidelines decreases a player’s risk from suffering a second concussion and possibly permanent symptoms.
According to the Cantu guidelines, a grade I concussion is mild and not associated with any loss of consciousness. Any confusion or amnesia, if present, resolves in less than 30 minutes. An athlete may return to play in one week if no symptoms remain. A grade II concussion involves loss of consciousness for less than five minutes and any confusion or amnesia resolves after 30 minutes and before 24 hours. Athletes may also return to play in one week if symptoms are gone. A grade III concussion involves loss of consciousness for more than 5 minutes or post-concussive amnesia for more than 24 hours. These patients should refrain from further play for at least a month.
The general consensus among sports physicians and neurologists is that repeated concussions throughout a season should cause an increase in the length of time before an athlete plays again, if he is allowed to play for the remainder of the season. The published guidelines from the American Academy of Neurology, however, allow players with very minor head injuries associated with concussive symptoms lasting less than 15 minutes to go back onto the field the same day if they have no lasting symptoms and have a completely normal neurological exam given by either the coach or trainer.
Post-concussive syndrome
Post-concussive syndrome can occur for weeks or even months. The symptoms include persistent headaches, dizziness, fatigue, drowsiness, memory and concentration problems, personality changes and insomnia. Athletes who experience these symptoms should not participate in activities that could put them at risk for another concussion. They should also follow up with their physician and probably even a neurologist.
Interestingly, I had a patient last week who hit his head quite hard a week earlier and had only a headache for the first two days. He then developed vertigo (dizziness) two days later which persisted for over a week. A CT scan of his head was normal so I reassured him and gave him a prescription for Antivert to help the vertigo. Last month I saw a 14 year-old with a significant head injury from playing football. He was lethargic, sleepy and kept perseverating (asked the same question over and over). Based on his symptoms, we were very worried about him. A CT scan showed the possibility of a tiny bleed around the brain, but the radiologist wasn’t sure. We then ordered an MRI to confirm or rule out the bleed and it came back normal. The patient slowly started to act more normal but we admitted him anyway for observation overnight. We usually will not send someone home unless they are fully alert and acting relatively normal.
Pain management and parental observation
After suffering a mild concussion, we often recommend Tylenol, if needed, for headaches. Parents always want to know if they have to wake up their child throughout the night after a head injury and my response depends on the severity of the injury and how long ago it happened. For a mild to moderate head injury that occurs during the evening hours, I would recommend waking up the child at least once during the night to check if he/she feels alright. If the injury occurs in the morning, afternoon or early evening and the patient can be observed for six hours before going to sleep, I wouldn’t recommend waking them if they already feel well before going to bed.
It is important to try and prevent head injuries from occurring by wearing helmets when possible, especially when riding a bicycle or horseback riding. I have seen several concussions from people falling off horses. Hopefully all football players are wearing helmets during practice and games. I wonder what the rate of head injuries is in Australia where they don’t wear helmets for Australian rules football.
Author’s note: This article encompasses general guidelines taken from several published sources as well as my ten years of personal experience as an emergency physician. There will often be exceptions to the above guidelines because the risk vs. benefit ratio of using any medication will be different for each patient.
Laurence Degelsmith graduated from Horace Greeley High School in 1985, has an undergraduate degree from Washington University in Saint Louis, attended New York Medical College and did his residency in emergency medicine at the University of Michigan. He is an emergency department physician at Northern Westchester Hospital in Mt. Kisco and a member of the Chappaqua Volunteer Ambulance Corps.
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