Concussion Management

Over the years we’ve learned a lot about concussion in athletics. Concussion has been linked to numerous chronic problems, including depression, dementia and Parkinson’s disease.¹ Substantial increases have been demonstrated in morbidity among victims who suffer multiple concussions in a short time.² As a result, a number of sports organizations have created or revised programs aimed at increasing awareness of what has proven a significant problem. The research has prompted several medical organizations, including the National Athletic Trainers’ Association (NATA) and American Academy of Neurology (AAN), to issue position statements and work toward developing guidelines regarding concussions in athletes.^3,4 Health professionals specializing in sports medicine are well aware of this focus. Unfortunately, EMS providers may not be as familiar with current research and practices, even though such understanding would be a great benefit to our practice.

Concussion Essentials

Concussion is classified as a mild traumatic brain injury that interrupts normal brain function.⁵ Though concussed patients may present with loss of consciousness, the majority do not.⁶ More patients will just appear dazed, and symptoms may resolve rapidly. It is this subtle neurological presentation that makes recognition of concussion a challenge. While specially trained physicians and athletic trainers are likely to be present at higher-profile professional, collegiate and even high school athletic contests, EMS providers will often be the first healthcare provider an injured athlete encounters in many other situations (e.g., youth sports events).

Further, although sports and recreation-related activities account for a substantial number of concussions, falls, motor-vehicle collisions and other mechanisms of injury commonly cause them too. As such, EMS professionals must be familiar with the recognition, treatment and disposition of at-risk patients.

Assessment of Head Injuries

As always, assessment of any head-injured patient begins with consideration of the mechanism of injury. Did your patient sustain a blow to the head? If so, how exactly did it happen, and where was the impact? Was the patient using protective equipment? Keep in mind that the use of safety equipment does not preclude significant injury.

Next direct your attention to airway, breathing, circulation and level of consciousness.⁵ Consider c-spine immobilization, especially in the unconscious patient, as forces that injure the head will often jeopardize the neck as well.⁷ Early and aggressive airway management may be indicated, particularly with serious head injuries.

Patients who experience a prolonged loss of consciousness should be transported for evaluation without delay,⁵ as it is impossible to differentiate concussions from more severe injuries in these patients. Aim physical examination at discovering associated injures, which should be managed promptly. Assess gross neurologic function and document the findings. Once immediate threats to life have been ruled out, the conscious patient may be thoroughly assessed for concussion, primarily by evaluating their cognitive function.

Concussion Recognition

Assessing cognition in head-injured patients need not be a difficult task. A typical patient interview will tell the clinician a great deal. Can the patient tell you their name? Can they describe the events that led up to their injury? Use specific questions to query your patient.⁵ Ask a young football player what team he’s playing against, or a motor vehicle crash victim where they were driving. Coaches, friends and family members on scene should be enlisted to verify the patient’s answers.⁵ Pay careful attention to your patient’s responses. Do they hesitate or seem to have trouble recalling? Is your patient easily frustrated? Even the most subtle change in cognition or personality may indicate concussion.