What to expect with first concussion?

WESTBOROUGH, MA March 21, 2016 Here is a blog that I first published in September 2013 when I first started to write this blog.  I occasionally am asked to “put up” a blog post that was previously published.  I resist this out of fear of growing irrelevant.  In any case, this blog cites some of the concerns people have when a child is diagnosed with concussion for the first time.  What can you expect?  I think it is a reasonable post that I will update with the current standard of care. Here are some of my early thoughts and those that are new.

classroom
Student athletes experience fatigue and decreased mental endurance

“I remember when my son was playing ice hockey.  He was 12 or 13 years old.  He was hit at center ice near the bench.  The opposing playing went low hitting Casey – toppling him head over heels.  He managed to get right up but had rubber legs and skated away from the bench not toward the bench and the safety of his coaches.”  Michael Sefton, Ph.D.

WHAT TO EXPECT ?

The first concussion results in a wide range of responses from players, parents, and coaches.  Some result in an ambulance ride to the local trauma center.  Whenever an athlete is suspected to have sustained a head or neck injury his spinal cord needs to be held at midline so that he may be immobilized.  This results in the placement of a cervical collar and usually being strapped to a long board and can be a scary process for a young athlete.  Yet most concussions do not require advanced life support for their management. While working in the ambulance I have taken care of many players with concussion – all of whom did just fine.

Shortly after injury and usually prior to EMS arrival someone may assess the injured athlete at rink side or in the locker room.  It is commonplace to use an assessment tool like the SCAT to measure the athlete’s orientation, awareness, concentration, and short-term memory.  A concussion does not require that an athlete be knocked unconscious to signal an event has occurred – most concussions do not result in unconsciousness.  Remember this if you ever have a son or daughter with a concussion.

What is most common is post-injury confusion, irregular balance, inattention, and decreased short-term memory.  Some athletes become emotional and cry.  This usually results from confusion and not understanding what has happened.  This may be limited if a parent or coach is with the player in the ambulance or hospital.

Once the ambulance hands of your son or daughter to the emergency department nurses he or she is likely going to have an x-ray of the head and neck and probably a C-T scan of the brain to rule out fracture and intracranial injury.  Sometimes lab studies are undertaken.  These tests are frequently negative in spite of active concussion.  Some parents leave with the false sense that nothing has happened to their child.  Why?

The answer to concussion lies in the metabolic cascade – a shift in neural transmission and the onset of reduced efficiency between centers of the brain.  Structurally the brain is uninjured but its intracellular transport system may be temporarily corrupt. This hallmark injury is difficult to document in the ED but clinically results in cognitive slowing and some physical signs like sensitivity to sound and light, headache, fatigue, irritability, and often poor balance and memory.  The symptoms frequently can be measured for 7-10 days before they are fully healed.  Athletes should not return to play before they are fully healed and cleared by a physician.

My first personal experience turned out well thankfully.  Casey underwent the million dollar work-up at the hospital and each test was normal.  We were given written instruction for what to watch in the unlikely event he was bleeding into his brain, somnolence, seizure, vomiting followed by unresponsiveness.  None of this occurred.  Our son was held off the ice for 2 weeks before he returned to practice.  He had about 3 days where he was not himself – a normally talkative, curious boy.  During his recovery he rested and was not permitted to use the many video game systems we own.  He needed to rest.  Slowly as we could see he was more himself he was given back a wide range of activities like attending the full school day.

Parents can expect a comprehensive evaluation when student athletes are injured from concussion.  Post-injury neurocognitive testing is sometimes recommended.  My son took 2 post-injury ImPACT tests until he reached his baseline.  By then he was feeling fine and beginning step one of the return-to -play protocol.  Some athletes require a few physical therapy sessions for balance, vestibular functions and proprioception.  These can be arranged by the pediatrician or brain injury specialist.  Consultation with school nurses and teachers should be considered given the reduction in cognitive functions like: attention.  Some athletes return to school for half days during the acute recovery from concussion.  I have written education plans for recovering students to have reduced homework load, delay all tests until recovery, early release, and well-timed rest breaks.  A small subset of injured players require more prolonged care and go on to develop post-concussion syndrome.  This results when symptoms persist beyond the normal trajectory of recovery.  In most cases, when an athlete has symptoms lasting over 6 months one can begin to think about post-concussion syndrome.  With effectice management and planning most athletes heal and recover from concussion without complication.  They should not be rushed and post-injury return-to-play plans should be addressed.  No player should go from zero play to tournament play without first undergoing a step-by-step protocol to make certain symptoms do not recur with exertion.

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