By A.J. Heightman, MPA, EMT-P
WATCH THE VIDEO – A great teaching moment re: Mechanism of Injury and a Period of Unconsciousness
NOTE: The critical impact moment is around 01:01 on the video
The injury to, and subsequent death of, Snowmobiler Caleb Moore during the Winter X Games in Aspen on Tuesday present EMS educators and training officers with the opportunity to emphasize to their personnel that you cannot always judge a book by its cover and also cannot always allow a patient, particularly and athlete who wants to show their fans a positive image after an incident, to ambulate to a waiting ambulance, particularly after a period of unconsciousness. Similar to what we are learning for football and battlefield injuries, concussion symptoms may be a key indicator of a Traumatic Brain Injury (TBI), particularly when there is a loss of consciousness for any period of time.
In this incident, Moore, a healthy, 25-year-old athlete walked off the snow with assistance and was transported with what was reported at the time to be just a concussion. A look at the video, the weight of the snowmobile, it’s height off the ground and compression and impact forces should trigger crews to assess the patient very carefully for internal injuries, present or potential for development, and treat, transport and alert the receiving hospital (a trauma center) accordingly so they are alert for the high potential for traumatic injury and prepared to assess and treat the arriving patient as a serious patient on arrival.
Moore’s condition deteriorated soon after hospital arrival, with bleeding around his heart and, according to reports from his family, complication involving his brain. He passed away on Thursday.
In this incident, a healthy, 25-year-old athlete walked off the snow with assistance and was transported with what was reported at the time to be just a concussion. A look at the video, the weight of the snowmobile, it’s height off the ground and compression and impact forces should trigger crews to assess the patient very carefully for internal injuries, present or potential for development, and treat, transport and alert the receiving hospital (a trauma center) accordingly so they are alert for the high potential for traumatic injury and prepared to assess and treat the arriving patient as a serious patient on arrival.
Moore’s condition deteriorated soon after hospital arrival, with bleeding around his heart and, according to reports from his family, complication involving his brain.
I teach students to follow the Colorado Medical Society Guidelines for “Return to Play” after a concussions, the American College of Rehabilitation Guidelines on TBI and American Academy of Neurology Guidelines, as assessment tools when assessing potential TBI patients in the field - as long as it does not conflict with their medical protocols. 1-5 (See below)
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Important facts about concussions and traumatic brain injuries
Colorado Medical Society guidelines for “return to play” Grade First concussion and Subsequent Concussions1-3
By these guidelines, an athlete who has suffered a concussion may return to sports after having been free of symptoms, both at rest and during exercise
Grade I Concussion
Symptoms for up to 15 minutes
• First Concussion – Free of symptoms after 15 minutes
• If this was not the person’s first concussion, they should not return to play for 1 week
Grade II Concussion
> 15 minutes of symptoms
• No return to play for 1 week
• If this was not their first concussion – Only return to play after 2 weeks, with a physician’s approval
Grade IIIa Concussion
Unconscious for seconds
• No return to play for 1 month
• If this was not their first concussion – Only return to play after 6 months, with a physician’s approval
Grade IIIb Concussion
Unconscious for minutes
• No return to play for 6 months
• If this was not their first concussion – Only return to play after 1 year, with a physician’s approval
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American Academy of Neurology guidelines4
The guidelines, developed in 1997 by the American Academy of Neurology (AAN) are based on those by the Colorado Medical Society.
According to the AAN guidelines, a Grade I concussion is associated with no loss of consciousness and symptoms of confusion last less than 15 minutes.
Grade II is the same, except symptoms last longer than 15 minutes.
In Grade III, loss of consciousness does occur.
Grade III can be further divided into grades IIIa and IIIb, with brief loss of consciousness (measured in seconds) and
prolonged loss of consciousness (measured in minutes) respectively.
According to the AAN, permanent brain injury can occur with either Grade II or Grade III concussion.
By these guidelines, an athlete suffering a single, Grade I concussion is given a neurological evaluation every five minutes starting immediately after the injury and may return to the competition if signs and symptoms resolve within a quarter of an hour.
Otherwise, the return to play rules are the same for the AAN and Colorado Medical Society guidelines.
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Guidelines presented in an article entitled, Mild Traumatic Brain Injury and Postconcussive Syndrome
by Elie Elovic, M.D., Edgardo Baerga, M.D., and Sara Cuccurullo, M.D., presented a succinct review of mild TBI and post concussive syndrome:4
• Mild TBI constitutes 80% to 90% of TBI cases in the United States
• ~ 2.3 million cases in the United States
• Multiple terms, definitions, and diagnostic criteria available for mild or minor traumatic brain injury
• The American Congress of Rehabilitation (1995) has defined mild TBI as a traumatically induced physiologic disruption of brain function with at least one of four manifestations:
• Any loss of consciousness (LOC)
• Any loss of memory for events immediately before or after the injury
• Any alteration in mental status at the time of the accident
• Focal neurological deficits that may or may not be transient
• Usually, mild TBI has negative radiological findings (CT/MRI)
• The injury cannot exceed the following severity criteria:
• LOC greater than 30 minutes
• Posttraumatic amnesia (PTA) > 24 hours
• Initial GCS ≤ 12 (13 to 15)
• Signs and symptoms after mild TBI include:
• Headache (most common)
• Hearing loss
• Blurred vision
• Altered taste and smell
• Sleep disturbances/insomnia
• Sensory impairments
• Attention and concentration deficits
• Slowed mental processing (slowed reaction and information processing time)
• Memory impairment (mostly recent memory)
• Most mild TBI patients have a good recovery with symptoms clearing within the first few weeks or months post injury (usually within 1 to 3 months)
• In some patients the symptoms (previously mentioned) persist and are associated with social and vocational difficulties that appear to be out of proportion to the severity of the neurologic insult. This condition has been termed post concussive syndrome (PCS)
• In a recent study, 14 mild TBI patients with unusually persistent deficits evaluated with single photon emission computed tomography (SPECT) showed significant anterior mesial temporal (lobe) hypoperfusion and less striking dominant (left) orbitofrontal abnormalities
• Memory and learning deficits have been associated with lesions at the hippocampus and related structures in the medial temporal lobes or with injuries to structures that control attention, concentration, and information processing in the frontal and temporal lobe
• Pharmacologic intervention may be used including antidepressants and psychostimulants
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Report on a study in TIME Magazine, entitled: Study: Kids Competing Too Soon After Concussions, in TIME Magazine, Jan. 21, 20095
This report noted that 41% of concussed athletes in 100 high schools across the U.S. (from 2005 to 2008), returned to play too soon, under guidelines set out by the American Academy of Neurology. The 11-year-old guidelines say, for example, that if an athlete's concussion symptoms, such as dizziness or nausea, last longer than 15 minutes, he should be benched until he's been symptom-free for a week.3
The most startling data point -- uncovered by the same researchers who, in 2007 brought to light the fact that girls have a higher incidence of concussion than boys, is that 16% of high school football players who lost consciousness during a concussion returned to the field the same day.
The article notes that the consequences of going back to action early can be dire and cited a September 2008 incident where a 16-year-old suffered a concussion during football practice at J.H. Rose High School in Greenville, N.C. A certified athletic trainer educated in concussion management wasn't onsite, and the school's first responder who examined Waller cleared him to play in a game two days later. During that game, Waller was tackled. Moments later, he collapsed on the sidelines. He died the next day.
A medical examiner determined Waller died from what is called second-impact syndrome, noting that "neither impact would have been sufficient to cause death in the absence of the other impact."
The study examined 1,308 concussion incidents reported by athletic trainers and found that:
1. In girls' volleyball and boys' basketball and baseball, more than half of concussed players returned to play too soon.
2. Not enough high schools have certified trainers who know how to deal with concussions -- just 42% did at that time according to the National Athletic Trainers' Association.
3. In some instances, over competitive coaches, who were not, at the time, required to be trained in concussion management, pushed players back onto the field. And too often the players themselves weren’t reporting head trauma, with team spirit giving them too much of a warrior mentality.
3. Collins MW, Iverson GL, Gaetz M, Lovell MR (2006). "24: Sport-Related Concussion." In Zasler ND, Katz DI, and Zafonte RD. Brain Injury Medicine: Principles And Practice. Demos Medical Publishing, LLC. ISBN 1-888799-93-5
6. http://www.ncbi.nlm.nih.gov/books/NBK27185/ Physical Medicine and Rehabilitation Board Review, Cuccurullo S, editor, New York: Demos Medical Publishing; 2004