Right now the subject of concussions and football is a hot topic. But concussions are a problem for all of us that incur trauma to our head. I evaluate people every day that come in after a fall or a motor vehicle accident worried about concussions.
The first thing about coming to the ER for a hit to the head is that you may not need a CT scan. CT scans involve radiation and we try not to irradiate your brain unless we have a good reason. CT scans cannot detect a concussion. Your story of what happened to you and how you’re feeling is how we decide if you have a concussion or not. The CT scan is good for detecting a fractured skull, bleeding into your brain or a mass or tumor.
For years no one could agree among the different doctor specialties how to evaluate head injuries and when to order CT scans. Pediatricians had their rules; neurologists had their own rules; trauma docs had their rules and on and on it went. We still don’t all agree on how concussions should be evaluated but we do have some guidelines especially regarding imaging. We follow these guidelines in the emergency department to determine who needs a CT scan of their head and who does not.
So what is a concussion? There is no universally accepted definition, but essentially it is any traumatic brain injury that results in altered brain function. The effects are usually temporary and usually include headaches, problems with memory and concentration, balance and coordination. They are caused by a blow to the head or violent shaking of the head.
The brain is gelatin inside the skull with a barrier of fluid it rests in to give it support. If the brain is shaken up too much the neurons begin misfiring but usually only for a short time, days to weeks. Symptoms can be instantaneous or delayed, severe or subtle. Some concussions are easily diagnosed. For instance, if you get knocked out, you have a concussion. If you took a hit to the head and have a mild pain you probably don’t have a concussion. But some concussions can be difficult to detect and so in recent years we have worked to develop a system for evaluating them to keep people safe from any long-term suffering.
While medical personnel do not all agree on any single system for evaluating head injuries, we do agree using the systems we have available to us today is better than what we had even 10 years ago. Concussion evaluations begin on the sideline for athletes. The trainer usually does an examination, which includes balance and gait testing, symptoms check-list, neurologic and memory testing.
The SAC test (standardized assessment of concussion) has been validated but there are other variations used. What we have learned is that none of these neurologic evaluation tools have been found to be particularly better than another. There are more advanced systems that involve computer testing of cognition done prior to entering sports and then done again if a concussion is suspected. They can help determine when an athlete is safe to return to activities, which is really what we want to know.
No one is supposed to be allowed to re-enter the game after sustaining a concussion that same day. They must sit out and be evaluated. The sideline evaluation isn’t all that’s done. The patient must be further evaluated throughout the next few days to few weeks. What we are looking for is a complete resolution of symptoms before we want you to go back to your sport. Most people will recover in a few days to a week but some take a month or more. It is important that we follow our guidelines, whichever set of guidelines your doctor prefers, to ensure we’re being safe before we clear you to return to activities.
Most people have a headache with a concussion. Some people are knocked unconscious, but most people with a concussion are not. You might feel off balance, dazed or dizzy. Nausea is common, but actual vomiting is seen less often. Amnesia is common especially regarding the actual event that caused the head injury. You may be slow to respond to questions or have slurred speech. Kids especially may appear irritable or cranky and have excessive crying.
It is advised that you seek medical attention if:
- you vomit more than once after your head injury
- were knocked unconscious longer than 30 seconds
- your headache is getting worse, not better
- you experience changes in behavior,
- you experience seizures
- you have abnormal pupils
- you are having generally worsening symptoms over time
- or have large head bruises other than on the forehead.
There really is no treatment for concussions other than rest. If you have symptoms like pain and nausea, there are medicines to help the symptoms. We prefer you to avoid medicines like ibuprofen in a concussion. Instead, use Tylenol for your headache.
The main therapy is avoiding any further head injury while you are suffering from a concussion. This means no physical impacts to the head but it also means resting your brain activity. No reading books or watching Youtube on your Ipad. It’s not that using your brain will cause you lasting damage but it will extend the time you are symptomatic. There is still debate about the effects of a second concussion while you’re healing from your first concussion so while the professionals debate this, it is advised to just avoid more hits to your head until you are healed completely. Safety equipment has not been found to do much to prevent concussions but they definitely help reduce other injuries like fractures.
The take-home message is if you take a hit to your head and you’re worried that the symptoms are serious then get evaluated by a medical professional. Remember not all concussions need a CT scan of the brain. Rest your brain until symptoms completely resolve and feel better.
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Dr. John Turner is a family medicine and emergency medicine doctor with 25 years of experience. He is also the owner of My Primary Care Clinic and My Emergency Room 24/7 here in Hays County. Dr. Turner may be reached at 512-667-6087.
