What is a concussion? Do I need a CT scan to show this? What is the treatment for concussion and why do I keep hearing about CTE, especially in NFL players?
What is a concussion? Do I need a CT scan to show this? What is the treatment for concussion and why do I keep hearing about CTE, especially in NFL players?
Welcome back everyone, how are y’all feeling? Thanks for joining us this week for another episode of Emergency Minute. This week I can’t wait to talk to you about Episode 6 - Concussions in athletes. Before we get started, I wanted to thank each and every one of you for listening, commenting, sharing, and reviewing. Much love to you. This week’s show is sponsored by all of you. Lastly, I have some of my podcasts on video now on YouTube now, so be sure to check them out as well at DrJParente. And don’t forget to click subscribe.
So, why do I care about concussions? More importantly, why do YOU care? Well, I see concussions everyday in the ER. So I spend quite a bit of time talking about them to patients and families. But what about you? Well, maybe after listening to this podcast, you can avoid a trip to the ER for a minor head injury? Maybe you will decide to let little Johnny play sports, after all? Or maybe you won’t haha. Or maybe you will finally buy your child a bike helmet, so my kids don’t feel like total freaks, because they are apparently the only kids on earth that are so oppressed that they are forced to wear them, but I digress.
Ok. So let’s jump right into it. What is a concussion? Essentially, it is a traumatic head injury that affects your brain function. Who gets concussions? Everyone. We primarily see 2 subgroups in the ER: younger patients that get hit in the noggin during sports, or most commonly, the elderly that go to ground (oh, and usually they are on blood thinners). As my attending in residency used to say, “So Grandma fell down the stairs, and now Grandma has a head injury.” Or, as we like to refer to it in healthcare is that the gravity is strong, or that someone “DFO’d” or done fell over. For the sake of this podcast, we will focus on the younger patient. Mostly because we aren’t as concerned about concussions in the elderly; rather, we are concerned about intracranial hemorrhage, which means bleeding in the brain. You see, as we collect birthdays in life (that’s a Johnism for getting old that I bust out on patients all the time), our brains actually shrink. When that happens, the skull, the boney structure that holds what’s left of our brain, stays the same size. So when we fall and hit our old heads, the brain sort of bounces around within the skull, which causes a tear in one of the bridging vessels, causing bleeding. This is what is called a subdural hematoma. But again, this is something we see mostly in elderly patients, and the focus of this podcast is on younger patients with concussions.
Boy did I get off track. Let’s get back to head injuries in young people. The question I hear at least once per day “Does Johnny have a concussion?” Well, what are the symptoms of concussion? And what is the difference between a sign and a symptom? Signs are things you can see. An example would be the magical person in the NFL who is authorized to have a player removed from the field if they see him walking off the field and walk crooked, nearly pass out, or even collapse as we saw last year. Teaser alert, I may or may not be discussion Damar Hamlin and athletes collapsing on the field next week. You might want to hit subscribe to hear that one. Sorry for the selfish plug. Moving on…
Signs of concussion that can be observed are things such as someone who is dazed or stunned. Someone who moves clumsily. Perhaps they are answering questions very slowly or can’t recall things they normally would be able to. Also, getting knocked unconscious is a sign of concussion. Memory loss is a big one, too. Often in the ER, especially after a high speed MVC, patients will ask me the same question over and over again. Another sign to look for, although this would be something observed down the road, is a change in mood or behavior. Patients may be more sluggish or grumpier than usual, which is basically like me after a night of drinking. Speaking of football, does anyone remember watching that scary scene last year with Tua Tagovailoa? He had such a bad concussion that he had an involuntary movement in his arm as his fingers were contracted and he couldn’t control them, and this was in a game broadcasted on national TV. This physical sign of concussion really shocked a lot of people.
Now, what are the symptoms of concussion? These are far more likely to be presented to us in an ER visit. Headache, nausea, dizziness, visual disturbance, feeling foggy or trouble concentrating are some of the most common. These are often what bring people to the ER. How do we diagnose this?
In the ER, we really only have one tool for this: to CT or not to CT. The problem is that a CT doesn’t show a concussion. As I tell my patients all the time, “A concussion is not something I can see on a CT or an MRI. It’s just a term that is used for a head injury that causes symptoms.” What is the purpose of the CT, then? Basically to rule out ICH, bleeding within the brain. There are other findings such as skull fracture, but that is much rarer. How do we determine who gets a CT and who does not? Luckily, we now have a scoring system called PECARN (which stands for Pediatric Emergency Care Applied Research Network) to help us sort this out. Basically, this is an algorithm that helps us pick one of 3 paths: we will get the CT, we won’t get the CT, and the middle ground option of not getting a CT but observing the patient for 4 hours to watch for any worsening signs or symptoms.
PECARN is based on several factors such as age, is the patient more sleepy, agitated, repetitive questioning, or other signs of altered mentation? Next, it takes into account loss of consciousness, severe headache, vomiting, falls from height, and high impact trauma (think of a baseball coming off an aluminum bat traveling at a high rate of speed, that’s someone who’s going to get a head CT). It also mentions dangerous mechanism, which is good, too. For example, if we see a patient who is in a rollover MVC and there were 4 victims total, 2 died on scene and 1 was flown to another center and you got the least injured victim, then hell yes you’re going to order a CT. In fact, there’s about a 99% that patient will get a “Pan scan” or CT scan of head, neck, chest, abdomen, and pelvis, just because of the fatalities of the other victims in the accident. This is pretty much the standard of care at most trauma centers.
So after we get the signs, symptoms, and sort of input the data into the PECARN algorithm, everyone gets recommended to fall into 1 of 3 buckets: get a CT, don’t get a CT, or don’t get a CT but hold in the ER to observe for 4 hours. Keep in mind this is just a guideline and occasionally parents are dead set on getting the CT scan. If a parent asks for a CT, 99% of the time I’m going to get it. I don’t want to miss ICH! Well, why don’t we just CT everyone, then? Radiation, cost, time, etc. But mostly radiation. Despite what our radiology colleagues think about us in the ER, we use discretion when ordering CT scans. It is a TON of radiation and ultimately increases your lifetime risk of cancer. The more you get, the more likely you will get cancer.
What is normal with a concussion? Mild headache, nausea, dizziness, feeling off or foggy, not as much energy as usual.
What is NOT normal? Severe headache, vomiting, ANY neurologic symptom. If you’re like Cousin Eddy in Christmas Vacation and every time Catherine revved up the microwave you piss your pants and forget who you are for about half an hour or so, you might want to head to your local ER and get checked out!
So what are the treatment options? Not much, really. Our job in the ER is to 1. Rule out the bad stuff and 2. Treat symptoms to control them and 3. Refer to a specialist if the injury is significant enough. We do the CT (or observe), offer medications such as nausea meds like Phenergan or Zofran, or even meds like Antivert (which is Meclizine) for dizziness, and refer with head injury precautions.
What are head injury precautions? First and foremost, prevent a repeat injury. So hold the child out of competitive sports or gym class. I always tell my patients this is like a bruise on the brain. What if I punched you in the arm and you had a large bruise, and then, two days later I punched you again in the same spot? What would happen? It would hurt more, there would be more bruising, it would take longer to recover, etc. What are some other things you can do to help yourself? Well, if you rolled your ankle, you would rest your ankle, right? So REST YOUR BRAIN. How does one rest their brain? Pretty sure my wife has an answer on what it looks like when I’m resting my brain! But in all seriousness, it means to remove your face that is buried into your phone/tablet/computer screen. I tell my patients, more screen time will lead to nausea, headaches, dizziness, and just generally not feeling well, just like if you got up and start running around on that sprained ankle from before. In this day in age, we don’t realize how much of our time is spent with our faces buried in one of our screens, but that’s another topic for a different podcast.
Can we prevent concussions? To some degree, yes. It does seem like the entire world is working towards making sports safer. Helmets are constantly changing to reduce chances of concussion. If you do get hit hard, coaches and trainers are certainly more aware of this more likely to pull you off the field to be evaluated. When I was playing football we used to call it “getting your bell rung” and no joke you were put in the very next play. And I think this trickles down to everyone else, too. If the coaches and players are more aware, so are the trainers, so are the sports medicine docs, family docs, or of course the ER docs.
And although football leads the headlines with some fairly high profile cases of concussions (especially guys like Andrew Luck who retired so young and early in his career, the saga of Tua Tagovailoa’s concussions on national TV last year), just about any sport has the potential for a significant head injury. Certainly Lacrosse, soccer, cheerleading (think pyramids and falls from height), hockey, MMA, boxing, etc. Sure, football is a large percentage of concussions, but I think you’d be surprised to see these other sports high up on the list, as well.
More recently we’ve seen another term become more mainstream: CTE, or Chronic Traumatic Encephalopathy. This is a disease that is a result of chronic, recurrent traumatic brain injuries. What’s interesting here is that we can only diagnose this, or at least PROVE the diagnosis, after the person dies and the brain is biopsied. We’ve known about this for about 100 years. We used to call it being “punch drunk” with boxers who appeared this way after their careers ended. Repeated brain trauma triggers a breakdown of brain tissue and buildup of an abnormal protein called Tau. This leads to some of the common symptoms of CTE: memory loss, confusion, impulse and judgement impairment, aggression, depression, suicidality, parkinsonism, and eventually progressive dementia.
We still have so much to learn about this disease process. Recently, there have been some high-profile suicides of former NFL players such as Junior Seau and Dave Duerson that likely pushed this issue to the forefront. Perhaps some good can arise from the deaths of these former players. According to study in 2017 of donated brains of former players, 99% of tested NFL brains had evidence of CTE! College football was 91%, some high school football was 21%. Now, the selection bias of this study is that only players who donated their brains were analyzed, and obviously those who had severe symptoms, or may have died from CTE, would be much more likely to donate their brains, then perfectly healthy players that had no symptoms. But still, this is an alarming finding.
You can donate your brain to the link in the social media post that I will attach to this podcast at: www.unitedbrainassociation.org and they encourage those who played and those who did not play to donate. Unfortunately, I feel like many of my listeners have already donated their brains. But in all seriousness, if this is something that you are passionate about, checkout their website.
So Dr. Parente, do you let your kids play? I do. But many do not feel this way. Bo Jackson has come out and publicly said that if he knew of the risks of CTE, he would not have played and he is very vocal about not letting his kids play. I will never forget watching Bo Jackson play. One of the most talented athletes we’ve ever seen. It would be a shame to not see that skill on display; but I get it, it’s his life, and I don’t get a vote on if he was to play or not. I am grateful for having seen him play, that’s for sure. But you can see how there may be athletes in the future that we don’t see as they choose not to play because of this disease process.
But I still think the good outweighs the bad. Most of these cases seem to be those with very lengthy college and NFL careers. Many of these players played at a time when you never came off the field and it was a sign of weakness if you did. Last year my son sprained his foot and didn’t play the rest of the game. I had to catch myself from being too hard on him, as I was brought up in a time when coming out of the game was weakness. Kids get a lot of benefits from team sports. Strength, fitness, camaraderie, leadership, participating within a team, discipline, etc. These kids are less likely to get into trouble, less likely to get into drugs. My oldest son is a pretty darn good football player and I enjoy watching him. Will I change my stance if he gets hit hard or gets a concussion one of these years? Maybe, I don’t know. I do know that he plays in numerous sports, and just a few years ago he finished his baseball season, and all seasons that year completely healthy without any significant injury. Only to go to the team party afterwards and fall off the top of the bounce house, breaking and completely deforming his forearm as he broke both his ulna and radius. So the take home is you can’t keep your kids in bubble wrap forever.
Well thank you for joining me for this week’s episode of Emergency Minute – Concussions. If you like what you’ve been listening to please consider sharing this show with someone you know. You can follow me on any social media platform at Drjparente. Join us next week for a really exciting show on sudden cardiac death and what happened to Damar Hamlin, trust me, you are NOT going to want to miss this. What are things that can kill a young healthy athlete on the football field? Is there anything you can do? Should you have your kids get elective Echocardiograms? Again, you’re not going to want to miss this.
Happy St. Paddy’s Day to everyone out there. And as always, peace, love, and happiness to everyone. Cheers guys!