Concussion Discussion

As an emergency medicine provider with nearly 20 years of experience, I’m no stranger to dealing with head injuries. I see them from falls from horses, falls from ladders, car accidents, assaults, bicycle crashes and even just falls from a standing height. 

Many factors can increase the risk of sustaining a serious head injury, or “traumatic brain injury” (TBI), and those include the height from which a person fell, the speed they had been traveling, the age of the person, and certain medications (primarily ones that “thin the blood”).

Head injuries can be broken down to mild, moderate and severe by two sometimes conflicting criteria–structural damage to the brain and/or neurologic symptoms. I say these are at times conflicting because a person can have concerning neurologic symptoms, but no visible damage to the brain (seen on an MRI or CT scan), and/or a person could have bleeding on the brain or a skull fracture, but little to no neurologic symptoms.

Many people are familiar with concussions as they are fairly common and they typically fall into the "milt traumatic brain injury" (mTBI) category. Concussions symptoms can range from short lived dizziness or nausea, to longer term difficulty concentrating and headaches. There is no specific treatment for concussions, and no specific test that can confirm or exclude a concussion. Any tests, like MRIs or CT scans are done only to look for other injuries such as bleeding.

With enough force, blood vessels in the brain and the brain tissue itself can get damaged, leading to bleeding. In some cases, a small amount of bleeding won’t cause long term problems, but more significant bleeding can lead to disability or even death.

In the woods, you won't have CT scans, nor will you probably have the training to do a detailed neurologic exam, so if you're ever with someone who hit his or her head, you really just need to break it down to "seems fine," "seems a bit off," or "this is not good."

A number of field assessment tools have been developed (to help coaches and trainers identify athletes with head injuries), but they can require pre-injury baseline tests and are not, in my opinion, helpful for a trail side evaluations.

*remember--when assessing for potential head injury, you have to consider the possibility of a cervical spine injury as well.*

As with all potentially serious injuries, the initial approach is to start with the level of responsiveness in a person: awake, responsive to being verbally provoked, responsive to painful stimuli (pinching a fingertip, rubbing the sternum with knuckles), or not responsive at all.

That's further broken down with something called the Glasgow Coma Scale, or GCS score. Best score you can get is a 15, worst score is a 3, and it's got three components, eyes, motor and verbal. I have colleagues that have trouble remembering the criteria for scoring the GCS, and there can be differences in scores even between trained providers (except at the top and bottom of the scores).

So, don't stress about a GCS score and again go back to what I mentioned; "seems fine," "seems a bit off," and "not good."

"Seems fine," should be pretty self explanatory. Someone hit their head, and, well, seems fine. No headache, no confusion, no nausea or vomiting, no problem. It's possible that symptoms will develop later, so depending on the impact and where the fall happened, it might be time to cautiously head out of the woods and head home. Is it okay to ride out? Maybe, if you take it slow. Is it okay to drive? That's less clear, and if you don't have to drive, it might be best to consider alternatives. The reason I tend to be a bit cautious with these is that even with minor head injuries, reaction times can be just a bit off, and that could be enough for something bad to happen. With the "seems fine" category, people who are on certain "blood thinning" medications (anticoagulants), still need to be evaluated in an emergency department as should people over the age of 65 as both need a CT to help exclude a more serious injury.

If someone "seems a bit off," that probably means that he or she maybe lost consciousness briefly or forgets what happened or any of several other symptoms. At this point, any of these symptoms suggest that the person has a concussion. Depending on the severity of the "seems off" symptoms and other patient factors, the person may still need imaging (CT scan) to exclude other more serious injuries, or may not (we have to weigh the risks and benefits of CT scan radiation exposure and try to avoid it in younger people). How you get out of the woods with a "seems a bit off" person really depends on several factors such as how far into the woods you are, and if there are other injuries. I still think it's reasonable to walk out with a person as long as you take it slow and avoid situations where a person might get injured again, but calling for help may be necessary. If you do walk out, a person who "seems a bit off," shouldn't drive but should get to the emergency department.

Finally, if someone hits their head, and you determine that "it's not good," then I don't need to tell you what to do. You know to call 911 and get help to you. What's not good? A few examples are:

  • Severe headache
  • Persistent vomiting
  • Seizure activity
  • Unresposiveness
  • Additional symptoms concerning for neck injury

Severe head injuries like that are uncommon, and let's hope you never have to deal with one on the trail.

Two other points, while the focus has been on "internal head injuries" (we call them "intracranial" to sound cool), external injuries like scalp lacerations can bleed a lot, so be prepared to compress and wrap. I'll cover those in more detail another time. And, if the person was riding, and a helmet saved their head, it did its job and needs to be replaced.

Bottom line,  most head injuries will be minor, but even mild hits can cause a concussion, which can have long term effects. And, that’s not even talking about the issue of multiple concussions over a lifetime which can lead to a condition known as Chronic Traumatic Encphalopathy (CTE). CTE has gotten plenty of publicity because of its effects on football players, but it can happen to anyone with a history of several head injuries How many? No one knows. So my advice is "don't hit your head." I didn't say it was particularly helpful advice, just "advice."

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