SPORTS-RELATED HEAD INJURIES

Author: Allan White, RN, ENC(c), Brampton, Ontario, CanadaSection Editor: Andrew D. Harding, MS, RN, CEN, NEA-BC, FAHA, FACHE

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Sports-related head injuries have been written aboutfrequently over the last few years. There are implica-tions for emergency nurses, particularly for how

emergency nurses care for patients with these injuries inthe emergency department. For many nurses working inthe emergency department, it can be difficult to assessand treat a patient who has sustained a head injury butmore so when the patient is a child. It is also disconcertingto send the patient home, relying on the patient’s family orfriend to serve as caregiver and continually assess thepatient for changes in mental status or look for other signsof worsening head injury.

Why is that? There are 2 major categories of head inju-ries that are found in sports, especially contact sports. Thefirst—bleeds—is easier to diagnose and treat in the emer-gency department, comprising intracranial, subarachnoid,subdural, and epidural bleeds. As serious as these injuriesare, emergency care providers are adept at managing thecare and treatment of these patients.

The second category—concussion—is more challen-ging to manage. According to the consensus statementon concussion in sport presented at the Third InternationalConference on Concussion in Sport, which was held inZurich, Switzerland, in November 2008, the diagnosis of asuspected concussion can include 1 or more of the followingclinical findings1:

1. Somatic symptoms (eg, headache), cognitive symptoms(eg, feeling like in a fog), and/or emotional symptoms(eg, lability)

2. Physical signs (eg, loss of consciousness or amnesia)

3. Behavioral changes (eg, irritability)4. Cognitive impairment (eg, slowed reaction times)5. Sleep disturbance (eg, drowsiness)

If any 1 or more of these components is present, a con-cussion should be suspected and the appropriate managementstrategy instituted.

What Is the Proper Management of a PatientSuspected of Having a Sport-Related Concussion?

The first intervention for patients with head injury is no dif-ferent than that in any other patient we look after in ouremergency departments. Emergency providers try to ruleout emergency medical conditions including cervical spineinjuries. Once life-threatening or emergent injuries havebeen addressed or excluded from differential diagnoses, thenemergency care providers can address assessing the patientfor a concussion. It is then suggested that the patient beassessed for a concussive injury by use of the Sports Concus-sion Assessment Tool (SCAT2)2,3 or similar assessmenttool. The patient should be observed for a minimum of4 hours. Emergency nurses should assess the patient forany deterioration in neurologic status. In addition, a com-prehensive medical history should be completed, includingevents leading up to and including the initial presentationof the patient at the scene of the injury. This informationmay be supplied by the on-scene medical team (ie, EMSor team’s licensed independent provider), trainer, coach,teammates, and parents (if the patient is a child).

The patient, coach, or parent will probably ask whenthe patient can return to play. That determination is beingwidely debated in the sporting community now.1,4,5 Someadult players may be able to return to play the same day theinjury occurred, barring that no signs or symptoms of con-cussion remain. If symptoms remain, then the patientshould not be allowed to return to play until the symptomshave subsided. At no time should a child be allowed toreturn to play the same day after having a concussion.1

A graduated return to activity should be implemented ata pace that allows the patient to remain symptom free. Withany return of symptoms, the activity should be halted untilthe patient is without symptoms and then restarted at the lastlevel of activity at which the patient was performing beforethe symptoms occurred (Table).

Allan White is staff RN, Emergency Department, William Osler Health Sys-tem, Etobicoke General Hospital, Brampton, Ontario, Canada.

For correspondence, write: Allan White, RN, ENC(c), Emergency Depart-ment, William Osler Health System, Etobicoke General Hospital, 11 AriaLn, Brampton, Ontario, Canada L6S 6J6; E-mail: Traumadog01@gmail.com.

J Emerg Nurs 2012;38:463-5.

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TABLEGraduated return to play1

Rehabilitation stage Functional exercise at each stage Objective of each stage

1. No activity Complete physical and cognitive rest Recovery2. Light aerobic exercise Walking, swimming, or stationary cycling—keep intensity to less

than 70% of maximum predicted heart rate; no resistance trainingIncrease heart rate

3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer; nohead-impact activities

Add movement

4. Noncontact training drills Progression to more complex training drills (eg, passing drills infootball and ice hockey); may start progressive resistance training

Exercise, coordination,cognitive load

5. Full-contact practice Participation in normal training activities after medical clearance Restore confidence,assessment of functionalskills by coaching staff

6. Return to play Normal game play

FIGURE

Pocket SCAT2. Reprinted with permission from the International Rugby Board.2

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How Can Nurses Be Better Prepared to HandlePatients with Head Injuries?

The best way nurses can take care of patients with headinjuries, especially those with concussions, is to use ourassessment and observation skills to determine changes inthe patients’ behavior and neurologic status. Obtaininginformation about the mechanism of injury, as well asevents leading up to and immediately after the injury,can be crucial in the management of such patients. Byusing all of our assessment findings, including patientbehaviors, vital signs, level of consciousness, and assess-ment tools specific to particular suspected head injuries(ie, Pocket SCAT22 [Figure] and National Institutes ofHealth Stroke Scale6), we will anticipate and recognizechanges in the patient’s condition.

Any changes in the patient’s condition must be broughtto the attention of the attending physician immediately forfurther evaluation and possible intervention. These changescan be very subtle. Therefore obtaining a baseline assess-ment of the patient is critically vital in determining whetherchanges have occurred. Serial evaluations by the emergencynurses are necessary for determining changes in the patient.The family of the patient should be asked to let the nursesknow if the family notices any changes too.

In conclusion, head injuries, especially concussions,must be taken seriously and treated accordingly. If thereis any doubt in the minds of the health care providers, itis warranted to err on the side of caution and recommendcomplete rest and relaxation until the patient can be furtherevaluated by a neurologist who specializes in concussions.

REFERENCES1. McCrory P,MeeuwisseW, Johnston K, et al. Consensus statement on con-

cussion in sport: the 3rd International Conference on Concussion in Sportheld in Zurich, November 2008. Br J Sports Med. 2009;43:i76-84.

2. International Rugby Board. Pocket SCAT2. Available at: http://www.irbplayerwelfare.com/pdfs/Pocket_SCAT2_EN.pdf. Accessed October 2, 2011.

3. Halstead ME, Walter KD; Council on Sports Medicine and Fitness.Clinical report—sport-related concussion in children and adolescents.Pediatrics. 2010;126(3):597-615.

4. Lun V, Benson B. Concussion in sport. Fam Health. 2008;24(3):17-21.

5. Whiteside J.W. Management of head and neck injuries by the sidelinephysician. Am Fam Physician. 2006;74(8):1357-62.

6. National Institutes of Health. NIH Stroke Scale. Available at: http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf. Published 2006. AccessedOctober 2, 2011.

Submissions to this column are encouraged and may be sent toAndrew D. Harding, MS, RN, CEN, NEA-BC, FAHA, FACHEADHardingRN@Gmail.com

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