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Concussion

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Concussion



 Introduction  

Concussion is the sudden but short-lived loss of mental function that occurs after a blow or other injury to the head. It is the most common but least serious type of brain injury.

The medical term for concussion is minor traumatic brain injury.

Symptoms of concussion include brief:



loss of consciousness after the head injury



periods of memory loss



disturbances in vision, such as "seeing stars" or blurry vision



a period of confusion, a blank expression, or a delay in answering questions immediately after the head injury



If a brain scan is carried out, concussion is only diagnosed if the scan is normal – for example, there is no bleeding or swelling of the brain.

 When to seek medical help 

Concussion should only be diagnosed by a health professional trained in assessing patients with head injury. They will be able to rule out serious brain injury that needs a brain scan or surgery.

You should visit your nearest accident and emergency (A&E) department if you or someone in your care has a head injury and develops the following signs and symptoms:



loss of consciousness, however brief



memory loss, such as not being able to remember what happened before or after the injury



persistent headaches since the injury



changes in behaviour, such as irritability, being easily distracted or having no interest in the outside world – this is a particularly common sign in children under five



confusion



drowsiness that occurs when you would normally be awake



loss of balance or problems walking



difficulties with understanding what people say



difficulty speaking, such as slurred speech



problems with reading or writing



vomiting since the injury



problems with vision, such as double vision



loss of power in part of the body, such as weakness in an arm or leg



clear fluid leaving the nose or ears (this could be cerebrospinal fluid, which surrounds the brain)



sudden deafness in one or both ears



any wound to the head or face



Anyone drunk or high on recreational drugs should go to A&E if they have a head injury as it's easy for others around them to miss the signs of a more severe injury.

Phone 999 for an ambulance immediately if the person:



remains unconscious after the initial injury



is having a seizure or fit



is bleeding from one or both ears



has been vomiting since the injury



is having difficulty staying awake, speaking, or understanding what people are saying



Certain things make you more vulnerable to the effects of a head injury. These include:



being aged 65 or older



having previously had brain surgery



having a condition that makes you bleed more easily, such as haemophilia



having a condition that makes your blood more prone to clotting, such as thrombophilia



taking anticoagulant medication, such as warfarin or aspirin, to prevent blood clots



There are things you can do at home to help relieve concussion symptoms, including:



apply a cold compress to the injury to reduce swelling – a bag of frozen peas wrapped in a towel will do



take paracetamol to control any pain – do not use non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin, as these can cause bleeding



avoid drinking alcohol or taking recreational drugs



 Recovery 

After experiencing concussion, careful monitoring is needed. This is usually for 48 hours.

This is because the symptoms of concussion could also be symptoms of a more serious condition, such as:



subdural haematoma – bleeding between the skull and the brain



subarachnoid haemorrhage – bleeding on the surface of the brain



 Outlook 

While the medical term "minor traumatic brain injury" can sound serious, the actual extent of damage to the brain is usually minimal and does not cause long-term problems or complications.

There is evidence that repeated episodes of concussion could cause long-term problems with mental abilities and trigger dementia. This type of dementia is known as chronic traumatic encephalopathy (CTE).

However, this seems to only be a significant risk for professional athletes who experience repeated episodes of severe concussion, such as boxers – CTE is sometime nicknamed "boxer's brain".

Post-concussion syndrome (PCS) is a poorly understood condition where symptoms of concussion can last for weeks or months afterwards.

 Who's at risk? 

Most cases of concussion occur in children and teenagers aged 5 to 14, with the two most common causes being sporting and cycling accidents.

Falls and motor vehicle accidents are a more common cause of concussion in older adults.

People who regularly play competitive team sports such as football and rugby have a higher risk of concussion.





 

 Responding to an emergency 

Get advice on first aid and when to dial 999, including what information to pass on to the emergency response units

 

 Symptoms of concussion  

Symptoms of concussion can be mild to severe, and in some cases emergency treatment may be needed.

The most common symptoms of concussion are:



confusion, such as being unaware of your surroundings, a delay in answering questions, or having a blank expression 



headache



dizziness



nausea



loss of balance



feeling stunned or dazed



disturbances with vision, such as double vision, blurred vision or "seeing stars" or flashing lights



difficulties with memory



Difficulties with memory can mean:



you are unable to remember events that occurred before the concussion happened (this usually only affects the minutes immediately leading up to the concussion) – retrograde amnesia  



you are unable to remember any new information or events after the concussion happened – anterograde amnesia



Both types of memory loss usually improve within a few hours.

 Less common symptoms 

Less common symptoms include:



loss of consciousness



slurred speech



changes in behaviour, such as feeling unusually irritable



inappropriate emotional responses, such as suddenly bursting into laughter or tears



 When to seek medical advice 

As a precaution, it is recommended that you visit your nearest accident and emergency (A&E) department if you or someone in your care has a head injury resulting in concussion and then develops any of the following signs and symptoms:



loss of consciousness from which the person then recovers



amnesia (memory loss), such as not being able to remember what happened before or after the injury



persistent headaches since the injury



changes in behaviour, such as irritability, being easily distracted or having no interest in the outside world – this is a particularly common sign in children under the age of five



confusion



drowsiness that goes on for longer than an hour when you would normally be awake



a large bruise or wound to the head or face



prolonged vision problems, such as double vision



reading or writing problems



balance problems or difficulty walking



loss of power in part of the body, such as weakness in an arm or leg



clear fluid leaking from the nose or ears (this could be cerebrospinal fluid, which normally surrounds the brain)



a black eye with no other damage around the eye



sudden deafness in one or both ears



Anyone taking warfarin should seek medical assistance after a head injury, even if they feel well. 

Anyone who is drunk or high on recreational drugs should also go to A&E if they have a head injury. It's often easy for others around them to miss signs of a more severe head injury.

Certain things make you more vulnerable to the effects of a head injury, such as:



being aged 65 or older



a previous history of brain surgery



having a condition that makes you bleed more easily, such as haemophilia, or having a condition that makes your blood more prone to clotting, such as thrombophilia



taking anticoagulant medication (such as warfarin) to prevent blood clots, or taking low-dose aspirin



 When to seek emergency medical treatment 

You should phone 999 for an ambulance immediately if the person:



remains unconscious after the initial injury



is having difficulty staying awake, speaking or understanding what people are saying



is having a seizure or fit



has been vomiting since the injury



is bleeding from one or both ears



 

 Causes of concussion  

Concussion occurs when a blow or impact to the head causes a sudden disruption to part of the brain known as the reticular activating system (RAS).

The RAS is located in the middle of your brain, and helps regulate your sense of awareness and consciousness. It also acts as a filter that allows you to ignore unimportant information by focusing on details you need.

For example, your RAS helps you to:



fall asleep and wake up as required



suddenly hear when your flight is being called in a noisy airport



notice news items that interest you when you are quickly scanning a newspaper or news website



During a head injury severe enough to cause concussion, your brain is moved out of its normal position for a short time. This rotation disrupts the electrical activities of brain cells that make up the RAS, which in turn triggers symptoms associated with concussion, such as:



loss of memory



a brief period of unconsciousness



mental confusion



 Increased risk 

The three main causes of concussion are:



being involved in a road accident



an accidental trip or fall



taking part in sporting or other recreational activities



Activities known to have a higher-than-average risk of concussion include:



rugby



football



cycling



boxing



martial arts, such as karate or judo



Most doctors would argue that the physical benefits of regularly taking part in these sports outweigh any potential risks associated with concussion.

But this is only if you (or your child) wear appropriate equipment, such as a helmet, and are supervised by a suitably trained referee, umpire or trainer with experience of diagnosing and treating concussion.

The exception to this is boxing, as most doctors – especially those who treat head injuries – have stated that the risks of serious brain injury associated with boxing are unacceptably high and the sport should be made illegal

 

 Diagnosing concussion  

Because of the nature of concussion, most diagnoses are either made at an accident and emergency (A&E) department, by a paramedic at the scene of an accident, or by a trained official at a sporting event.

The person making the diagnosis will perform a careful physical examination to check if there are any noticeable signs and symptoms of a more serious brain injury, such as bleeding from the ears, while making sure breathing is unaffected.

If you are conscious, you will be questioned so your state of mind (particularly your memory) can be assessed.

Possible questions include:



Where are we?



What were you doing before the concussion?



Can you repeat the months of the year in reverse order?



You may be asked to try what is known as the "finger-nose-finger" test. The person running the test will hold one of their fingers in front of you. You are asked to touch their finger and then touch the tip of your nose as quickly as possible.

This test is a good way of assessing what effect the concussion has had on your balance and co-ordination.

If you are unconscious, as a precaution it is assumed that you have a serious neck or spinal injury until proved otherwise. You should therefore not be moved until a specialist brace can be fitted around your neck and spine to protect it.

Similarly, if you see a person who is unconscious, make no attempt to move them unless they are in immediate physical danger. Instead, dial 999 for an ambulance and wait with them until paramedics arrive.

 Further testing 

In some circumstances, further testing may be recommended if there are any signs or symptoms that suggest a more serious injury to your brain. The most widely used test for suspected brain injury is a computerised tomography (CT) scan. 

However, if it is thought you may have damaged the bones in your neck, an X-ray may be used to assess the damage quickly. CT scans are avoided on children under 10 where possible, but may be necessary in some cases.

A CT scan takes a series of X-rays of the inside of your skull and puts them together using a computer. The image that is created forms a cross-section of the inside of your skull and brain.

Adults

A CT scan is usually recommended in adults who:



have persistent problems in speaking, carrying out instructions or opening their eyes



have signs and symptoms that suggest the base of the skull is fractured, such as clear fluid running from the nose or ears, or very dark blotches above and below the eyes ("panda eyes")



have a seizure or fit after the injury



have vomited more than once since the injury



are unable to remember events more than 30 minutes before the injury



have any signs of neurological problems, such as loss of feeling in certain parts of the body, problems with balance and walking, and persistent changes in eyesight



A CT scan is also recommended for adults who have experienced some loss of consciousness or memory since the injury and who:



are aged 65 or over



have a problem that makes them prone to uncontrollable bleeding, such as a blood clotting disorder (for example, haemophilia) or are taking the anticoagulant medication warfarin



were injured in a particularly serious accident, such as a road accident or falling from a height of more than one metre



Children

A CT scan may be recommended in children who:



lost consciousness for more than five minutes



are unable to remember what happened before or after the injury and this has lasted more than five minutes



are unusually drowsy



have been sick three times or more since the injury



had a seizure or fit after the injury



have signs and symptoms that suggest the base of the skull is fractured, such as "panda eyes"



have memory loss



have a large bruise or wound to the face or head



A CT scan is also usually recommended for babies less than a year old who have a bruise, swelling or cut on the head bigger than 5cm (2 inches).

 

 Treating concussion  

There are a number of self care techniques you can use to relieve mild concussion symptoms. If more serious symptoms start to develop, seek immediate medical treatment.

Some self care techniques for mild symptoms of concussion are outlined below.



apply a cold compress to the injury to reduce swelling – a bag of frozen vegetables wrapped in a towel could be used, but never place ice directly on the skin as it's too cold; apply the compress every two to four hours and leave it in place for 20 to 30 minutes



take paracetamol to control pain – do not use non-steroidal anti-inflammatory drug (NSAID) painkillers such as ibuprofen or aspirin as these can sometimes cause bleeding at the site of the injury



get plenty of rest and avoid stressful situations where possible



avoid drinking any alcohol or taking recreational drugs



only return to work, college or school when you feel you have completely recovered



only drive a car or ride a bike when you feel you have completely recovered



do not play any contact sports for at least three weeks without seeing your GP first – this includes sports such as football and rugby



make sure you have someone to stay with you for the first 48 hours after the injury – this is in case you experience more serious follow-up symptoms



When to seek follow-up advice

Sometimes the symptoms of a more serious brain injury do not occur for several hours, or possibly days, after the initial injury has taken place. This means it's important that you remain alert for signs and symptoms that could suggest a more serious injury has occurred.

If you or someone in your care has any of the signs or symptoms listed below, go to your nearest accident and emergency (A&E) department as soon as possible:



unconsciousness or lack of consciousness, such as problems keeping your eyes open



mental confusion, such as forgetting who or where you are



any drowsiness that goes on for longer than one hour when you would normally be wide awake



any problems understanding or speaking



any loss of balance or problems walking



any weakness in one or both arms or legs



any problems with eyesight



a very painful headache that will not go away



any vomiting



any fits or seizures



clear fluid coming out of the ear or nose



bleeding from one or both ears



sudden deafness in one or both ears



Returning to sports

Despite being one of the most common sport-related injuries, there is no internationally agreed consensus on advice about when it is safe to return to playing a contact sport, such as rugby, after a concussion.

Most national sporting federations and organisations recommend a "step-wise" approach, where you wait until you are free from symptoms and then resume a low level of physical activity.

If the symptoms do not return, you can step up to a more intense level of activity. If symptoms are still under control, continue to step up through the levels, eventually returning to playing the sport.

A 2013 conference of experts in sports medicine recommended these steps:



complete rest until symptoms have passed for at least 24 hours



light aerobic exercise, such as walking and cycling



sport-specific exercises, such as running drills for football or rugby (but no activity that involves impact to the head)



non-contact training, such as passing drills for football



full training, including physical contact such as tackling



return to play



If you are symptom-free, you should be able to return to play within a week. If you experience a return of symptoms, rest for 24 hours, drop down to a previous step, and then attempt to move up again.

 

Complications of concussion 

Post-concussion syndrome (PCS) is the term used to describe a collection of symptoms that can last for several weeks or months after the concussion.

The exact cause of PCS is not known. One theory is that PCS is the result of a chemical imbalance in the brain triggered by the initial injury that caused the concussion. Another theory suggests PCS may be caused by damage to nerve cells in the brain.

Symptoms of PCS

The symptoms of PCS fall into three main categories:



physical



psychological



cognitive (affecting a person's thinking ability)



Physical symptoms of PCS can include:



headaches – often described as similar to migraines in that they cause a throbbing pain on one side or the front of the head



dizziness



feeling sick (nausea)



sensitivity to bright lights



sensitivity to loud noises



ringing in the ears – the medical term for this is tinnitus



double or blurred vision



fatigue



lost, changed or reduced sense of smell and taste



Psychological symptoms of PCS can include:



depression



anxiety



irritability



lack of energy and interest in the world around you



having problems sleeping



changes in appetite



sudden and inappropriate outbursts of emotion, such as having fits of laughter or crying for no apparent reason



Cognitive symptoms of PCS include:



decreased concentration



forgetfulness



difficulty remembering things or learning new information



difficulties with reasoning (working out problems)



Treating PCS

There is no specific treatment for the symptoms of PCS, though many medications used to treat migraines have also proved effective in treating the headaches caused by PCS.

Antidepressants and talking treatments such as psychotherapy may help control the psychological symptoms, such as depression and anxiety.

Most cases of PCS will resolve within three to six months, and only 1 in 10 people will still have symptoms after a year.

 

Preventing concussion 

There are a number of commonsense precautions you can take to reduce your risk of concussion.

These precautions include:



always wearing the recommended equipment when taking part in a contact sport such as rugby or boxing



making sure any contact sport you or your child are taking part in is supervised by a properly qualified and trained person



always wearing a seatbelt when driving



wearing a motorcycle helmet – this is a legal requirement if you are riding a motorcycle in England



wearing a cycle helmet – this is not a legal requirement, but cycle helmets have been recommended by several leading organisations, such as the Royal Society for the Prevention of Accidents



It is also easy to underestimate how many cases of concussion occur as the result of a fall or slip at home or in the garden, especially in older people. Following some or all of the suggestions below will help keep your home and garden as safe as possible.



keep stairways clear so you do not trip over anything



use appropriate safety equipment if you're doing any kind of DIY



use appropriate equipment to change a light bulb, such as a stepladder



clean up spillages to prevent someone slipping
 
Concussion