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SKILLS STATION Concussion Recognition Assessing cognition in head-injured patients need not be a diffi cult task. A typical patient interview will tell the clinician a great deal. Can the patient tell you their name? Can they describe the events that led up to their injury? Use specifi c questions to query your patient.5 Ask a young football player what team he's playing against, or a motor vehicle crash victim where they were driving. Coaches, friends and family members on scene should be enlisted to verify the patient's answers.5 Pay careful attention to your patient's responses. Do they hesitate or seem to have trouble recalling? Is your patient easily frustrated? Even the most subtle change in cognition or personality may indicate concussion. An injured patient may be assessed for antegrade amnesia by reading a simple series of words or numbers and having them repeat the series back. What physical symptoms is your patient experiencing? Headache, dizzi- ness, nausea, confusion and tinnitus are common symptoms,7 but may not be obvious, so thorough assessment is warranted. Does the patient have a prior history of concussion? If so, apply a much higher index of suspicion for current injury. Patients who have suffered a recent concussion, particu- larly if symptoms remain, are at great risk for substantial complications from injury, a condition known as second- impact syndrome.2,5,6 Education and Disposition If a concussion is suspected, physi- cian evaluation is indicated. As stated Second Impact Syndrome Second-impact syndrome (SIS) is thought to occur when the brain suff ers new injury before it has completely healed from a previous one. Through a complex series of autoregulatory processes, the injured brain alters its metabolic functions and blood fl ow to compensate for insult. These protective measures may continue for several weeks. Research suggests that injury suff ered during this healing period can disrupt the brain's ability to continue compensation, leading to unchecked cerebral edema, rapid increases in ICP, herniation and ultimately death or profound disability.2 to precipitate SIS. Though the incidence of SIS is diffi cult to estimate, experts do not believe it's a common condition.5 easily avoided—thereby warranting attention from EMS providers. Concussion Assessment Tools In recent years sports medicine has contributed a variety of assessment tools aimed at identifying concussion. Some of these tools require some sort of pre-injury screening of athletes to determine baseline performance in a variety of representative tasks. These results are compared to post- injury results to aid in diagnosing concussion. Other tools, such as the CDC's Acute Concussion Evaluation (ACE), follow a checklist format to assess common concussion symptoms in the absence of pre- injury data.10 The DoD has also developed a screening document in conjunction with its concussion management protocol.11 Use of these tools by EMS providers could be benefi cial in the recognition of concussion in all patient populations. earlier, many concussion symptoms mimic those of more serious injuries, such as cerebral contusion and intra- cranial hemorrhage. Under no circum- stances should a concussed patient be allowed to resume activity that involves risk of further head injury—the risk of second-impact syndrome is too great.2 Athletes should sit out until asymp- tomatic.4 Many sports organizations, including the NCAA, Pop Warner and numerous high school athletic associations, require that participants who suffer concussions be completely symptom- free and receive physician clearance before being allowed to return to play.8,9 applied to those who suffer concussion outside the realm of sports. Patients who have suffered concussion should be monitored continuously for signs of more serious injury as discussed above. Above all, patients must be made aware of the serious nature of their injury and the very real potential for death or disability from further injury. Conclusion Profi ciency at the assessment and management of concussion is an important skill for EMS providers at all levels. Whether the patient is an injured athlete, an elderly fall victim or a driver hurt in an MVC, concus- sion is a common and potentially deadly condition. Fortunately, awareness and thorough assessment techniques can help responders provide treatment and patient education, substantially mitigating the danger. REFERENCES 1. Guskiewicz KM, Marshall SW, et al. Recurrent concussion and risk of depression in retired professional football players. Medicine & Science in Sports & Exercise 39(6): 903–09, 2007. 2. Bey T, Ostick B. Second impact syndrome. Western J Emerg Med 10(1): 6–10, Feb 2009. 3. Guskiewicz K, Bruce SL, et al. National Athletic Trainers' Association position statement: Management of sport- related concussion. J Athletic Training 39(3): 280–97, 2004. 4. American Academy of Neurology. Position Statement on Sports Concussion, www.aan.com/globals/axon/ assets/7913.pdf. 5. Harmon KG. Assessment and management of concussion in sports. Am Fam Physician 60(3): 887–92, Sep 1, 1999. 6. Cantu RC. Head injuries in sport. Br J Sports Med 30(4): 289–96, Dec 1996. 7. Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care, 2nd Edition. Prentice Hall, 2002. 8. Runkle D. National Collegiate Athletic Association. Concussion Management Plan, www.ncaa.org. A similar approach should be 9. Pop Warner Little Scholars. 2010 In Season Safety Rule Amendment Re: Concussions, www.popwarner.com/ admin/pdf/2010%20Concussion%20Rule%20Change. pdf. 10. Gioia G, Collins M. Acute Concussion Evaluation, www. cdc.gov/concussion/headsup/pdf/ACE-a.pdf. 11. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guidelines for Management of Concussion/Mild Traumatic Brain Injury (mTBI), www. healthquality.va.gov/mtbi/concussion_mtbi_full_1_0.pdf. It is important to note that neither injury needs to be particularly serious It is, however, devastating to victims and Doug Edenburn is a paramedic from North Carolina. He works full-time for Cabarrus County EMS and part-time for the Department of Special Events and Sports Medicine at Carolina's Medical Center-Northeast. He also teaches EMS classes at Rowan-Cabarrus Community College in Salisbury, NC. Contact him at dedenburn@gmail. com. EMSWORLD.com | FEBRUARY 2012 23