by Last week, I reviewed diagnosis of a concussion and management as well as patient education. And like always, when you read it, you then have a few patients that week with that diagnosis
What i wanted to continue with this week is the importance of educating our patients on the SECOND injury.
This is the patient that doesn’t listen to your brain rest and physical activity restrictions, goes out and gets hit on the noggin a second time.
Second Impact Syndrome
Rare and potentially fatal complication that involves diffuse cerebral edema secondary to a recurrent or second concussion while the patient is still symptomatic from the first injury. The epidemiology data only mentions a few case series
From the initial concussion, the brain develops slight cerebral edema (where the memory impairment, headaches,
and disorientation) and begins to slow cerebral blood flow while it heals as well as increased extracellular potassium causing hypermetabolism leaving the brain very vulnerable to secondary injury. With the second injury, the brain loses the ability to regulate these processes leading to more swelling eventual cerebral edema and possible herniation.
Although research on this is still pretty young, it looks as though the incidence of second injury syndrome are higher in children versus adults. Again, older people brain atrophy is protective cheers! (shots for the alcoholic brain too!)
if there is not herniation, the repeated injuries, and driving force behind the movie Concussion starring my long-time crush Will Smith, leads to something called Chronic Traumatic Encephalopathy progressive deterioration of brain function
So what should we do in the ED?
Since it can acutely lead to herniation, the likelihood of us catching this in the ED is pretty slim to mostly none so it is best to treat those that may present like any impending herniation patient
PROTECT THE AIRWAY… GET NEUROSURGERY ON BOARD…ELEVATE THE ANGLE OF THE BED….GIVE MEDS
-administer either mannitol or hypertonic saline (whatever the flavor of the month is at the time of practice)
More importantly for my fellow event medicine interest friends, when you’re on the sidelines and you see these sport-related concussions happen first hand, here are some guidelines to help with discussions on the field:
Happy Graduation Week!!
References:
https://westjem.com/articles/second-impact-syndrome.html https://www.sciencedirect.com/science/article/pii/S0099176703001077
https://lifeinthefastlane.com/concussion-in-sport-2015/
