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Concussion and Second Impact Syndrome

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    Concussion and Second Impact Syndrome

                            Head injury has a broad classification and includes injury to the scalp, skull or the brain. It is the most common cause of injury resulting to death in the United States. According to the Centre for Disease Control and Prevention, approximately 1 million people receive treatment for head injuries every year 230,000 of these are hospitalized, 80,000 have permanent disabilities and 50,000 people die (CDC, 2001). Traumatic brain injury is one of the most serious forms of head injury that results to death. This is a result of a motor vehicle accidents, car accidents, violence and falls. Head injuries are also common to those that are hit by hard objects or a hit from a fall on hard surfaces.  Groups that are at high risk for head injury are those at age 15 to 24 and are males at a rate twice of the females. It is estimated that 5.3 million Americans today are living with injuries as a result of a traumatic brain injury (CDC, 2001).

    The most common consideration to head injury is whether or not the brain has been injured. Apparently even minor injury can cause damage to the brain which is secondary to the obstructed blood flow and decreased tissue perfusion. The brain is not able to store the right amount of oxygen and glucose to a significant degree because of this. The cerebral cells need an uninterrupted blood supply to obtain these nutrients, irreversible damage to the brain and cell death occurs when blood supply has a shortage even for a few minutes.

                Some researches suggest that not all damage to the brain take place at the time of impact. Damage to the brain during an injury takes two forms: Primary injury and secondary injury. A primary injury is the initial damage to the brain that results from traumatic events. It includes concussion, contusions, lacerations and torn vessels from impact or from penetration of foreign objects. Secondary injuries are injuries involve the consequent hours and days after the initial injury. This is primarily due to brain swelling or ongoing bleeding including Secondary Impact syndrome that may lead to hypoxemia and electrolyte imbalances. Injury to the brain is different from other areas of the body due to its delicate and unique characteristics. The brain resides within the skull, a rigid closed compartment. Unlike an injury from the ankle where the skin as its covering expands during swelling, the confine of the skull is different because it does not allow expansion of its contents. As a result any bleeding or swelling within the skull increases the volume of its contents and thus causing increased intracranial pressure.

                 Increased pressure to the brain within the skulls causes a downward or lateral displacement of the brain within the structure of the skull. This causes restricted blood flow towards the brain, decreasing the oxygen delivery and waste removal. Cells within the brain become anoxic and cannot metabolize properly causing Ischemia, infarction, irreversible brain damage and eventually brain death.

    Literature Review


                A cerebral concussion is a head injury results to a temporary loss of neurological function with no apparent structural damage. A concussion involves a period of unconsciousness lasting from a few seconds to a few minutes. It is not as life threatening as other injuries but can cause long term problems as well.  It is a result of a closed head injury caused by either a sharp force trauma to the head such as falls, accident or a hit on the head with a hard object (eMedicineHealth, 2007). The jarring of the brain maybe so slight that it only causes temporary dizziness and headache, sometimes it maybe severe to cause a complete loss of consciousness for a period of time. If the brain tissue of the frontal lobe is affected the person may show bizarre or strange irrational behavior. Whereas if the temporal lobe is affected this would cause temporary amnesia or disorientation to the person.

                A concussion was once thought as a minor head injury without significant consequence. However, nowadays studies have shown that there are often disturbing and sometimes residual effects including headache, lethargy, personality behavior changes even attention deficits, memory discrepancy and disruption of work habits (Ponsford et al., 1999).

    Elderly patients must be assessed carefully with the given injury as it will more likely that an elderly person will suffer more severely than a young person with head injury. They often recover more slowly and sustain more complications (Perdue et al., 1998). The elderly patients with confusion or behavior disturbances should be assessed with head injury, because unrecognized minor head trauma may account for behavioral and confusion episodes in some elderly people (Walshaw, 2000). A misdiagnosed or untreated episode of confusion in elderly patients may result to a long term disability that could have been avoided if patient had been detected and treated on time.

    The common signs and symptoms of a concussion is loss of consciousness, there is confusion most commonly in elderly patients, severe headache, and blurred vision. It is also accompanied by nausea and vomiting and weakness of the side of the body. When a person has loss its consciousness sometimes it also accompanied by loss of short term memory, it maybe that you would not be aware of what has happened during the injury or the activities that you did before the injury. There are some cases when the patient is preservating; it is repeating the same thing over and over again even if the answer has been already informed. Anxiety is also present to some that is why the patients are usually advised to resume activities slowly and to observe signs and symptoms that may lead long term problems. Identification of these signs and symptoms helps lessen the chances of developing major complication to the brain that would eventually be fatal if not properly assessed and given the right consideration.

    Second Impact Syndrome

                Second Impact syndrome happens when athletes who sustained a head injury sustains another head injury without the symptoms of the first clearing up. This usually happens when an athlete returns to a competition without the first symptoms of the injury are resolved. Athletes do not realize the risk when a symptoms of a head injury is unresolved, they are not aware that it takes days or weeks before a concussion symptoms are determined and treated. Second Impact Syndrome is mostly affects young athletes that are in junior and senior high but it does not exclude those athletes that return to play their sports after sustaining a head injury. Incidence is really unknown because the total populations of at risk are unidentified (Cantu, 1996).

                Secondary injury may occur from days to weeks following the first one. Although loss of consciousness is evident it is not a requirement for the condition as this may be a result of other conditions that are related to head injury. Secondary Impact syndrome (SIS) maybe a mild and athletes may appear to be dizzy but this condition actually causes the cerebral edema and Herniation which leads to death within minutes or even seconds (David, C., 2008). Only 17 cases of SIS have been reported and recorded that it is why the pathophysiology is really unclear although figure 1.1 shows a simple way of what happens with SIS.

    Pathophysiology of Second Impact Syndrome

                                                           First head injury is sustained

    A second blow to the head is sustained (even if only minor)

    Results to the loss of auto regulation of the brain’s blood supply

    Brain swelling

    Increased intracranial pressure

    Herniation of the brain

    Brainstem failure (2-5 minutes)

    Ocular movement and respiratory failure results

    Figure 1.1 (Cantu, 1996)

                It is important the person who suffered from initial brain injury have already resolved (6-18 months after injury) because the effect of multiple concussion and other head injuries usually results to a longer term deficit in the neurologic function.

    Within seconds or minutes of the second head injury the athlete or patient may collapse and loss consciousness. This can also lead to semi comatose with rapid dilated pupils, loss of eye movement and the most fatal is respiratory arrest. Other signs and symptoms include memory loss or impairment, easily fatigability

    A case study of how fatal SIS is done on amateur athletes. The first one is done to a 16 year old ice hockey player, who was struck back of the head on the ice. There is a short loss of consciousness, headache and unsteadiness. After 4 days of sustaining an injury the athlete was then again struck left temple on ice causing a second injury. There was loss of consciousness but the duration was unknown. The outcome consists of cerebral swelling, hematoma, hemorrhaging causing the death of the athlete 2 hours after the second injury (McCory & Berkovic, 1998).

    A study on American high school and college was done to football players were 94 catastrophes of head injury were demonstrated with significant intracranial bleeding and edema over 13 year period. Only 2 of theses occurred at college level and seventy one percent of high school players suffering with injuries had a previous concussion, and thirty nine percent are with residual symptoms. The National Football league also conducted a study of concussion, results shows no catastrophes on head injuries as well as SIS on players that returned to play the same game after the symptoms have been resolved (David,C., 2008).


                A survey will be done to amateur athletes about the sustaining head injuries like concussion and how aware they are about its effect. A survey questionnaire will be used to collect data from amateur athletes. The questionnaire is a self directing instrument structured with questions and indicators for the patient to react upon. It will measure the information level, opinions, attitudes and perception as well as the gathered factual information from the respondents. The first of the questionnaire will be use to gather the demographic variables of the athletes. This includes the age and gender of the athletes. The second part of the questionnaire (modified) will be about the how many athletes sustained a head injury after playing and how aware are they to the consequences of this injury to their health and performance as an athlete.

    Data analysis and results

                Out of the 50 amateur athletes that were surveyed 90% of them, both females and males, has sustained a head injury and only 10% have not. The data also shows that of the 90%, who has sustained an injury, 30% of them are females and the rest are males. Among the 90% both female and males, 60% of them were aware of the effects and consequences of a head injury on their health and behavior but failed to comply with the proper equipment and measure to prevent head injury. Out of the 90% who sustained a head injury, 85% of them are have sustained a primary head injury such as concussion and 15% of these athletes have had secondary head injuries. Only 10% of the athletes are aware of the danger a concussion or any head injury have on them and how important it is for the symptoms to be resolved before playing again. 65% of the athletes that have experienced signs and symptoms of head injury but only 15% of them were hospitalized. Of 90% athletes who sustained a head injury none of them was reported to have Second Impact Syndrome.


                As evident on the conducted survey, there are a high percentage of amateur athletes who at an early age sustained injury of the head. This indicates that there is high incidence of amateur athletes sustaining injury especially from the head. It is also evident that there is a high awareness to the effects of head injuries to their health yet most of the athletes still ignores this and does not comply with the protective measures and proper management of head injuries.

                As the conducted survey amateur athletes are not aware of the great consequences a head injury like concussion is to their health. Only a few is aware of the importance of consulting a doctor and other specialist when sustained with a head injury. It a sad motion as well that little information is made known to athletes of how important it is to resolved first the symptoms of the first head injury before engaging in their plays. Without proper maintenance, little do they know that these minor or primary injuries can further aggravate and lead to a more serious problem.

    Management of Concussion and Second Impact Syndrome

                Proper assessment and diagnosis of the extent of the injury is important to prevent any further complication from emerging. Initial physical and neurologic examination is done. CT scan and MRI are the primary neuro imaging diagnostic tools that are helpful in analyzing and evaluating the soft tissue injuries in the brain. Positron emission tomography (PET) is another method used in examining the brain function rather than just its structure.

    A short time after a concussion, the person may be hospitalized overnight for observation. Treatment with concussion involves being observed for headache and its severity, dizziness, lethargy, irritability and anxiety. These symptoms that occur after a concussion is referred as post concussion syndrome, pertinent information and explanation to the person with encouragement would help lessen the problems of post concussion syndrome. The patient is then advised to resume normal activities slowly and relatives are instructed to report signs and symptoms like difficulty awakening, difficulty in speaking, confusion and weakness of one side of the body as this maybe an emergency and may need attention right away to prevent further complications (Smeltzer & Bare, 2004)

    There are some people who believe that a person should stay awake specially children after a concussion or a head injury. It is not really necessary to keep a child awake after a head injury because often time’s children with head injuries are emotionally upset and would be exhausted physically and would need to fall asleep to calm down. When the child has its sleep it would be a help for the doctor because the patient has already calmed down and easily awaken. It would provide a better chance for the doctor to observe and assess the severity of the head injury. If the patient who is normal after sustaining a head injury cannot be awaken or is difficult to wake then the person is likely to have one or more serious head injury that would need further evaluation to prevent serious complications (eMedicine, 2007).

    All therapy is directed towards preserving the homeostasis of the brain and preventing secondary injury and cerebral edema. Intracranial pressure is monitored. Increased intracranial pressure can cause a great damage to blood circulation to the brain.  It is managed by providing adequate oxygenation by elevating the head of the bed. It is also important to monitor the blood volume of the brain and maintained at a normal level.

    Surgery is performed to person that sustained blood clots and infarcts as a result of the head injury; this is usually done to severe cases where complication arises due to the lack of compliance and direct observation of the head injury.

    Other tests include neuropsychologic testing. This is a thorough examination of patient’s, who sustained concussion specially those with SIS. Neuropsychologists examine and evaluate the thought process of the person with a head injury. The tests are done through a variety of cognitive and behavioral tests that would indicate the severity of the injury or any issues concerning the patients. This test showed that person with multiple concussions is associated with lessened cognitive performance.

    Supportive Measures

                Supportive measures are done with treatment like ventilator support, seizure prevention, fluid and electrolyte maintenance, nutritional support and pain and anxiety management. Seizures are very common to a head injury which is the common cause of secondary brain injury that is why anti seizure agents are administered. Bedodiazepines may be prescribed to an agitated patient to calm him or her without compromising the level of consciousness. These medications are a good choice for patients with head injury as this causes no effects to the brains intracranial pressure.

    Rehabilitation Measures

                When a person has sustained a concussion or any head injury, the person’s maximum function is changed that is why rehabilitation programs are needed to maintain optimum function of the person.  Physical therapy is one of the rehabilitation programs aiming to maximize the strength and independent function of the person who has sustained a head injury. This therapy is helpful   in patients with motor function deficit and those that are immobile. Exercises are provided to patient in order to prevent contractures and help the patient to return to their daily activities with ease. Occupational therapy and recreational therapy are also done to patients with brain injuries. This therapies help motivate patients that have motor and cognitive deficits. This helps them improve their abilities in performing a task and their ability to perform the usual activities they have before the injury. Recreational activities promote their socialization skills and help them cope up with their environment (eMedicine, 2007).

                It is important that a support system is ready and available. Counseling is advised to those patients that are having confusion and are agitated because of the head injury. Families and friends are also a good help in maintaining the state of mind of the persons with a head injury whether a concussion or SIS. It is important even a minor hit in the head even without concussion occurring or any symptoms present, it is still advisable to consult a physician in order to lessen the chances of serious problems to arise.


                A concussion maybe a minor case of injury but without proper treatment or observation from doctors it can lead to serious problems like SIS (second impact syndrome) that could be fatal within minutes or seconds.

                 Professional athletes or even amateur ones can prevent head injuries like concussion by wearing a protective head gear specially those that at risk of head injuries because a concussion can be repetitive that may result to future concussion or even worst to SIS. That is why the use of protective gears is significant in reducing the number of head injuries that can be fatal.  The key factor in preventing SIS (second impact syndrome) is the early detection of a concussion. Early management of concussion would help prevent other serious problems like SIS especially to athletes. Athletes with concussion should be prevented from playing unless they are free from the symptoms of their head injury.

                Prognosis of head injuries differs which is dependent to the extent of the injury. Early detection of concussion can prevent worst complication like SIS, as they have a good outcome and a few long term side effects. It is important that athletes and their coaches are educated regarding the potential catastrophes of concussion like SIS. Health professionals should also be aware that in order to reduce the risk SIS, it is important that athletes should first recover to the initial or previous head injury before playing.

                Awareness and sense of responsibility is one way of preventing incidence of head injuries. As many people would agree to it is always better to prevent than to cure.

    Works cited

    Cantu, R.C. “Head injuries in sports.” British Journal of Sports medicine. 30(1996): 289-296.     29 April 2008

    “Centers for Disease Control and Prevention” 2001, National Center for injury and Prevention             Control,Malistop K65, 4770 Bufford Highway NE, Atlanta. 29 April 2008             <>

    “Concussion”.eMedicineHealth.29 April 2008             <>

    David, Cifu. “Repetitive Head Injury.” eMedecineHealth.29 April 2008             <>

    McCory, R., & Bekovic, S.T.”Second impact syndrome.” Neurology 50(1998): 677-683

    Perdue, P., Watts, D., Kaufmann, C., & Trask A.”Differences in mortality between elderly and             younger adult trauma patients: Geriatric status increases risk of delayed death.”Journal of             trauma- Injury Infection and Critical care 45(1998): 805-810

    Ponsford ,J., Willmott C., et al.”Cognitive and behavioral outcome following mild traumatic     head injury in children.” Journal of head Trauma Rehabilitation 14(1999): 360-372

    Smeltzer, Suzzane C., Bare, Brenda G.Brunner and & Sudarth’s Medical Surgical Nursing. New          York: Lippincott Williams & Wilkins. 2004

    Walshaw, L. K.”Assessment of the head Injuries in a minor injuries unit” Accident & Emergency             Nursing 8(2000): 210-213

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