Patient Care, Training, Trauma

How a Cautious Approach to TBI Patients May Help Reduce Incidents of Second Impact Syndrome

Issue 1 and Volume 39.

The sharp crack of football helmets from two colliding players running at a high rate of speed forced a collective gasp—then silence—from the crowd that realized the outcome of the violent collision couldn’t be good. Both players were able to leave the field on their own power and continued to play, one of whom sustained a second serious blow to the head that appeared to have stunned him. Following the game, the player begins vomiting and loses consciousness. The school athletic trainer stabilizes the athlete on the floor of the locker room until EMS is called and providers transport him to a regional hospital where he died the following day.

Although this is a fictitious scenario, the reality is second impact syndrome has occurred with greater frequency than may be reported, especially on the high school football level. This phenomenon is disturbingly real, causing coaches and sideline medical personnel in all sports where trauma to the head can occur to rethink their procedures for allowing players to return to play.

First reported in 1984,1 second impact syndrome is a nebulous sequelae of short- and long-term events precipitated by subsequent blows to the head following an initial insult causing neurological disturbance that typically has catastrophic results. Essentially, the brain is not given the opportunity to recover from the initial blow before sustaining further trauma, however mild. It remains a somewhat controversial definition among many in neurologic medicine, but the semantics mean little for the athlete and those thrust into rendering care.

Robert Cantu, MD, a renowned Boston neurosurgeon who has extensively researched second impact syndrome, said there are countless cases missed each year. “Many doctors don’t even know about second impact syndrome,” Cantu says. “It’s missed all the time.”

Cantu says second impact syndrome goes underreported because research and classification is limited, especially in the tragic cases where a young athlete dies secondary to the head injury.

“Tragically, most medical examiners are not even pathologists, and since no foul play is involved in the athlete’s death, rarely is an autopsy conducted,” Cantu says. “It’s just assumed the cause of death is because of the head injury.”

Technically, deaths associated with second impact syndrome are associated with head injuries that manifest a subdural hematoma because auto-regulation of brain perfusion is lost.

The chain of catastrophic events occurs with the subsequent blow to the head, however subliminal. The brain loses its ability to regulate blood volume—resulting in an increase in cerebral blood volume—which results in brainstem herniation and death. This sequence of events can occur in three to five minutes, making prompt evaluation and prehospital care crucial for the athlete’s survival.

The consequences of concussions in collegiate and professional athletes, especially in football, have only been seriously addressed by athletics organizations in the past decade with the short- and long-term effects contributing not only to the end of careers, but chronic disability and even suicide. And these are the athletes who have teams of trained medical personnel at their daily disposal. When looking at scholastic sports, many schools have recognized the value of a certified athletic trainer, but most still resort to EMS standby crews only on game day.

In the case of EMS crews solicited to provide on-field standby services for sporting events, the importance of observing the action on the field can’t be overstated. All too often, EMS personnel are summoned to the sideline after the initial insult while the pathophysiological events have already been set in motion. Knowledge of the mechanism of injury for sports concussions is worth knowing to assess a potential injury the athlete they may not even know they’re experiencing. This addresses the need for on-call medical personnel to be strategically located to have a clear view of the field to observe players and their reaction to contact either with another player or the ground.

Concussion Basics & Stats
Concussions are characterized by neurologic impairment due to a direct blow to the head, such as colliding helmets or contact with the ground/floor as well as indirect trauma causing a contrecoup reaction of the brain in the cranium. This can be seen in a whiplash type mechanism when a player is violently struck in the anterior or posterior torso causing the head to suddenly whip in the opposite direction.

Most concussions are mild in nature and usually self-correcting, but shouldn’t receive any less attention. Significant concussions can lead to unconsciousness, coma and death.

According to a 2011 report by the Centers for Disease Control (CDC), which studied incidents of traumatic brain injury (TBI) via the National Electronic Injury Surveillance System, ED visits for non-fatal sports and recreational TBIs among persons aged ≤19 years increased dramatically from 153,375 in 2001 to 248,418 in 2009.2 The report says the highest incidents of TBIs occurred in bicycling, followed by football, playground head injuries, basketball, soccer and baseball.

But the startling statistic claimed by the CDC is the occurrence of some 3.8 million concussions per year sustained by athletes on all levels, many of which go un- or improperly evaluated.3 The assumed risk also runs high with the presumption that 10% of athletes who participate in contact sports will sustain at least one concussion annually. The concern is further exacerbated by a report from the American College of Sports Medicine, which estimates that 85% of sports TBIs go undiagnosed.4

Football has accumulated the most deaths and attention from brain-related trauma. According to the National Center for Catastrophic Sports Injury Research at the University of North Carolina, there were 32 fatal brain injuries attributed to football between 2001 and 2010. The center also found a significant increase in long-term brain disability associated with football. Between 1981 and 1990, there were 27 reported cases, then more than a 100% increase occurred between 1991 and 2000 with 52 cases; 66 cases occurred between 2001 and 2010. The belief is that not only are athletes bigger and faster, more high schools have athletic trainers than 20 years ago, which has provided more accurate assessment of these injuries that may have otherwise gone unrecognized.5

To minimize risk of second impact syndrome, even patients experiencing a brief loss of consciousness should be properly immobilized and transported for further evaluation.

Recent Incidents
So far, in the 2013 high school football season, three players have died of brain trauma. In the case of Dodi Soza,16, of Downey, Calif., there have been media reports that he suffered a concussion in practice two days before he collapsed at a game and died, raising the specter of second impact syndrome.6

Even in the presence of trained personnel, these injuries can be confounding. In September 2013, a New Jersey school district paid $2.8 million in a 2009 negligence lawsuit filed by the family of a 16-year-old football player who died in 2008, reportedly secondary to second impact syndrome. Named in the suit were the school’s coach and athletic trainer, who assumed the athlete had recovered from the initial trauma.7

“Ryne Dougherty was prematurely allowed to participate in football, as he wasn’t fully symptom-free and still in the recovery phase,” Cantu said.

Dougherty had received his initial blow to the head on Sept. 18, 2008. The athletic trainer found him to be dizzy, complaining of a headache, and vomiting. He was kept out of football for 25 days but was struck in the head again during a practice. Once again, the athletic trainer reported Dougherty to be dizzy and nauseous. The athletic trainer subsequently had Dougherty complete a concussion questionnaire where he reported a complaint of “fogginess.” The results were never checked. Even Dougherty’s doctor cleared him to play after two days, when he still complained of lethargy and a headache.

In the first quarter of the ensuing game, Dougherty was struck in the head again while making a tackle and collapsed on the way to the sideline where he ultimately fell into a coma. He died two days later.

This warning bell should bring EMS personnel closer not only to the action, but also to understanding what to look for in the case of a TBI.

Training Gaps in EMS
Eve Kwiatkowski, a New Mexico paramedic and EMS instructor coordinator, is the first to admit that TBI-specific training is lacking for EMS personnel, as well as athletic mechanisms of injury.

“Sports injuries are an entirely separate discipline,” Kwiatkowski says. “In my opinion, as with rodeo or stand-by medicine, this is a separate area and should be taught as a stand-alone certification in addition to EMT-Basic.”

When it comes to EMS being aware of its state’s sports concussion care criteria, Kwiatkowski agrees but with a caveat. “It doesn’t have to be a football game to have a sports injury,” she says. “The challenge that is faced is that there is so much already in EMT curricula. Where do you put it? What gets left out? And if you add hours, who pays for it?”

All too often, in the heat and rush of a game, a player will become dazed from a hit. But as long as they don’t lose consciousness, there’s a traditional assumption that it isn’t serious. Then there’s the machismo element of sports where an athlete shuns showing weakness or is concerned about losing their spot on the field.

“Are you OK to play?” is typically the extent of a coach’s sideline evaluation. In the absence of any visible signs such as staggering, slurred speech or loss of memory, the assumption of a minor injury persists despite the athlete experiencing tinnitus, headache or nausea, all of which escapes coaches and even some sideline medical personnel. The athlete is then returned to play only to sustain subsequent hits to the head, then subsequently succumbing to cerebral edema.

Plethora of organizations such as USA Football, the National Collegiate Athletic Association, and the National Athletic Trainers Association, the CDC, and the National Association of School Psychologists, have launched aggressive campaigns to raise awareness for coaches and parents to the signs of a TBI. And to press the point further, all states except for Mississippi have enacted some kind of legislation to protect scholastic athletes following a concussion.8 New York passed the Concussion Management and Awareness Act in 2012, which requires coaches, physical education teachers, nurses and athletic trainers to complete an approved course on concussion management, and set standards for the care of athletes who have suffered even minor brain trauma. New Mexico parents must read and sign a concussion management document for their child at the beginning of each season.

Sideline Assessment
Researchers can’t seem to agree on the incident rates of secondary impact syndrome, but do agree there are consequences to a subsequent insult to the brain following an initial incident, regardless of how seemingly mild it may appear. This supports the need for sideline medical personnel to be especially vigilant in observing the manner in which players emerge from an event where contact to the head may have occurred. These observations would include a player reticent to getting up from the ground, or slowly rising, or perhaps walking with an ataxic gait (i.e., staggering).

While any decision to return a player to the field after a TBI should ultimately be made by a physician, the following sideline tests augment the primary and secondary survey. These tests and the above signs/symptoms should be checked and recorded at least every five minutes to monitor whether the athlete’s condition is improving or deteriorating.

  • Use a neurocognitive test such as the Maddocks Score where the athlete is asked where they are currently playing, which half the game is currently in, who scored last, who they played against in the last game and who won.
  • Balance can be checked by having the athlete stand with their feet together—first with eyes open, then closed. Any swaying or instability should be observed. If this test proves negative, progress to a one-legged stand with eyes open and closed. Have the athlete then walk heel-toe along a straight line.
  • Have the athlete stand with their feet together and their arms at shoulder height. With eyes open, then closed, watch for any dipping of the arms. The test is concluded by having the athlete close their eyes and attempt to touch their nose with alternating index fingers.

Prehospital Treatment
Field management is first and foremost dictated by state and local protocols. Cantu says non-steroidal anti-inflammatory drugs and aspirin shouldn’t be given to an athlete complaining of a post-concussion headache because of the potential to increase intracranial pressure. He says acetaminophen (Tylenol) is the only option, but cautions that subsequent evaluation of whether the headache persists or worsens because of progressing intra-pressure may be hampered. A fundamental primary survey should be conducted, especially in the case of an unconscious athlete. Any patient who experiences a prolonged loss of consciousness (i.e., more than a few seconds) should be transported with cervical spine precautions for evaluation without delay.9 However, transporting any patient who experiences even a brief loss of consciousness might help to prevent further injury due to second impact syndrome.

It’s incumbent of EMS to closely monitor the presence of hypotension and hypoxia. The Brain Trauma Foundation provides specific guidelines to address the critical consequences of hypoxia and/or hypotension, both of which are predicators for a negative outcome.10 Hypotension can double the incidence of mortality and care should be taken not to hyperventilate the patient.

Oxygen saturation must be maintained above 90% with supplemental oxygen. Intubation may be necessary. Respirations should be kept under 20 breaths per minute and closer to 10–12 with EtCO2 in the range of 35–40 mmHg. EtCO2 is growing in popularity as a reliable asset in prehospital brain injury management. Studies have found that following a head injury, hypoperfusion with a decrease of cerebral spinal fluid by as much as two-thirds can occur. By hyperventilating the patient there can be a further decrease in cerebral blood flow.

Hypotension, with a systolic blood pressure below 90 mmHg, requires immediate fluid replacement to address the decreased cerebral perfusion, which can increase the occurrence of secondary brain injury contributing to a poor outcome. There are indications of the benefits of hypertonic fluid replacement over normal saline in the chance of survival of patients with a Glasgow Coma Scale of less than 9. However, a hypotensive patient should be treated with isotonic fluids, according to the Brain Foundation recommendations.9

Return to Play Criteria
It’s likely not in the purview of EMS to make a return-to-play decision for the concussed athlete, but being the only medical personnel on a sideline can put you in a precarious position. The bottom line is that if an athlete exhibits any signs of a concussion, whether it be headache, nausea or diminished neurocognitive function, they shouldn’t be permitted to return to play. And when they do become asymptomatic for 24 hours, there should be a gradual return to play process that begins with light physical exertion. If this can be performed asymptomatically, they can progress further until ultimately cleared by a physician. The physical component must also be complemented with a neurocognitive test. What most athletes, coaches and parents don’t realize is that this process can last days to weeks or even longer.

Cantu cautions medical personnel who cover athletic events to be aware of the concussion management laws that exist in their state and to not divert from it. “There are many well-meaning medical professionals who cover athletic events for little to no money, but they should still be competent to treat concussions,” Cantu says. “If you return someone to play and they come up with second impact syndrome—case closed!” 


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3. Centers for Disease Control and Prevention. (Jan. 6, 2011.) Heads up: Facts for physicians about mild traumatic brain injury (MTBI). Retrieved Nov. 18, 2013, from

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8. Breslow JM. (Aug. 13, 2013.) What are the youth football laws in your state? Frontline. Retrieved Nov. 18, 2013, from

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10. Badjatia N, Carney N, Crocco TJ, et al. Guidelines for prehospital management of traumatic brain injury, 2nd edition. Prehosp Emerg Care. 2008;12(Suppl1):S1–S52.