Mark Greve MD FACEP Assoc Prof Emergency Medicine. Brown University Division of Sports Medicine Team MD Rally UHC
“Having things organized is only for small-minded people.The genius controls the choas.” Jens Voight
Management and Pathophysiology of Severe TBI 1 • Severe TBI GCS < 8 after • Primary Injury resuscitation • Damage from direct trauma including blunt, • Protocol driven mgmt penetrating, acceleration, • Early intubation deceleration and rotational • Rapid ACLS transport forces. • Early CT scan • Secondary Injury • Immediate evacuation of • Bimolecular and mass lesions physiological cascade • Meticulous ICU mgmt • Hypoxia • Hypotension Greve MW, Zink BJ Pathophysiology of traumatic brain injury . Mt Sinai J Med. 2009 Apr;76(2):97-104.
Traumatic Brain Injuries • Acute • Severe • Moderate • Mild • CTE • THESE ARE NOT CONCUSSIONS!!! • Concussion care is the same. Our problem is timely diagnosis
The Problem with Finding out if you have a concussion • We are probably the highest risk sport for TBI outside of contact sports • But we can’t stop play to assess you • NO STANDARD OF CARE EXISTS IN CYCLING • Problems • Assessing athletes in play • Where are they? • Where is medical? • What language, whats the local care like, wheres the hospital….
Paradigm Shift • We cannot expect team physicians to be available or even on site to assess riders at the time of injury • Welcome to the medical team kids • Key new members of the medical team • On course • Mechanics • Directors • Riders
Reminder….you didn’t go to medical school • You are not responsible for diagnosing riders with head injuries • But you are now empowered and expected to hold riders for medical evaluation if there is reasonable concern for injury or inability to safely compete. • Head injury is a dynamic process • Head injury is a dynamic process • Reassessment is key • Time window is usually 3 hours for intercranial bleeding
End of Event • Riders have not been assessed for concussion. • Just because they finished doesn’t mean they’re not injured • Now we can follow standards of care • Soigniers and directors are key members of post event care • SWAY-IMPACT • Remote Medical Consultation
Head injury checks • On course evaluations • Staff/Rider Assessments of Rider post crash • On going observation • Immediate Post event • Consult medical • Sway-Balance • King Devick • Next AM eval • Repeat Sway-Balance
Concussions • Iniital impact causes shearing forces across synapses- alteration of electron transport • If it progresses to concussion then there is disruption in neurotransmitors at around 48-72h • Cognitive rest for 72h is the first and best window for recovery • Do what you can. Don’t worry about flying. Get somewhere you can rest.
Staged Recovery
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