Mark Greve MD FACEP Assoc Prof Emergency Medicine. Brown University - - PowerPoint PPT Presentation

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 TBI1

• Severe TBI GCS < 8 after

resuscitation

• Protocol driven mgmt
• Early intubation
• Rapid ACLS transport
• Early CT scan
• Immediate evacuation of

mass lesions

• Meticulous ICU mgmt
• Primary Injury
• Damage from direct trauma

including blunt, penetrating, acceleration, deceleration and rotational forces.

• Secondary Injury
• Bimolecular and

physiological cascade

• 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