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Can an icy sidewalk kill you?

date

Matthew Vasey, MD



HEADLINE: Autopsy: Richardson died from bleeding in brain

The answer is yes of course otherwise I wouldn't be writing this, and it can happen quite simply from slipping and smacking your head against the concrete. Your brain is enclosed in a fixed volume space so if vessels break open and blood starts pouring into where it shouldn't be, part of your brain may potentially get squeezed downward and out of your skull. I don't mean out of your head onto the sidewalk, that's a whole'nother problem. I mean what's called "herniation" where your brain gets squeezed out of the base of your skull like a play-doh machine into your spinal canal. It just so happens that the area squeezed controls breathing. Obviously, if you're not breathing you end up dead. While death may not ensue, you have at least given yourself a concussion, one hell of a headache and perhaps a big bleeding cut on your head. Neck injuries are also of concern. Fortunately, less than 10% of patients have bleeding vessels inside their head after a concussion, and less than 2% require a neurosurgical procedure to drain the accumulating blood. (2)

A concussion is basically the result of taking a hit to the head that knocks you out. That means there is a brief period of time that you are completely unconscious before you wake back up. Because the brain is suspended in fluid there is the potential for sheering forces. Imagine shaking a pickle in a pickle jar. Your brain is connected to your spinal cord which is fixed. It is that transition area from a fixed spinal cord to a suspended brain that is affected. That is the area of your brain responsible for being alert and explains why you get knocked out from a concussion. (5) Hence, getting "your bell rung". Sometimes there is even a brief convulsion episode that can be confused for a seizure right after a concussion. (3,4) An accurate timeline of events is important in medical decision making so if something like this is ever witnessed, please pass the information on the EMS paramedics. It can be of help in that patients care.

In the U.S. concussions occur in about 128 people per 100,000. (1) They are most commonly the result of sports injuries, automobile and bicycle accidents and falls. While most concussions are uneventful over the long term, initially you have to watch out for brain bruises and bleeding from blood vessels inside your head. Anytime there is a loss of consciousness whether there was a blow to the head or not a visit to the emergency department is warranted. Not all concussions require a CT scan of the head but it is important to be seen by an ER doctor promptly to determine if it is necessary to get your "cat" scanned.

As far as athletes are concerned there are no definitive answers as to how to manage a concussed athletes return to action. There are only guidelines based on expert opinion. They are basically based on loss of consciousness with confusion lasting more or less than 15 minutes and what other symptoms the athlete has on the sidelines after the event. These guidelines are under review and much of the recommendations are considered to be areas of uncertainty. You can never go wrong with erring on the side of caution in regard to when a concussed athlete can get back out playing again.

Here is a link to the guidelines:
http://content.nejm.org/cgi/content-nw/full/356/2/166/T3

REFERENCES:
1. Bazarian JJ, McClung J, Shah MN, Cheng YT, Flesher W, Kraus J. Mild traumatic brain injury in the United States, 1998-2000. Brain Inj 2005;19:85-91.
2. Ibanez J, Arikan F, Pedraza S, et al. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg 2004;100:825-834.
3. McCrory PR, Berkovic SF. Concussive convulsions: incidence in sport and treatment recommendations. Sports Med 1998;25:131-136.
4. Perron AD, Brady WJ, Huff JS. Concussive convulsions: emergency department assessment and management of a frequently misunderstood entity. Acad Emerg Med 2001;8:296-298.
5. Ropper AH, Gorson KC Concussion N Engl J Med 2007, 356:166.

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