Acute Subdural Hematoma in a High School Football Player After 2 Unreported Episodes of Head Trauma: A Case Report

CASE REPORT

The patient was an 18-year-old high school football player, with an unremarkable medical history, who was 181 cm tall and weighed 84 kg. While walking toward the sideline, the athlete took off his helmet and appeared confused. Falling to his knees, he began to vomit. However, the patient was oriented to time, person, and place. His immediate complaints included severe head pain, nausea, and vertigo. No neck pain or any lower or upper extremity paresthesias were present.

The specific head injury or head contact that precipitated this event could not be identified. However, the athlete recalled being hit on 2 separate occasions during the game, although he did not report the incidents to the coaching staff or certified athletic trainer. The patient stated that he had a headache and nausea, but he continued to participate in the game.

To prevent a catastrophic outcome, even though loss of consciousness was not witnessed, paramedics were summoned on the field for transfer because of the patient's 2 unreported episodes of head trauma and symptoms associated with a concussion. While he was being prepared for transfer, the patient's level of consciousness decreased, and he became less responsive. The neck was stabilized with a cervical collar to prevent further injury, although there was no cervical spine tenderness, and the patient appeared to have a mild seizure, becoming temporarily unresponsive to stimuli. In the ambulance during transport, the patient had a witnessed seizure and was incontinent of urine. Attempts to intubate him were unsuccessful due to his resistance.

On arrival at the emergency department, the athlete was oriented to time, person, and place. He complained of severe headache, nausea, and retching. He denied any neck or back pain or paresthesias. Mannitol, 80 g, was given to reduce intracranial pressure. The neurologic examination revealed a Glasgow coma scale score of 15. Pupils were equal, round, and reactive to light. No nystagmus or periorbital or retroauricular ecchymosis existed, and extraocular function was intact. Reflexes and sensation were normal. Cervical, thoracic, and lumbosacral x-ray films were normal. An immediate computed tomographic (CT) scan suggested a left frontal-temporal acute subdural hematoma that measured 1.2 cm, with an equivalent left-to-right shift (Figure), although the images were not particularly remarkable.

The patient was given phenytoin (dosage was not stated in the patient's record) for prophylaxis of seizures, which were thought to be a possible result of the subdural bleeding. He was admitted to the surgical intensive care unit for monitoring of his neurologic status and for an additional CT scan, if his condition worsened during the night, to assess the need for neurosurgical intervention. Additional CT scans and examinations throughout the night did not indicate the need for surgical intervention. Approximately 24 hours later, the CT scan revealed a significantly smaller amount of blood than on the previous examination, with no additional subdural collections or mass effects. The athlete was released under his parents' care. He complained of a headache and inability to recall specific events involving his transport to the emergency department (anterograde amnesia). The parents were instructed not to let the patient participate in any activities, such as school or sports, until he was cleared by the physician and follow-up CT scan.

One week later, the patient returned for a follow-up CT scan and electroencephalography. The CT scan revealed that the subdural hematoma had resolved. The athlete complained of severe headache and nausea, not uncommon after such an injury. Acetaminophen was prescribed for pain and headache and trimethobenzamide for nausea (medication dosages were not stated in the patient's chart). The electroencephalogram revealed abnormal sharp waves, consistent with seizure activity, and therefore, phenytoin was prescribed for 6 months. The patient was instructed not to participate in football for the remainder of the season or drive for 6 months and was withheld from school for 2 weeks.

Twelve days after the initial head injury, the patient complained of continued headaches and nocturnal neck pain. Clinical examination by the physician revealed an area of marked tenderness that measured 1 to 2 cm in diameter beneath the left occipital protuberance and increased pain when the patient turned his head to the right. No cervical spine radiographs were taken during the evaluation. The clinical impression was a cervical ligament strain from the previous injury. A prescription for ketorolac, 10 mg/d, was given in conjunction with diazepam, 5 to 10 mg/d.

One month later, the patient was progressing well and able to increase daily activities. The nocturnal neck pain from the cervical ligament sprain had ceased. The athlete was restricted from physical education class until fully asymptomatic and cleared by the physician. He was able to complete a full day at school but still had mild headaches at the end of the day or after walking to classes and excessive activity in class. The patient's restrictions included no contact sports, such as football, for at least 1 year. However, depending on recovery, he might be able to participate in the upcoming high school baseball season with the use of special protective equipment at all times, such as a helmet, and clearance from the physician. Nonetheless, the sport health care team must make a careful decision in allowing the athlete to participate in the baseball season. Although a protective helmet would be used, requirements for participation would include sprinting, base running, and sliding, all of which could result in contact or collision.

DISCUSSION

Cantu and Mueller¹¹ reported the number of catastrophic and fatal injuries in high school football, including head injuries, had decreased dramatically between 1982 and 1996. The authors noted 1.76 fatalities per 100 000 high school football participants, with a low of 0 in 1990.¹¹ However, to prevent possible catastrophic outcomes, health care professionals must immediately recognize, evaluate, and manage athletes with head injuries. First, to successfully care for head injuries, both players and coaches need to understand the risks of multiple head injuries and how return-to-play guidelines guide decision making. Players often decide to return to play after a head injury without seeking medical attention. This action is at times motivated by the fear of ridicule from the coaching staff and fellow players. Also, players often are ignorant of the possible life-threatening consequences of returning to play without proper medical attention.¹

Second, according to Ransone and Dunn-Bennett,¹² coaches alone did not meet adequate first-aid standards in dealing with injuries and may make decisions that exceed their training. To date, sport first-aid and safety training for high school coaches is only required in 28 states.¹³ Certified athletic trainers can not only provide proper recognition and care of athletic injuries but also play an important liaison role among the team physician, coaches, and athletes.¹⁴

CONCLUSION

This case report reveals how 2 unreported episodes of head trauma can be associated with an acute subdural hematoma, a potentially life-threatening condition. Although an athlete who has been unconscious may, in some instances, be able to return to play safely, an athlete who has remained conscious may, in fact, be developing a subdural hematoma or other severe traumatic brain injury.²⁶ Loss of consciousness is used in all the current guidelines; however, Collins et al,²⁷ using neuropsychological measures, demonstrated that the presence or absence of consciousness does not predict severity of injury.²⁷ Although our patient sustained no distinct loss of consciousness, his severe head injury needed to be recognized and evaluated to prevent a catastrophic outcome.

Appropriate education and training for players and coaches regarding the care of head injuries is needed to prevent potentially catastrophic events. According to a recent report from the Scientific Affairs Council of the American Medical Association,¹⁴ certified athletic trainers are proposed to be present in secondary schools to provide proper recognition, care, and management of athletic injuries in conjunction with the team physician. Finally, within the sport health care team, agreement is needed before the season on which concussion grading and return-to-play guidelines will be used. Also, there should be agreement that the sport health care team will make all on-field and off-field decisions on the evaluation and treatment of head injuries. Compliance by the team physician, athletic trainer, coaching staff, and players is needed at all times to prevent catastrophic outcomes.