Second influence syndrome (2023)

Continuous Education Activity

Secondary Impact Syndrome (SIS), also known as Repetitive Head Injury Syndrome, describes a condition in which an individual experiences a second head injury before fully recovering from the initial head injury. Athletes who sustain a concussion and return to sport early are thought to be at particularly high risk. Although this is a relatively rare condition, clinicians should be aware of SIS and educate patients who have experienced or are at risk of head injury, as this syndrome is often fatal. This activity describes the pathophysiology, evaluation, and management of the second impingement syndrome and highlights the role of an interprofessional team in the management of affected patients.


  • Description Risks related to secondary impact syndrome.

  • Determine the risk factors of secondary impact syndrome.

  • Review of controversies around the lesion mechanism in second effects syndrome.

  • Explain the importance of improving the nursing coordination of cross -equipment members of the cross -equipment members to improve the prognosis of patients affected by the second impact syndrome.

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The second affects syndrome (SIS) or repeated head injury syndrome, describing a situation, i.e., the individual sustained a second head injury before the initial head injury made a full recovery.[1]Essentially, SIS has attracted people's attention because many cited athletes perform brain shocks and return to this sport as soon as possible because they are particularly dangerous. Although this is a relatively rare disease, doctors must realize SIS and educate patientsWith a risk of head injury because this syndrome is usually fatal.The term of the syndrome entered the medical dictionary in 1984. The case reported that a soccer player died in his death.He died four days after returning to the game in the game the same day and died four days after the head injury. He collapsed and died after the second head injury.[2]


To date, there have been few confirmed cases of SIS, so the exact incidence, risk, and pathophysiology of the disease are unknown. Between 1.6 and 3.8 million sports-related concussions occur in the United States each year, according to the Centers for Disease Control and Prevention.[2]Although the etiology of brain shocks is generally known, the etiology of the second impact syndrome is unknown.The generally accepted reason has to do with suffering a second brain shock before the brain has had the opportunity to recover completely from the initial damage.The athlete will quickly develop a mental condition and loss of knowledge seconds after the second blow, which will result in catastrophic neurological damage.[3]Disaster damage is caused by automatic regulation of functional disorders caused by increased intracranial pressure. The pressure increases rapidly and eventually leads to brain herniation. Brain herniations can occur inside the falx cerebri or under the pores of the pillow bones, causing brain stem damage and rapid deterioration, and death leads to death in 2 to 5 minutes. A recent case report revealed the mode of damage[4]. An athlete returns to practice five days after an initial concussion. He had a normal CT scan on day four, but a persistent severe headache. After practice a day later, he collapsed a few games after complaining of a headache and not being able to feel his legs. A second CT performed at the local emergency room showed bilateral but slender subdural hematomas. However, subsequent MRI demonstrated caudal displacement of the midline structures and both thalamus were injured, resulting in a torsional herniation.[4]


A 2016 review article completed a Pubmed search and found only 36 cases informed in 15 publications, of which 17 cases complied with the inclusion criteria.[3]Athletes vulnerable to secondary impact injuries were characterized as men, from 13 to 24 years of age, who practiced contact sports such as American football, boxing and grass hockey.Only seven of the 17 received direct blows in the head, and it is believed that the others received blows in the body with force transmitted to the head.Computed tomography showed diffuse brain edema with deviation from the midline that led to a brain hernia in 4 cases.In addition, all cases presented fine or moderate subdural bruises, of which 2 cases were subarachnoid hemorrhage and 3 ischemic stroke cases.

pathological physiology

Patients who have experienced brain shock show well known but complex neuron, metabolism and ion changes. The mechanism of damage appears to be related to shaft shear. This can cause rapid exfoliating, neurotransmitted release and movement of ions, cell leakage extracellular ions and instead of intracellular sodium and calcium. This can cause cerebral blood loss and cause edema. Therefore, the increase in glucose utilization and decrease in damage-related static cerebral blood flow restriction will that the energy does not match.[5]All these changes require time and effort to restore the normal physiology of neurotransmitters.In general, it is considered that this takes between 7 and 10 days, but younger athletes can take more.Metabolic anomalies that follow an initial brain shock can make the brain more vulnerable to a greater injury.[6]

History and Physics

Any athlete returning to play after a brain shock must be carefully monitored, even after an appropriate recovery period and completing a protocol back to the game.Patients with brain shocks report any combination of symptoms, including headache, nausea, memory loss, dizziness, blurred vision, confusion, fatigue, photophobia or sound sensitivity, loss of movement or sensitivity, poor coordination hand-alk or irritability/emotional irritability.In the physical exam, patients may have altered levels of consciousness, retrograde or post -traumatic amnesia, but in general, the concentration is difficult and the balance seems to be persistently affected.In addition, there may be sensory or motor anomalies, visual anomalies.Unless players have already been eliminated, they can show signs of ataxia, disorientation or slow reflexes if they remain in the field.

Since the brain shock has been more widely recognized, complications related to insufficient recovery have been better recognized, so the evaluation of the lateral line has been developed. The evaluation of the edge of the cognitive function is an important part of theDamage Evaluation. The short neurostene test (NP) of the attention and memory function has proven practical and effective. Display tests include SCAT5, which contains Maddocks problems and a standardized evaluation of brain vibration (SAC).[7]

Regarding suspected SIS collapse, Glasgow coma score, pupil response, deep muscle tendon reflex, upper extremity/lower extremity clonus, and existence of Babinski reflex prior to transport or before transportation, there is no emergency room.

Due to the composition of the second impact syndrome, the lack of research and rapid development of the disease, it is difficultCerebral that they see, especially in male athletes from 13 to 24 years, can be the second impact syndrome, and closely observe the signs of progress or signs of the progress of injured athletes or symptoms.


Obtaining a complete medical history is essential in the evaluation of patients with suspicion of brain injury.Although it is unlikely that the patient provides a complete medical history, as much information as possible of those who could have witnessed the event should be collected.It is especially important to determine how the lesion occurred, if there was a history of seizures or brain shocks, if there was alcohol consumption or illicit drugs, if there was loss of knowledge, weakness or resulting paresthesia, difficulty walking or incontinence of the bladder or intestine.

Patients who have sustained severe injury or loss of consciousness, persistent symptoms, neurologic impairment, or neurologic deficit should be evaluated with imaging studies.

Alcohol or illicit drug screening is recommended. Computed tomography (CT) is the imaging modality of choice for acute traumatic brain injury. It is a more sensitive imaging modality for detecting acute bleeding (eg, noncontrast CT). It provides better skeletal delineation (eg, for detecting skull fractures) and is more sensitive for detecting acute bleeding and identifying any surgically reversible damage.

Current guidelines recommend CT with suspicions of skull fractures, intracranial hemorrhage or other intracranial disease according to physical exam findings.[8]Due to the loss of consciousness due to the damage of the secondary impact syndrome, it seems advisable to start from the computed tomography of the head.


Due to the limited understanding of the disease and inadequate research of the dispute between the disease, the management of the secondary impact syndrome is limited. The management of this situation began in the timely identification of brain shocks related to movement and protectionFrom athletes until they recovered from the initial lesion. Current treatment guidelines include cognition and physical relative rest, and then a hierarchical return competition. Dately, this should be supervised by team doctors (experience in vibration managementbrain) and sports coaches. Before athletes complete the return in the field and medical staff grant a license, they should not be allowed to restore integral participation.[5]

differential diagnosis

  • subarachnoid hemorrhage

  • Ischemic stroke

  • hematoma subdural

  • Base skull fracture

  • Skull fracture

Patient deterrence and education

At this point, prevention seems the most logical response to deal with the second shock syndrome.Parents and athletes should receive information about the possible complications of brain shock, the symptoms and the expected recovery time.This includes a discussion of the possible problems associated with playing prematurely, including prolonged recovery times, persistent symptoms and second impact syndrome.The stimulus of parents and coaches will help athletes avoid the minimization of symptoms and premature return to competition.Most of the protocols return to the game take at least seven days so that athletes can compete.

Improve healthcare team outcomes

The diagnosis of concussion remains a clinical one, as it is based on a constellation of symptoms. Therefore, it is recommended that the team physician be experienced in the evaluation and management of concussions. An interprofessional team with clear communication between the athlete, parent, coach, athletic trainer (if available), and doctor or nurse practitioner. Currently, second impact syndrome is a preventable injury. It is believed that if athletes are allowed to fully recover from the initial concussion and are not allowed to return too quickly, a second impact event will be less likely to occur. School nurses must be involved in the education of patients and their families.

If a player falls on the field with a suspected head injury, there should be clear communication between on-site medical personnel, emergency personnel, and the ER to optimize care for the injured athlete. Using a standard communication tool like SBAR will allow for clear and effective communication between healthcare teams. [Level 5]



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