Second Impact Syndrome

Second Impact Syndrome

by Liz Morris ATC
December 10, 2007


A concussion is a change in mental status caused by direct trauma to the head. It is accompanied by confusion, loss of memory, and sometimes, loss of consciousness. Concussions range in severity from mild to severe, depending on the amount of trauma involved. A concussion can temporarily interfere with normal brain function, often affecting memory, judgment, speech, balance, and coordination. Since concussions do not always involve a loss of consciousness, many people experience a concussion without knowing it. Concussions are common, particularly in contact sports including football. When an athlete experiences a concussion, regardless of the severity, they need proper time to heal before returning to activity. Without proper care and evaluation of a concussion, an athlete can return to activity not knowing the risks they are taking, including the risk of second impact syndrome.

What is Second Impact Syndrome?

Second Impact Syndrome is a traumatic injury that occurs when an athlete with a previous head injury, sustains a second head injury before the symptoms of the previous injury have completely resolved. Coaches and athletes often fail to realize that days or weeks may be needed before concussion symptoms can resolve and the athlete can return to normal activity.
With Second Impact Syndrome, a loss of auto regulation of the brain’s blood supply can occur, resulting in rapid swelling and herniation of the brain. Herniation occurs due to the increased intracranial pressure in the brain resulting from a direct blow. Brainstem failure is quite rapid, once second impact has occurred, taking two to five minutes. Once this compromise occurs in the brain, respiratory failure is likely to result.
Second Impact Syndrome can be minor and may not even involve a blow to the head. A sudden blow to the chest or back can create enough force to snap the athletes head and send extreme force to an already compromised brain. This is why removing the athlete from activity is mandatory once the first concussion has occurred. The athlete should not be allowed to return until all symptoms have resolved and he or she has been cleared to participate. Repeated head injury can lead to diffuse brain swelling. This potentially fatal brain swelling can have catastrophic results if not immediately attended to. Although the second injury may be far less forceful than the first, the result can be life threatening due to the brain’s previous impaired state. Therefore, Second Impact Syndrome is rare but it can be a fatal complication of multiple concussive brain injuries.

Signs and symptoms

With Second Impact Syndrome, the athlete can appear stunned and can remain conscious. The athlete may even be able to leave the playing field under his or her own power. However, within a matter of seconds, the athlete’s condition worsens rapidly. The athlete who is conscious can:
• Collapse to the ground
• Become semi comatose with rapidly dilating pupils
• Experience a loss of eye movement
• Show evidence of respiratory failure
Second Impact Syndrome is a life threatening situation that has a mortality rate of approximately 50 percent. If Second Impact Syndrome is expected, EMS should be notified immediately.


While the incidence of Second Impact Syndrome is low, it is more likely to occur in high school athletes. Between the years of 1992-1997, 17 cases of Second Impact Syndrome were reported due to football injuries alone. Many of these resulted in death. Football, as well as many other high contact sports including hockey and boxing can cause successive injuries leading to this life threatening syndrome. Any athlete who returns to play before symptoms of the first concussion has resolved, is at risk of experiencing Second Impact Syndrome.

Prevention & Management

Second Impact Syndrome is a life threatening emergency that must be addressed immediately. Often, dramatic life-saving measures must be performed in an emergency-care facility when Second Impact Syndrome has occurred. Symptoms of a concussion are recognizable and should be noted at once. In order to prevent these types of fatal injuries an athlete must not return to play before symptoms of their concussion have resolved. If an athlete has experienced a concussion he or she must be cleared by a physician before returning to activity. Although fatal effects of Second Impact Syndrome can occur rapidly, some measures can be taken to investigate the damage and effects. Magnetic Resonance Imaging (MRI) is more sensitive to traumatic brain injuries when compared to a Computed Tomography (CT Scan), used to show bleeding in the brain.
Even if Second Impact Syndrome is not the problem, multiple concussions can significantly worsen long-term cognitive functioning. Athletes are 3 times more likely to sustain a second concussion once they have had their first when compared to athletes experiencing no concussions.
Multiple concussions increase the risk of symptoms including headaches, memory loss, and difficulty concentrating. The higher the rate of concussions, the higher the athlete’s risk of long-term cognitive dysfunction.

Liz Morris ATC on Second Impact Syndrome

Liz Morris, ATC is a second year graduate student and recipient of the Hughston Athletic Training Fellowship Program in Columbus, Georgia. She received her Bachelors of Science Degree in Athletic Training from Georgia College and State University in May of 2007, where she also minored in Dance. While at GC&SU Liz worked with men’s and women’s tennis, as well as softball, and completed a high school rotation with Tattnall Square Academy and First Presbyterian Day School both in Macon. She was a member of the Kinesiology club and received the Presidential Volunteer Service Award. She is an active member of the National Athletic Trainers Association (NATA) and the Georgia Athletic Trainers Association (GATA). Liz is responsible for the overall healthcare of the athletes at Glenwood School in Phenix City, Alabama.


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