concussion in the ed what you know, need to know and better know to make correct treatment dave...
TRANSCRIPT
Concussion in the EDWhat You Know, Need to Know
and Better Know to make Correct Treatment
Dave Milzman, MD FACEPDave Milzman, MD FACEPProfessor of Emergency MedicineProfessor of Emergency Medicine
Senior Advisor for Clinical ResearchSenior Advisor for Clinical ResearchGeorgetown U School Of MedicineGeorgetown U School Of Medicine
Professor of Biology Georgetown UniversityProfessor of Biology Georgetown UniversityResearch Director: Georgetown/WHC EM ResidencyResearch Director: Georgetown/WHC EM Residency
Clinical Director MedStar Emergency and Trauma Clinical Director MedStar Emergency and Trauma Concussion ProgramConcussion Program
Wash, DCWash, DC
ConcussionDiagnosis , Treatment and Follow UpDiagnosis , Treatment and Follow Up•Definition: Mild Traumatic Head Injury Definition: Mild Traumatic Head Injury ++ LOC with any of LOC with any of 22 common symptoms most common Headache, Dizzy, 22 common symptoms most common Headache, Dizzy, Fogginess, Trouble Concentrating, Trouble SleepingFogginess, Trouble Concentrating, Trouble Sleeping
•Initial Evaluation: Good Neuro Eval, include Balance Initial Evaluation: Good Neuro Eval, include Balance Testing, (BESS) and DonTesting, (BESS) and Don’’t Image Unless you Plan to Need t Image Unless you Plan to Need Admit ( < 0.3% Positive Scan in all Sport Concussion)Admit ( < 0.3% Positive Scan in all Sport Concussion)
•Most Important Thing You Can Do On Discharge:Most Important Thing You Can Do On Discharge:•Diagnosis, REST for 3 days, No School, No Sport and Be Diagnosis, REST for 3 days, No School, No Sport and Be Re-Evaluated, 60% will Improve in 7 days. Re-Evaluated, 60% will Improve in 7 days.
•Neuro-Psychology is your Best Consultant !!Neuro-Psychology is your Best Consultant !!
Ice Hockey #3 sport for mTBI
16 year old male
Injury - Elbowed In Forehead During Hockey Injury - Elbowed In Forehead During Hockey GameGame
Initially, No Symptoms, Returned to Ice for 1 Initially, No Symptoms, Returned to Ice for 1 shift, But Within 10 Minutes, Became shift, But Within 10 Minutes, Became ““FoggyFoggy”” With Poor Concentration, Memory, DizzinessWith Poor Concentration, Memory, Dizziness
Subsequent Loss Of Memory For Event, Subsequent Loss Of Memory For Event, Irritability, Headaches, Reduced Energy, Irritability, Headaches, Reduced Energy, Sensitive To Light And Noise, Sleeping More Sensitive To Light And Noise, Sleeping More Than Usual, Poor BalanceThan Usual, Poor Balance
Initial Eval, RX and TX 10th grade honors student 10th grade honors student Seen in the ED and sent Home for 1 week no Seen in the ED and sent Home for 1 week no
school, lots of sleep , Motrin and Fluidsschool, lots of sleep , Motrin and Fluids No texting no gaming, light TV and reading No texting no gaming, light TV and reading Concussion Clinic at Day 7 & 14Concussion Clinic at Day 7 & 14 Neuropsychological Concussion Evaluation Neuropsychological Concussion Evaluation
initially demonstrated:initially demonstrated: Poor attentionPoor attention Poor Poor ““working memoryworking memory”” Slowed processing speedSlowed processing speed Reduced reaction timeReduced reaction time
By 14 days, excellent recovery & return to By 14 days, excellent recovery & return to ““baselinebaseline”” values values
What Works in Student Athletes
Educate and guide the family and patient and the primary Educate and guide the family and patient and the primary care doctorcare doctor
Make recommendations for initial accommodations Make recommendations for initial accommodations in schoolin school
Kept him safe by managing his gradual return to Kept him safe by managing his gradual return to School and SportsSchool and Sports
The Easy Decision and return is SportThe Easy Decision and return is Sport Return to Learn is NOT Automatic, Return to Learn is NOT Automatic, Know This , Practice This ; If Nothing Else, Give all Know This , Practice This ; If Nothing Else, Give all
3 Day Total Rest.3 Day Total Rest.
Epidemiology - Concussion Most frequent diagnosis in injured child is: HEAD Most frequent diagnosis in injured child is: HEAD
INJURY TBIINJURY TBI Every 11 minutes 1 child in the US has a brain Every 11 minutes 1 child in the US has a brain
injury resulting in permanent disabilities or 35,000 injury resulting in permanent disabilities or 35,000 annuallyannually
5,000,000 children with head injuries 5,000,000 children with head injuries 3.8 million concussions/annually Emergency 3.8 million concussions/annually Emergency
Department VisitsDepartment Visits ~~ 90%: mild TBI/ GCS 14-15 90%: mild TBI/ GCS 14-15 Majority with mTBI sent home from EDMajority with mTBI sent home from ED
STATISTICSSTATISTICS
Incidence in HS football = 6%-8% per year.Incidence in HS football = 6%-8% per year.
BoyBoy’’s + Girls + Girl’’s soccer = football.s soccer = football.
GirlGirl’’s basketball 250% greater risk than Boys basketball 250% greater risk than Boy’’ss
Sports and recreational injuries with LOC = Sports and recreational injuries with LOC =
300,000 per year.300,000 per year.
Sports and recreational injuries with and Sports and recreational injuries with and without LOC = 1.6 million per year.without LOC = 1.6 million per year.
DEFINITIONDEFINITION
Complex pathophysiologic Complex pathophysiologic process affecting the process affecting the brain, induced by brain, induced by traumatic biomechanical traumatic biomechanical forces.forces.
COMMON FEATURESCOMMON FEATURES
Caused by a direct or indirect blow to the Caused by a direct or indirect blow to the head, face or neck.head, face or neck.
Results in rapid onset of short-lived Results in rapid onset of short-lived impairment of neurological function.impairment of neurological function.
A concussion may or may not involve LOC.A concussion may or may not involve LOC.
The clinical symptoms reflect a functional The clinical symptoms reflect a functional rather than a structural disturbance.rather than a structural disturbance.
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Mechanism of InjuryMechanism of InjuryRotational Much Worse Rotational Much Worse than Linearthan Linear
Impact decelerationImpact deceleration
Chemical/VascularChemical/Vascular11stst 7-10 days 7-10 days
↑↑K / ↑Ca / ↑glc / ↑glutK / ↑Ca / ↑glc / ↑glut
↓↓CBFCBF
““Period of vulnerabilityPeriod of vulnerability””
Anatomical Timeline of a ConcussionDefining the Key Factors
LOC<10%
Antero-grade
Amnesia25-40%
CONCUSSIONCONCUSSION
Pre-InjuryRisks
Retro-grade
Amnesia20-35%
Neurocog dysfx &Post-Concuss Sx’s
Sec-Hrs Hours - Days - Weeks+Sec-MinSec-Hrs
A. Injury Characteristics B. Symptom AssessmentC. Risk Factors
1-3 Days Dayy 5-10Pre-Concussion Baseline Testing
Dayy 12-16
*Barth et al., 2002
ConcussionConcussion
Clinical ProtocolNeurocognitive TestingClinical ProtocolNeurocognitive Testing
ConcussionConcussion
Pre-Concussion Baseline TestingPre-Concussion Baseline Testing
Symptoms
CognitiveFunctions
NEUROCOGNITIVE NEUROCOGNITIVE COMPUTERIZED TESTINGCOMPUTERIZED TESTING
ImPACT (UPMC)ImPACT (UPMC)
CogSport (Australia)CogSport (Australia)
CRI (Headminder)CRI (Headminder)
ANAM (NRH) ANAM (NRH)
OVERVIEW OF ImPACTOVERVIEW OF ImPACT
Proven in measures of reliability and validityProven in measures of reliability and validityProvides useful concussion screening and Provides useful concussion screening and management informationmanagement informationValidated with multiple peer-reviewed studiesValidated with multiple peer-reviewed studiesDoes not substitute for medical evaluation and Does not substitute for medical evaluation and treatmenttreatmentDoes not substitute for comprehensive Does not substitute for comprehensive neuropsychological testingneuropsychological testing
IMMEDIATE POST-CONCUSSION IMMEDIATE POST-CONCUSSION ASSESSMENT and COGNITIVE ASSESSMENT and COGNITIVE
TESTING (ImPACT)TESTING (ImPACT)
8 separate tests8 separate tests
Word memoryWord memory
Design memoryDesign memory
XX’’s and Os and O’’ss
Symbol MatchSymbol Match
Color MatchColor Match
Three LettersThree Letters
Interference testsInterference tests
6 composite scores6 composite scores
Verbal memoryVerbal memory
Visual memoryVisual memory
Visual motor speedVisual motor speed
Reaction timeReaction time
ImpulsivityImpulsivity
Total symptom scoreTotal symptom score
COMPUTERIZED TESTINGCOMPUTERIZED TESTING
Format allows portability and efficiency.Format allows portability and efficiency.
Each vendor has their unique menu of Each vendor has their unique menu of cognitive domains that their product measures.cognitive domains that their product measures.
20 – 30 minutes to administer.20 – 30 minutes to administer.
Used as a Used as a ““tooltool”” to measure recovery and not to measure recovery and not to make a diagnosis or solely direct to make a diagnosis or solely direct management.management.
CONCUSSION SYMPTOM SCALECONCUSSION SYMPTOM SCALE
Standardized survey with Standardized survey with 0-6 scale rating 0-6 scale rating
Developed by Lovell and Developed by Lovell and Collins in 1998Collins in 1998
Sensitive tool to measure Sensitive tool to measure recoveryrecovery
Symptoms generally Symptoms generally classified into 3 main classified into 3 main categories: Physical, categories: Physical, Cognitive, and Cognitive, and Emotional/BehavioralEmotional/Behavioral
4 Symptom Categories
PhysicalPhysical• HeadacheHeadache• Fatigue Fatigue • Dizziness Dizziness • Sensitivity to light Sensitivity to light
and/or noiseand/or noise• NauseaNausea• Balance problemsBalance problems
EmotionalEmotional• IrritabilityIrritability• SadnessSadness• Feeling more emotionalFeeling more emotional• NervousnessNervousness
• CognitiveCognitive• Difficulty rememberingDifficulty remembering• Difficulty concentratingDifficulty concentrating• Feeling slowed downFeeling slowed down• Feeling mentally foggyFeeling mentally foggy
• SleepSleep• DrowsinessDrowsiness• Sleeping less than usualSleeping less than usual• Sleeping more than usualSleeping more than usual• Trouble falling asleepTrouble falling asleep
GENERALGENERALMANAGEMENTMANAGEMENT
Majority of injuries will recover spontaneously.Majority of injuries will recover spontaneously.
Physical Physical andand cognitive rest are required while cognitive rest are required while symptomatic.symptomatic.
When symptom free and improved When symptom free and improved ““functionallyfunctionally”” graduated return to play protocol should be utilized.graduated return to play protocol should be utilized.
Same day return to play—NEVER!!!Same day return to play—NEVER!!!
PREDICTING RECOVERY PREDICTING RECOVERY TIMELINESTIMELINES
ALL ATHLETES ARE NOT ALL ATHLETES ARE NOT CREATED EQUALLYCREATED EQUALLY
CONCUSSIONCONCUSSIONMODIFIERSMODIFIERS
Threshold—Repeated concussions occurring with Threshold—Repeated concussions occurring with less force or slower recovery.less force or slower recovery.Age—Child and adolescent < 18 years old.Age—Child and adolescent < 18 years old.Co-morbidities—Migraine, depression or other Co-morbidities—Migraine, depression or other mental health disorders, ADHD, learning mental health disorders, ADHD, learning disabilities and sleep disorders.disabilities and sleep disorders.Medication—Psychoactive drugs and Medication—Psychoactive drugs and anticoagulants.anticoagulants.Behavior—Style of play.Behavior—Style of play.Sport—Contact or collision sport, high-risk.Sport—Contact or collision sport, high-risk.
RETURN TO PLAY RETURN TO PLAY PROTOCOLPROTOCOL
No activity while symptomatic.No activity while symptomatic.
Light aerobic exercise.Light aerobic exercise.
Sport-specific exercise—no head impact drills.Sport-specific exercise—no head impact drills.
Non-contact training drills.Non-contact training drills.
Full contact practice.Full contact practice.
Return to game play.Return to game play.
Recovery From Concussion:How Long Does it Take?
0
10
20
30
40
50
60
70
80
90
100
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+
All Athletes No Previous Concussions 1 or More Previous Concussions
N=134 High School athletes
WEEK 1
WEEK 2
WEEK 3
WEEK 4
WEEK 5
Collins et al., 2006, Neurosurgery
Clinicians’ Return to Play Decisions
100
80
60
40
20
00
ATC used GSC, SAC, BESS (testing w/ symptom report)
ATC used only GSC (player symptom report)
Marshall, Guskiewicz, & McCrea; In Review, 2006.
NFL CONCUSSIONNFL CONCUSSIONGUIDELINESGUIDELINES
Established in 2009.Established in 2009.
No same day return to No same day return to practice or game play.practice or game play.
Players encouraged to Players encouraged to be honest and report be honest and report symptoms.symptoms.
Independent neurology Independent neurology opinion for each injury.opinion for each injury.
CHRONIC TRAUMATIC CHRONIC TRAUMATIC ENCEPHALOPATHYENCEPHALOPATHY
CHRONIC TRAUMATIC CHRONIC TRAUMATIC ENCEPHALOPTHYENCEPHALOPTHY
NFL Survey—NFL Survey—> 50 = 5x risk> 50 = 5x risk30-49 = 19x risk30-49 = 19x risk
Comparative data from Comparative data from the Framingham heart the Framingham heart study.study.Concept of Concept of subconcussivesubconcussive trauma. trauma.Sports Legacy Institute.Sports Legacy Institute.
Concussion’s Effects on School Learning
Return to School
Concussion’s Effects on School
Learning & Performance ““Which specific types of problems are you Which specific types of problems are you
experiencing in school?experiencing in school?”” Students reported an average of 4 problems Students reported an average of 4 problems
below. below. Headaches interfering Headaches interfering 71.3% 71.3% CanCan’’t pay attn in class t pay attn in class 62.5% 62.5% HW taking much longer HW taking much longer 59.5% 59.5% Difficulty studying for test/quiz Difficulty studying for test/quiz 51.9% 51.9% Too tired Too tired 50.6% 50.6% Diffic understanding material Diffic understanding material 44.0% 44.0% Difficulty taking notes Difficulty taking notes 28.8% 28.8%
Concussion’s Effects on School
Learning & Performance ““Which classes are you having the most trouble Which classes are you having the most trouble
with?with?””(Percent reporting trouble in class) (Percent reporting trouble in class)
Parent Parent StudentStudent Math Math 60.3% 60.3% 73.7% 73.7% Reading/LA Reading/LA 38.1% 38.1% 46.1% 46.1% Science Science 38.1% 38.1% 47.4% 47.4% Soc Stud Soc Stud 38.1% 38.1% 40.8% 40.8% Foreign Lang Foreign Lang 38.1% 38.1% 38.2% 38.2% Music Music 6.3% 6.3% 17.9% 17.9% PE PE 7.9% 7.9% 10.5% 10.5% Art Art 3.2% 3.2% 5.3% 5.3% -None-None 25.4%25.4% 6.6% 6.6%
General Principles of Recovery
No additional forces to head/ brain No additional forces to head/ brain Resting the brain & getting good sleepResting the brain & getting good sleep Managing/ facilitating physiological recoveryManaging/ facilitating physiological recovery
Avoid activities that produce symptomsAvoid activities that produce symptoms Not over-exerting body or brainNot over-exerting body or brain
Ways to over-exertWays to over-exert PhysicalPhysical Cognitive! Cognitive! (concentration, learning, memory)(concentration, learning, memory) (Emotional)(Emotional) Even taking Neuro-Cognitive Testing is Contra-Even taking Neuro-Cognitive Testing is Contra-
Indicated in Symptomatic PatientIndicated in Symptomatic Patient
4th International Conference on 4th International Conference on Concussion in Sport held in Zurich, Concussion in Sport held in Zurich,
November 2012November 2012
Consensus Statement on Concussion in
Sport
Consensus Statement on Concussion in
Sport
CURRENT BEST REVIEW TILL APRIL 2013
Zurich CIS Consensus Concussion ManagementConcussion Management
Physical AND Cognitive Rest 48-72 HoursPhysical AND Cognitive Rest 48-72 Hours Graduated RTP: when asymptomatic at restGraduated RTP: when asymptomatic at rest
stepwise progression, proceed to next level if stepwise progression, proceed to next level if asymptomatic at current. asymptomatic at current.
Each step take 24 hours; would take Each step take 24 hours; would take approximately one week to proceed through the approximately one week to proceed through the full rehabilitation protocol full rehabilitation protocol
Same Day RTP: NEVER appropriate in child or Same Day RTP: NEVER appropriate in child or adolescent student-athlete (possible in adult ONLY if adolescent student-athlete (possible in adult ONLY if within well established system)within well established system)
Recognized delayed onset of symptoms 15-Recognized delayed onset of symptoms 15-30 minutes is Usual30 minutes is Usual
Changing Presentation Rates For mTBI Changing Presentation Rates For mTBI (Concussion) And Changing Imaging (Concussion) And Changing Imaging
Rates.Rates.
Dave Milzman, MD, FACEP Dave Milzman, MD, FACEP Sam Frankel MS, Colin Leiu MS, Katy Taxiera, Steve Sam Frankel MS, Colin Leiu MS, Katy Taxiera, Steve
Swinford MS, Zach Hatoum.Swinford MS, Zach Hatoum.Georgetown U. School of Medicine, Wash D.C.Georgetown U. School of Medicine, Wash D.C.MedStar Sport Concussion Center; Wash, D.C.MedStar Sport Concussion Center; Wash, D.C.
Results•2000-20122000-2012: Rapid rise in past 5 year with number : Rapid rise in past 5 year with number of concussions increased by 140% compared to of concussions increased by 140% compared to ED and Trauma patient volume increased only by ED and Trauma patient volume increased only by 23.9%; p< 0.02. 23.9%; p< 0.02.
•Increases in CT for concussion: 25.8% /10 yr Increases in CT for concussion: 25.8% /10 yr with less than 1.2% of mTBI with positive Head with less than 1.2% of mTBI with positive Head CT ; 24% MRI have No- Therapeutic Positive CT ; 24% MRI have No- Therapeutic Positive Findings MEANINGFindings MEANING• None Required NeuroSurgical Intervention.None Required NeuroSurgical Intervention.
Concussion & Imaging 2000-2011
Media and Medicine for Concussion
Discussion
Media And Medicine Has Met And Increased Media And Medicine Has Met And Increased Awareness As Awareness As mTBImTBI Presentation And Concussion Presentation And Concussion Visits are Increasing at Increased rates Compared Visits are Increasing at Increased rates Compared to All other ED and Trauma Visitsto All other ED and Trauma VisitsCT and MRI Increased In Use With No Improved CT and MRI Increased In Use With No Improved
Treatment Intervention. Treatment Intervention.
Controversy over CT for Controversy over CT for Minor TBI Minor TBI
• Preventable morbidity/mortality due to unrecognized TBIs
• CT provides visual information about the skull and the brain
• Preverbal children difficult eval.
• When indicated, benefit of CT greatly outweighs risk, however…
Arguments for liberal use of CT:Arguments for liberal use of CT:
Investigations Neuroimaging (CT, MRI)Neuroimaging (CT, MRI)
Contributes little to concussion evaluationContributes little to concussion evaluation Use when suspicion of intracerebral structural Use when suspicion of intracerebral structural
lesion exists:lesion exists:prolonged loss of consciousnessprolonged loss of consciousnessfocal neurologic deficitfocal neurologic deficitworsening symptomsworsening symptomsDeterioration in conscious stateDeterioration in conscious state
MRI still not proven benefit aids detection not MRI still not proven benefit aids detection not treatment.treatment.
Controversy over CT for Controversy over CT for Minor BHT Minor BHT
• Of the 325,000 children evaluated Of the 325,000 children evaluated with CT after BHT, fewer than 1% with CT after BHT, fewer than 1% have significant TBI and < 0.3% have significant TBI and < 0.3% require any Neurosurgical require any Neurosurgical intervention.intervention.
• Drawbacks of CT include transport Drawbacks of CT include transport outside the ED, pharmacological outside the ED, pharmacological sedation, sedation, costs costs (charges (charges $2-3K/patient)$2-3K/patient)
• lethal malignancy risk from CT lethal malignancy risk from CT may be as high as 1:1250may be as high as 1:1250
Arguments against liberal use of CT:Arguments against liberal use of CT:
Lifetime Cancer Mortality Risk
NEJM, Brenner et al.NEJM, Brenner et al. Lifetime cancer mortality risk with single CT head in Lifetime cancer mortality risk with single CT head in
year 1 of life:year 1 of life: i-Vi-V
PECARN Prediction Rules
Age 2 years and olderAge 2 years and older GCS < 15 or abnormal mental statusGCS < 15 or abnormal mental status LOC LOC History of emesisHistory of emesis Severe mechanism of injurySevere mechanism of injury Signs of basilar skull fractureSigns of basilar skull fracture Severe headacheSevere headache
Kuppermann/Holmes/Dayan/Hoyle/Atabaki et al 2009Kuppermann/Holmes/Dayan/Hoyle/Atabaki et al 2009
Proportion of BHT Patients with CT Performed
0%
5%
10%
15%
20%
25%
30%
35%
Jan-
10Fe
b-10
Mar
-10
Apr
-10
May
-10
Jun-
10Ju
l-10
Aug
-10
Sep-
10O
ct-1
0N
ov-1
0D
ec-1
0Ja
n-11
Feb-
11M
ar-1
1A
pr-1
1M
ay-1
1Ju
n-11
Jul-1
1A
ug-1
1Se
p-11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Intervention
y = -0.0138x + 0.258R2 = 0.7621
y = 0.0002x + 0.2394R2 = 0.0002
Results—Positive CT Proportion*
* Preliminary data. O.R. = 3.01 (95% CI 2.07-4.37)
Traumatic Brain Injury
ModModMildMild SevereSevere
Severe GCS ≤ 8
Moderate GCS 9 - 12Mild GCS 13 - 15
Teasdale et al Lancet 1974;
Sports concussionSports concussion
?
““MinimaMinimal”l”
Glasgow Coma Scale
51
Distribution of Head AccelerationsDiv I American Football (3 teams, 4 seasons)
20g – buddy head butt
300+ g recorded
Crisco et al, 2012Crisco et al, 2012
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“The majority of the high level impacts occurred during practices, with 29 of the 38 impacts above 40 g occurring in practices.”
“Although less frequent, youth football can produce high head accelerations in the range of concussion causing impacts measured in adults.”
“In order to minimize these most severe head impacts, youth football practices should be modified to eliminate high impact drills that do not replicate the game situations.”
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Video Incident Analysis of Concussion Mechanisms in Boys’ High School Lacrosse
• 1750 boys between ages of 14-18 participating in 1750 boys between ages of 14-18 participating in varsity and junior varsity lacrosse varsity and junior varsity lacrosse
• All home contests (518) at 25 high schools (50 All home contests (518) at 25 high schools (50 teams) in the Fairfax County (Va) Public Schools teams) in the Fairfax County (Va) Public Schools during 2008 and 2009 seasonsduring 2008 and 2009 seasons
• 44 injuries were diagnosed by a Certified Athletic 44 injuries were diagnosed by a Certified Athletic Trainer as a concussionTrainer as a concussion
• 34 (77%) cases had sufficient image quality for 34 (77%) cases had sufficient image quality for analysisanalysis
Impact Characteristics of Concussion Injuries in Boys’ Lacrosse, 2008-2009 (n=34)
Characteristic Frequency (n)
Percentage (%)
Primary injury mechanism - Bodily collision 34 100
Striking player 2 6
Struck player 23 **68
Both players 9 26
Secondary impact – head/body to ground 24 71
Impact source (striking player)
Head 27 **79
Upper extremity/shoulder 7 21
Stick/ball 0 0
Struck player readiness for contact
Unanticipated (“defenseless hit”) 19 56
Anticipated – good body position 8 24
Anticipated – poor body position 5 15 55
Comparison of Concussion Injuries in Boys’ and Girls’ Lacrosse
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Common injury scenario (Pre-injury)
57
58
59
60
Concussion Causation in Lax• Player-to-player contact was the mechanism for Player-to-player contact was the mechanism for
allall concussions in males. concussions in males. • > 75% --The striking player used his head to > 75% --The striking player used his head to
initiate impactinitiate impact• >50% ---The struck player’s head was the initial >50% ---The struck player’s head was the initial
point of impactpoint of impact• >50% -- the struck player was unaware and >50% -- the struck player was unaware and
unprepared for contact unprepared for contact • These “defenseless hits” represent These “defenseless hits” represent
scenarios for rule changes/enforcement scenarios for rule changes/enforcement to protect vulnerable playersto protect vulnerable players
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Sideline And ED Sideline And ED Assessment of Assessment of
ConcussionConcussion
Examine, DonExamine, Don’’t Rely on t Rely on ImagingImaging
Sideline ToolPocket SCAT2
Also Best for the ED
Aids to sideline assessment
Knowing the patientKnowing the patient Systematic examinationSystematic examination Repeating the examinationRepeating the examination
Components of exam Observation and history Delay Assessment Observation and history Delay Assessment
10-15 min after occurrence.10-15 min after occurrence. Mini mental status (baseline tests ideal)Mini mental status (baseline tests ideal)
OrientationOrientation Memory Memory Concentration Concentration Symptom check listSymptom check list
Neurological examNeurological exam Cranial nerveCranial nerve Balance - BESS (baseline tests ideal)Balance - BESS (baseline tests ideal)
Balance Error Scoring System
3 Positions Hold each with Eyes closed for 20 3 Positions Hold each with Eyes closed for 20 seconds Mean Baseline Score is 3 ptsseconds Mean Baseline Score is 3 pts Double leg, tandem stance (dominant foot Double leg, tandem stance (dominant foot
forward), single leg stance (non-dominant forward), single leg stance (non-dominant foot) foot)
Hands on hips, eyes closed, 20 second trials, Hands on hips, eyes closed, 20 second trials, count errorscount errors
Hands lifted off hips, open eyes, step/stumble, Hands lifted off hips, open eyes, step/stumble, hip move > 30 degrees abduction, hip move > 30 degrees abduction, forefoot/heel lift, out of position > 5 secondsforefoot/heel lift, out of position > 5 seconds
BESS Positions ERROR PointsERROR Points Double Leg Stance Double Leg Stance 0.090.09 Single Leg Stance Single Leg Stance 2.452.45 Tandem Stance Tandem Stance 0.910.91 Surface Total = 3.37Surface Total = 3.37
Novel approaches to sideline assessment
Quantitative EEG (10-12 minutes)Quantitative EEG (10-12 minutes) (Brainscope)(Brainscope)
1.1. Brain Sentry is an AccelerometerBrain Sentry is an Accelerometer
2.2. It picks up a Impact Force > 70 gIt picks up a Impact Force > 70 g
3. 3. The Problem Is That You Want To The Problem Is That You Want To Never Miss A Concussion, But Never Miss A Concussion, But DonDon’’t Want To Have Too Many t Want To Have Too Many False Positive But Optimally No False Positive But Optimally No False Negative.False Negative.
ACCURACY is Key ACCURACY is Key
Best Can DO : 75-80% Sensitivity Best Can DO : 75-80% Sensitivity 35%Specificty35%Specificty
“What’s the worst thing that can happen to my son?”
[Father of football player with multiple concussions in one season, 2003]
Second Impact Syndrome Described by Saunders & Harbaugh, 1984Described by Saunders & Harbaugh, 1984 RareRare Most commonly seen in adolescentsMost commonly seen in adolescents Can be fatalCan be fatal
November 10, 2012 72
Second Impact Syndrome Athlete suffers a concussion (typically grade 1 or Athlete suffers a concussion (typically grade 1 or
2) Most are 12-16 yo2) Most are 12-16 yo Still suffering from symptoms of concussion and Still suffering from symptoms of concussion and
returns to playreturns to play Suffers a second concussionSuffers a second concussion Second blow may be remarkably minor, Second blow may be remarkably minor,
sometimes not directly to the head, but causing sometimes not directly to the head, but causing the athletethe athlete’’s head to snap which imparts s head to snap which imparts accelerative forces to the brainaccelerative forces to the brain
The athlete may appear stunned or dazed, but The athlete may appear stunned or dazed, but usually remains on feet for 15 seconds to a usually remains on feet for 15 seconds to a minute, similar to someone suffering from a grade minute, similar to someone suffering from a grade 1 concussion without loss of consciousness1 concussion without loss of consciousness
73
Second Impact Syndrome Disordered cerebral autoregulation of Disordered cerebral autoregulation of
cerebral blood flow cerebral blood flow vascular vascular engorgementengorgementincreased ICPincreased ICPBrainstem Brainstem herniationherniation
Rapid Development of coma, ocular Rapid Development of coma, ocular involvement, and respiratory failure ensueinvolvement, and respiratory failure ensue
MortalityMortality 50-100% 50-100% due to due to brainstem brainstem herniationherniation
Never Diagnosed in ED, Always in Extremis Never Diagnosed in ED, Always in Extremis on Presentation, < 30 in 30 yrs.on Presentation, < 30 in 30 yrs.
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November 10, 2012 75
SIS: Treatment On-field treatment of SIS requires rapid On-field treatment of SIS requires rapid
intubation, hyperventilation (to facilitate intubation, hyperventilation (to facilitate vasoconstriction by lowering blood carbon vasoconstriction by lowering blood carbon dioxide levels), and intravenous dioxide levels), and intravenous administration of an osmotic diuretic (such as administration of an osmotic diuretic (such as 20% mannitol). 20% mannitol).
Needs Immediate Decompression in 30 min.Needs Immediate Decompression in 30 min. The unconscious athlete who sustains a head The unconscious athlete who sustains a head
injury should always be transported with his injury should always be transported with his or her neck immobilized.or her neck immobilized.
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Risk Factors for Complicated Post
Concussion Syndrome
9
Medications in Concussion There are NO medications which are There are NO medications which are
FDA approved for FDA approved for ““concussionconcussion”” or or ““mild TBImild TBI””
What are some possible indications for What are some possible indications for medications?medications?
Existing Medication Should be Existing Medication Should be Continued.Continued.
i.e. ADHD, Depression, etc. i.e. ADHD, Depression, etc. No Literature Exists Finding Improved No Literature Exists Finding Improved
Outcomes in RCTOutcomes in RCT
78
Medications in Concussion When to startWhen to start
Headache: acute, subacute, chronicHeadache: acute, subacute, chronic Vertigo: acute if severe; unable to tolerate Vertigo: acute if severe; unable to tolerate
therapy/functiontherapy/function All other indications should only be All other indications should only be
treated with medications if treated with medications if Fail therapy/non-pharmacological Fail therapy/non-pharmacological
managementmanagementPersistentPersistent
79
Concussion Clinic Patients seen within 1 week of referralPatients seen within 1 week of referral Brain Injury PhysicianBrain Injury Physician NeuropsychologistNeuropsychologist ImPACT testing/Neuropsych evaluationImPACT testing/Neuropsych evaluation Patient/family educationPatient/family education Return to sports (work, school, etc.) Return to sports (work, school, etc.)
recommendationsrecommendations Follow up for persistent symptomsFollow up for persistent symptoms
80
Management CORNERSTONE =CORNERSTONE = rest until asymptomaticrest until asymptomatic
Rest from activityRest from activityNo training, playing, exercise, weightsNo training, playing, exercise, weightsBeware of exertion with activities of daily Beware of exertion with activities of daily
livingliving Cognitive restCognitive rest
No television, extensive reading, video No television, extensive reading, video games?games?
Caution re: daytime sleepCaution re: daytime sleep
REST = ABSOLUTE REST!REST = ABSOLUTE REST!
Sports concussionFollow-up Management
RestRest RestRest RestRest Expect gradual resolution in 7-10 daysExpect gradual resolution in 7-10 days Start graded exercise rehabilitation when Start graded exercise rehabilitation when
asymptomatic at rest and post-exercise asymptomatic at rest and post-exercise challengechallenge
Recovery
How long asymptomatic before How long asymptomatic before exercise?exercise? If rapid and full recovery, then 24-48 If rapid and full recovery, then 24-48
hourshours One approach is to require that they One approach is to require that they
remain asymptomatic (before starting remain asymptomatic (before starting exertion) for the same amount of time exertion) for the same amount of time as it took for them to become as it took for them to become asymptomatic.asymptomatic.
Symptom Categories
RTP:Graded Exertion Protocol
• 24 hours per step• If recurrence of symptoms at any stage, return to previous
step
Rehabilitation stage Functional exercise at each stage of rehabilitation
Objective of each stage
1. No activity Complete physical and cognitive rest. Recovery
2.Light aerobic exercise Walking, swimming or stationary cycling keeping intensity < 70% MPHR No resistance training.
Increase HR
3.Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities.
Add movement
4.Non-contact training drills Progression to more complex training drills e,g. passing drills in football and ice hockey. May start progressive resistance training)
Exercise, coordination, and cognitive load
5.Full contact practice Following medical clearance participate in normal training activities
Restore confidence and assess functional skills by coaching staff
6.Return to play Normal game play
Coach/ Player/ Parent Concern: Isn’t this
Concussion program going to hold my players out
longer?
Questions?