concussion & mild traumatic brain injury · 2012-05-30 · traumatic brain injury in h.s...

Concussion & Mild Traumatic

Brain Injury

Bradley Jaskulka, M.D.

Emergency Medicine Grand Rounds

5/24/12

Objectives

• Cases

• Definitions

• Pathophysiology

• Si/Sx of concussion/TBI

• Management

• Dispo

• Return to play

Case #1

• 17 y.o. H.S. football player presents to ED

after injury during game

• Pt states “got my bell rung.”

• GCS 15

• Feels tired

• Normal Neuro exam

• CT?

• Dispo?

Case #2

• 35 y.o. female driver involved in MVA

• Brief LOC

• c/o HA and vomiting

• Unsure of events

• CT?

• Dispo?

Case 3

• 2 y.o. dropped by mother

• Frontal scalp hematoma

• No vomiting

• Acting normal

• CT?

• Dispo?

Epidemiology

• Center for Disease Control and Prevention’s

National Center for Injury Prevention and

Control2: Annual statistics for U.S.

– 1.4 million TBI in U.S. annually

– 50,000 deaths from TBI

– 475,000 occur in pts aged 0-14 yrs

– 80,000 – 90,000 experience long term disability due

to TBI

• Center for Disease Control and Prevention’s

National Center for Injury Prevention and

Control2: Annual statistics for U.S.

– Males 2 times likely as females to sustain TBI

– 0-4 y.o. and 15-19 y.o. highest risk for TBI

– >75 y.o. highest rate of TBI related hosp and death

– Falls: 28%

– MVA: 20%

– Struck by or against objects: 19%

– Assault: 11%

• ½ of pts with mild TBI are 15-34 y.o.4

Epidemiology

• High Risk Populations5:

– Young people

– Low income individuals

– Unmarried

– Ethnic minority

– Resident of inner city

– Men

– H/O substance abuse

– H/O previous TBI

Epidemiology

• Economic Burden to U.S.3:

– $37.8 Billion in 1985

• $4.5 Billion direct expenditures (hosp care,

extended care, other medical services)

• $20.6 Billion in work related losses and disability

• $12.7 Billion in lost income from premature death

Traumatic Brain Injury in H.S

Athletes7

• 235 U.S. high schools over 3 year period

• 10 H.S. sports

• 23,566 reported injuries in 10 sports over

3 yrs

• 1219 (5.5%) were mTBI

• Median lost time: 3 days

• 4 subdurals, 2 Intracranial bleeds


Athletes7

• 1219 mTBIs:

– Football 773 (63.4%)

– Wrestling 128 (10.5%)

– Girls soccer 76 (6.2%), boys soccer 69 (5.7%)

– Girls basketball 63 (5.2%), boys 51 (4.2%)

– Softball 25 (2.1%), baseball 15 (1.2%)

– Field hockey 13 (1.1%)

– Volleyball 6 (0.5%)


Athletes7

• Football: 693 different players sustained mTBI

– 621 (89.6%) sustained 1 injury

– 65: 2 mTBI

– 6: 3 mTBI

– 1: 4 mTBI

– 72 reinjured: 47 had 2nd mTBI in same season, 14

had 2nd in next season, 1 had 3 mTBI in same

season and 1 had 4 in same season

Definitions

• TBI:

– Nondegenerative, noncongenital insult to the

brain

– From an external mechanical force

– Possibly leads to permanent or temporary

impairment of cognitive, physical and

psychosocial functions

– Can have assoc diminished or altered state of

consciousness

Classification

• Methods used to categorize severity

– Glasgow Coma Scale

– Full Outline of Unresponsiveness (FOUR)

– Duration of LOC: mild: LOC < 30min

• Mod: LOC 30min – 6 hrs

• Severe: LOC > 6 hrs

– Simplified Motor Score (SMS):

• 0 – withdraws to pain or worse

• 1 – localizes pain

• 2 – Obeys commands

Glasgow Coma Scale

• Universally accepted

• Simple, reproducible

• Limited by: sedation, paralysis, intubation

and intoxication

Glasgow Coma Scale

• Eye opening:

– Spontaneous = 4

– To Speech = 3

– To painful stimuli = 2

– No response = 1

• Verbal response:

– Oriented = 5

– Disoriented = 4

– Inappropriate words = 3

– Incomprehensible

sounds = 2

– No response = 1

Glasgow Coma Scale

• Motor response:

– Follows commands = 6

– Localizes to pain = 5

– Withdrawal to pain = 4

– Flexor (decorticate) posturing = 3

– Extensor (decerebrate) posturing = 2

– No response = 1

GCS

• Mild TBI: GCS 13-15

• Moderate TBI: GCS 9-12

• Severe TBI: 3-8

FOUR6

• Full Outline of UnResponsiveness

• Developed to eliminate the issues of the

GCS (can be performed in intubated, etc

pts)

• Not as well studied as GCS in predicting

prognosis

• More complicated to perform

• Score ranges 0-16

• Lower the score, more severe head injury

Definitions

• Some define concussion = mild TBI

• Others state concussion is even milder

• Concussion: a complex pathophysiological

process affecting the brain, induced by

traumatic biomechanical forces1

Concussion: Concensus Statement

on Concussion in Sport1

• Caused by direct blow to head, face, neck or

elsewhere on body

• Rapid onset of short lived impairment of

neurologic function that resolves spontaneously

• A functional disturbance rather than structural

injury

• May or may not involve LOC

• No abnormality on neuroimaging studies

• http://www.youtube.com/watch?v=VASrG

GsC234

http://www.youtube.com/watch?v=VASrGGsC234


Pathophysiology

• Brain Injury divided into primary and

secondary brain injury

• Primary brain injury occurs at the time of

trauma

• Common mechanisms: direct impact, rapid

acceleration/deceleration, penetrating

injury and blast waves

Primary Brain Injury

• Shearing mechanisms lead to diffuse

axonal injury (DAI)

– Small lesions within white matter tracts

– Often present with coma and increased

ICP

– Poor outcomes


• Cerebral contusions: most freq

encountered lesion

– Result from acceleration/deceleration

injuries

– Coup: occur in area of direct impact with

skull

– Contrecoup: located opposite site of

impact


• Skull Fractures:

– Vault Fx: tend to be linear

• Can be open or closed

• Depressed or nondepressed

• Simple or compound

– Basal Skull Fx

• Assoc with inj to CN

• Discharge from ear, nose and throat


Intracranial Hematomas• Epidural Hematoma

– Torn dural vessel, ex:

middle meningeal art

– Lenticular shape

– Usually assoc with

skull fx

– Rapid deterioration


Intracranial Hematomas• Subdural hematoma:

– Damage to bridging

veins

– Crescent shaped

– Often assoc with

cerebral injury


Intracranial Hematomas


Intracranial Hematomas• Subarachnoid hemorrhage:

– Rupture of superficial vessels in subarachnoid

space

• Intracerebral hemorrhage:

– In parenchyma due to lac or contusion of brain with

injury to cerebral vessels

• Intraventricular hemorrhage:

– Occurs with very severe TBI, Poor prognosis

Secondary Brain Injury

• Cascade of molecular injury mechanisms

• Start at time of injury

• Continue for hours or days


• Neurotransmitter mediated excitotoxicity

causes glutamate and free radical injury to

cells

• Electrolyte imbalances

• Mitochondrial dysfuction

• Inflammatory responses

• Apoptosis

• Secondary ischemia from vasospasm,

vessel injury


• Increased ICP

• Cerebral Edema

• Hydrocephalus

• Brain Herniation

Symptoms

• Early:

– HA

– Dizziness

– Vertigo/imbalance

– Lack of awareness

– N/V

• Late:

– Mood/cognitive

disturbances

– Sensitivity to light and

noise

– Sleep disturbances

Signs of mTBI

• Vacant stare

• Slow to answer questions

• Inabilty focus attention

• Disoriented

• Slurred/incoherent speech

• Incoordination

• Memory deficits

• LOC

Clinical Features

• Hallmarks: confusion and amnesia

• Amnesia usually involves loss of memory

of the traumatic event

• Often without LOC, but LOC may occur

• Si/Sx may develop immediately or evolve

over minutes to hours

Clinical Features

• Seizures:

– Not considered epilepsy

– Occur in fewer than 5% of mTBI8,9

– ½ occur within 1st 24 hrs, ¼ within 1st hr12

– Immediate: 1st 24hrs; Early: 2-7 d; Late >7 d

– Cohort study: 5 yr prob of Sz was 0.5 % in pts

with mTBI10

Clinical Features

• Seizures

– Pt who have not had but are at risk for early

Sz, AEDs reduce incidence of early Sz

– Dilantin effective during 1st wk after TBI13

– Discontinue after 1st wk if no Sz develops

– No effect in preventing late Sz13

• http://pepperonsports.tumblr.com/post/120

52486855/chargers-g-kris-dielman-out-

after-suffering

http://pepperonsports.tumblr.com/post/12052486855/chargers-g-kris-dielman-out-after-suffering














Evaluation• Pt with concussion or mTBI should have

medical evaluation

• Standardized Assessment of Concussion

(SAC)

– Sideline evaluation

– Measures orientation, immediate memory,

concentration, delayed recall, neuro screening

and exertional maneuvers

– Pts with concussion have lower scores14

– Best when have a baseline measure

Evaluation

• Westmead Post-Traumatic Amnesia Scale

WPTAS

• Galveston orientation and amnesia test

• Sport Concussion Assessment Tool 2

(SCAT2)

• Modified WPTAS: simple, less than 1 min

to perform

Modified WPTAS15

• What is your name?

• Name of this place?

• Why are you here?

• What month?

• What year?

• What town/suburb are

you in?

• How old are you?

• What is your birth date?

• Time of day (morn,

afternoon, evening)?

• 3 pictures for

subsequent recall?

• Any wrong answer is a

pos test for cognitive

impairment

Evaluation:

Neuroimaging• Usually normal in patients with concussion or

mTBI

• CT scan abnormalities in 5% of pts with GCS

15 and 30% with GCS 1316

• Abnormalities leading to neurosurg intervention

is 1%16

• Brain CT is best choice: most clinically

important and all neurosurgical abnormalities

visible on CT 17

Canadian CT Head Rules18

• 10 Lg Canadian hospitals, 3121 pts

• GCS 13-15

• 8% had clinically important brain injury

• 1% required neurosurgical intervention

• CT scan required for pts with minor head

injury with any 1 of following: GCS 13-15,

witnessed LOC, amnesia or confusion,

injury within 24 hours


• 5 high risk factors:

– 100% sens for predicting need for neurosurg

intervention

– Would require 32% of pts to get Head CT

• 2 Medium risk factors:

– 98.4% sens, 49.6% spec for clinically

important brain injury

– Require 54% of pts to undergo CT


High Risk

• GCS < 15 2 hrs after inj

• Suspected open or

depressed Skull Fx

• Any sign of basal skull Fx

• 2 or more episodes of

vomiting

• 65 yrs or older

Medium Risk

• Amnesia before impact of

30 or more min

• Dangerous Mechanism

– Ped struck by motor

vehicle

– Ejected from vehicle

– Fall >3 ft or >5 stairs


• Excluded pts with:

– Neurologic deficit

– Sz

– Presence of bleeding diathesis

– Oral anticoag use

• These pts should also undergo CT

New Orleans Criteria24

• Only pts with GCS = 15

• Obtain CT if any 1 of following present:

– HA

– Vomiting

– > 60 y.o.

– Drug or alcohol intox

– Persistent anterograde amnesia

– Visible trauma above clavicle

– SZ

Comparison of the Canadian CT head Rule

and the N.O. Criteria in pts with minor head

injury19

• 9 EDs in Large Canadian hosp

• 2707 pts

– 41 (1.5%) with neurosurg intervention

– 231 (8.5%) with clinically important brain inj

• Both 100% sensitive for detecting

neurosurg and clinically important brain inj

• CCHR was more specific resulting in lower

CT rates 52.1% vs 88%

External Validation of the CCHR and N.O.

Criteria for CT scanning pts with minor head

injury20

• 3181 pts GCS 13-15

– 17 pts (0.5%) with neurosurg intervention

– 312 (9.8%) with neurocranial CT finding

• Both 100% sens for neurosurg intervention

• Sens for any intracranial abnl higher in NOC

99.4% vs 87.2%

• Spec higher in CCHR 39.7% vs 3.0%

• Reduction in CT scans: NOC 3.0%, CCHR 37.3%

EvaluationThe Value of CT Scans in Patients with Low-

Risk Head Injuries24

• 658 pts admitted to single hosp

• GCS 13-15 with brief LOC or amnesia

• 18% of pt abnormalities seen on initial CT

scan

• 5% required surgery

• None of 542 pts admitted with normal CT

had deterioration or needed surgery

The Value of CT Scans in Patients

with Low-Risk Head Injuries24

• Pts with GCS 13: 40% had abnl CT and

10% required surg

• Maybe GCS of 13 should be considered

moderate-TBI rather than mild

What about us?

Evaluation

• Canadian CT Head Rules and New

Orleans Criteria for pts >16

• Pediatric Emergency Care Applied

Research Network (PECARN)

• Identification of children at very low risk of

clinically-important brain injuries after head

trauma: a prospective cohort study22

– Lancet 2009

• Head trauma in pts 18 and younger23

– 7400 deaths

– > 60,000 hospital admissions

– > 600,000 ED visits per year

Evaluation: Children

• Pts younger than 18 yr presenting within 24 hrs

• GCS 14-15

• 25 North American EDs

• 42,412 children

• CT scans on 14,969 pts (35.3%)

• Clinically important traumaic brain injury (ciTBI)

in 376 (0.9%) and 60 (0.1%) underwent

neurosurgery

Evaluation: Children < 2 y.o.

• No need for CT if:

– Normal mental status

– No scalp hematoma except frontal

– No LOC or LOC < 5 sec

– Non-severe mechanism of injury

– No palpable skull fx

– Acting normal

• Neg predictive value for ciTBI 100%

• Sensitivity 25/25 (100%)

Evaluation: Children > 2 y.o.

• No CT if:

– Normal mental status

– No LOC

– No vomiting

– Non-severe mechanism of injury

– No signs of basilar skull fracture

– No severe HA

• NPV 99.95%

• Sensitivity of 61/63 (96.8%)

Evaluation

• Neither decision rule missed any children

who required neurosurgery.

• 25% of children age < 2 years and 20% of

children age ≥ 2 years met the criteria of

their age-appropriate decision rule, and

thus did not require a head CT scan.

• http://www.mdcalc.com/pecarn-pediatric-

head-injury-trauma-algorithm/

http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/











Concensus Statement on

Concussion in Sport1

• Neuroimaging: Panel recognized that

neuroimaging was usually normal in concussion

• CT contributes little to concussion eval

• Perform when suspicion of intra-cerebral

structural lesion exists

• Ex: prolonged disturbance of conscious state,

focal neuro deficit or worsening symptoms

Disposition• 24 hour observation recommended

• Hospital admission for:

– GCS <15

– Abnl CT

– Sz

– Abnl bleeding parameters

– If no responsible person at home to monitor pt

for progression of symptoms

• Most pts with abnl CT should have follow

up CT within 24 hrs

Disposition

• Home:

– Pt with GCS 15

– normal examination

– normal head CT

– No predisposition to bleeding

• Pt should be awakened every 2 hours

• Avoid strenuous activity for at least 24

hours (exercise, reading, tv, videogames)

Disposition• Home: Warning signs to return21

– Inability to awaken pt

– Severe or worsening HA

– Somnolence or confusion

– Restlessness, unsteadiness or Sz

– Difficulty with vision

– Vomiting, fever or stiff neck

– Urinary or bowel incontinence

– Weakness or numbness

Disposition

• If pt returns with above signs:

– May indicate intracranial bleeding or evolving

cerebral edema is occurring

– Repeat thorough neuro exam

– Repeat head CT

• If new intracranial pathology, admit and consult

neurosurg

Complications

• Post consussion syndrome

– HA, dizziness, neuropsych sx, cognitive impairment

– Develop in 1st few days last few wks to few mo

• Post traumatic HA

• Post traumatic epilepsy

– Pts have 2 fold incr in risk of epilepsy for 1st 5 yrs

• Post traumatic vertigo

Complications• 2nd impact syndrome

– Diffuse cerebral swelling

– Occurs after 2nd concussion while athlete still

symptomatic from previous concussion

– Generally fatal

• Cumulative neuropsych impairment

– Aka chronic traumatic encephalopathy

– Caused by repeated concussions

– Behavior changes, personality changes,

depression and suicidiality

Concensus Statement on Concussion

in Sport1

• When player shows any feature of concussion:

– Remove player from practice or play

– Onsite medical eval, exclude c-spine injury

– Assessment of concussion using SCAT2 or similar

– Player should not be left alone

– Player with Dx concussion should not be allowed to

return to play on the day of injury

Concensus Statement on

Concussion in Sport1

• Graduated Return to play:

– 6 stages

– Each step should take 24 hours

– Start after asymptomatic at rest

– Proceed to next stage if asymptomatic at

current stage

– Drop back to previous asx stage if symptoms

return

Case #1

• 17 y.o. H.S. football player presents to ED

after injury during game

• Pt states “got my bell rung.”

• GCS 15

• Feels tired

• Normal Neuro exam

• CT?

• Dispo?

Case #2

• 35 y.o. female driver involved in MVA

• Brief LOC

• c/o HA and vomiting

• Unsure of events

• CT?

• Dispo?

Case 3

• 2 y.o. dropped by mother

• Frontal scalp hematoma

• No vomiting

• Acting normal

• CT?

• Dispo?

Conclusion• Thorough History (mechanism, si/sx of

head injury)

• Good neuro exam

• Use clinical decision rules to determine

need of CT

• Consult for abnl CT scans

• Observe vs Discharge

• Appropriate discharge instructions for si/sx

for when to return

Conclusion

• Sports: when in doubt, hold them out

• No return to play until evaluated and

graded return to play performed

Remember When In Resus

• PROTECT

• Blunt Head Injury

• Age >18

• GCS 4-12

• Time of injury < 3 hrs

• Call Joe Miller at any time even 3:30am

Henry Ford Concussion Clinic

• CAM

– Tuesdays

– 313-972-4216

• Columbus Center

– Thursdays

– 313-972-4216

References1. McCrory P, Meeuwisse W, Johnston K, et al. Concensus statement on

Concussionin Sport 3rd International Conference on Concussion in Sport held in

Zurich, November 2008. Clin J Sport Med 2009; 19:185.

2. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United

States: Emergency Department Visits, Hospitalizations and Deaths. Atlanta, Ga:

Centers for Disease Control and Prevention; Jan 2006.

3. Max W, MacKenzie EJ, Rice DP. Head injuries: cost and consequences. J Head

Trauma Rehab. 191;6:76-91.

4. Kraus JF, McArthur DL. Epidemiologic aspects of brain injury. Neurol Clin 1996;

14:435.

5. Tieves KS, Yang H, Layde PM. The epidemilogy of traumatic brain injury in

Wisconsin, 2001. WMJ. Feb 2005;104(2);22-5,54.

6. Wijdicks EF, Bamlet WR, Maramattom BV, et al. Validation of a new coma scale:

The FOUR score. Ann Neurol 2005; 58:585.

7. Powell JW, Barber-Foss KD. Traumatic Brain Injury in High School Athletes. JAMA;

Sept 8, 2009; 282(10):958.

8. Lee ST, Lui TN. Early seizures after mild closed head injury. J Neurosurg 1992;

76:435

References9. Barry E. Posttraumatic epilepsy, In: The treatment of epilepsy: Principles and

practice, 3rd ed, Wyllie E (Ed), Lippincott Williams, Philadelphia 2001. p. 609

10. Annegers JF, Hauser WA, Coan SP, Rocca WA. A population-based study of

seizures after traumatic brain injuries. N Engl J Med 1998; 338:20

11. Schierhout G, Roberts I. Anti-epileptic drugs for preventing seizures following acute

traumatic brain injury. Cochrane Database Sst Rev 2001; :CD000173.

12. Pagni CA. Posttraumatic epilepsy. Incidence and prophylaxis. Acta Neurochir Supl

(Wien) 1990; 50:38.

13. Temkin NR, Dikmen SS, Wilensky AJ et al. A randomized, double-blind study of

phenytoin for the prevention of post-traumatic seizures. N Engl J Med. Aug 23

1990;323(8):497-502.

14. McCrea M, Kelly JP, Kluge J, et al. Standardized assessment of concussion in

football players. Neurology 1997; 48:586.

15. Shores EA, Lammel A, Hullick C, et al. The diagnostic accuracy of the Revised

Westmead PTA Scale as an adjunct to the Glasgow Coma Scale in the early

identification of cognitive impairment in patients with mild traumatic brain injury. J

Neurol Neurosurg Phchiarty 2008; 79:1100.

16. Borg J, Holm L, Cassidy JD, et al. Diagnostic procedures in mild traumatic brain

injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain

Injury. J Rehabil Med 2004; :61

References17. Manolakaki D, Velmahos GC, Spaniols K, et al. Early magnetic resonsnce imaging in

unnecessary in patients with traumatic brain injury. J Trauma 2009; 66:1008.

18. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients

with minor head injury. Lancet. 2001;357:1391-1396.

19. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule

and the New Orleans Criteria in patients with minor head injury. JAMA 2005;

294:1511.

20. Smits M, Dippel DW, de Haan GG, et al. External validation of the Canadian CT

Head Rule and New Orleans Criteria for CT scanning in patients with minor head

injury. JAMA 2005; 294:1519.

21. Lawler KA, Terregino CA. Guidelines for evaluation and education of adult patients

with mild traumatic brain injuries in an acute care hospital setting. J Head Trauma

Rehabil 1996; 11:18.

22. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk

of clinically-important brain injuries after head trauma: a prospective cohort study.

Lancet 2009;374(9696):1160-1170.

23. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United

States. In: CDC, ed. National Center for Injury Prevention and Control, 2006

References

24. Haydel MJ, Preston CA, Mills TJ, et al. Indications for Computed Tomography in

Patients with Minor Head Injury. N Engl J Med 2000;343:100-5.

• http://pepperonsports.tumblr.com/post/120

52486855/chargers-g-kris-dielman-out-

after-suffering

• http://www.mdcalc.com/pecarn-pediatric-

head-injury-trauma-algorithm/

• http://www.youtube.com/watch?v=VASrG

GsC234




























concussion & mild traumatic brain injury · 2012-05-30 · traumatic brain injury in h.s...

Documents