on-field management assessment and differential diagnosis · king‐devick ... head injury warning...
TRANSCRIPT
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Sports Medicine Concepts
The CMS Program
A serious educational undertaking:
take you beyond entry‐level
• 15 EBP CEUs are earned!
• 4 live sessions;
• Recorded sessions;
• 3 quizzes:
• Live sessions;
• Recorded sessions;
• Seminar readings;
• Concussion project:
• Case study:
• Essay:
• CPR/AED
• Request for Credential
http://wp.me/P37IZa‐tu
Chat section of Participation Panel
Participant Resource Page
Open dialogue = cool
Questions?
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Represent A Standard of Care
Position statements
Peer‐Review
2Min Drill
• Over‐reaching document
• Venue‐specific
• Annual rehearsal
• Critical Care Triangles Approach
TeamEMSoft
Must NOT BeWithout EAP
Perhaps the most critical element of an EAP
The Medical Timeout
Obvious vs. Subtle
• Follow the ball
• Scan the sideline
• Watch players coming off the field
• Consider an Injury Spotter
Eyes on The Field at All Times
I really like this!
MC1
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Gain control of field
Primary objectives
• LOC
• CABN
• Protect cervical neutral position
• Determine extent of neurological injury
Phase I: On‐Field Management
Spreading depression
Head Trauma and The Unconscious Athlete
Brief vs. Prolonged
Cantu Evidence‐Based Grading System• Grade 1 (mild)• No LOC• PTA <30 min
• PCSS <24 h
• Grade 2 (moderate)• LOC <1 min or • PTA > 30 min <24 h
• or PCSS >24 h <7 d
• Grade 3 (severe)• LOC >1 min• or PTA >24 h
• or PCSS >7 d
LOC and Transport
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Progressive Transition
• SMC’s Progressive Algorithm• Reposition• CABiN• Apprehension• Reassess in seated
position• Reassess in standing• Support
Vital Sign Triad
Sure CABiN, but what else can we get from vital signs?
• Pulse rate
• Systolic blood pressure
• Body temperature
Initial Vital Signs
Radial Pulse Check
• Screen for accelerated heart rate
• Screen for regular pulse pattern
• Rates > 140 may indicate abnormal heart rhythm
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Electronic oral or tympanic
• Initial temperature readings > 100 occur during heat stress
If elevated heart rate or low systolic blood pressure
Temperature
Vital Sign Trending
Rule of 100
• Pulse >100
• Temperature > 100
• Systolic BP <100
Serial measurements at 10 minute intervals for 30 minutes
• Differentiate between serious and minor injury
Trending
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Pulse Rate Blood Pressure
Initial readings of 140‐170mmHg
Normalize to 120/70
Persistent systolic pressure elevations• significant head trauma
Conditioned athletes normalize within 20‐30 minutes
• Pulse rate >100• Anxiety
• Temperature
Trending
Post Concussion Blood Pressure
Widened pulse pressure with bradycardia
• increased intracranial pressure
• 120‐70 = pp 50
Serial Temperature Readings
Performed to confirm initial readings
Useful in assessing heat illnesses
Internal injury
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Pulse Oximetry
SpO2
Applied again following vital sign trending
• 30 min normalization for majority of injured athletes
• Persistent triad abnormalities referred to ED
• Normal vitals following trending sent for physician consultation
SMC’s Enhanced Vital Signs Trending Report
Rule of 100
Lucid Interval
• Intermittent improvement / deterioration of level of consciousness and other s/s
• More typical of hematoma than concussion
Interpretation of Signs / Symptoms
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Body’s compensatory reflexes will accommodate small rises in ICP
• Initial inc may not be readily observable
• When ICP reaches MAP there is a decrease in CBF
• Inc systolic blood pressure to compensate for dec CBF
• Vicious cycle with devastating consequences
Intracranial Pressure
• Bradycardia
• Hypo‐hypertension
• Respiratory depression
• Systemic vasoconstriction
• Lucid interval
• Hyperventilation
• Sluggish or dilated pupils
• Widened pulse pressure
Hematoma
Relatively minor blow
• loss of auto‐regulatory centers of the brain
• cerebral hyperemia and edema that is virtually impossible to control
• Elevated ICP w/herniation
• Adverse affects on CNN within minutes
• Death in 50% of cases
Second Impact Syndrome
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Acute S/S Resemble SRC Children and Risk
Children appear to more vulnerable to cerebral swelling and subdural hematoma
• Increased sensitivity and more conservative approach
• Loss of coordination
• Rapid LOC
• Coma
• Dilating pupils that are motionless
• Respiratory distress
a minor concussion, but readily deteriorate due to pressure on CNN
Acute Signs & Symptoms of SIS
Level 1 Trauma Center
• Cannot rule out CSI
• Hematoma S/S
• Increased intra‐cranial pressure
Indications for Transport
• Monitor vitals and LOC every 5 min
• Lucid interval
• Deteriorating S/S
• Inc number of
• Inc graded symptom score
When to Refer
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Protect immediate health / Prevent protracted recovery / PCS
What you do from minute 1 could make the difference between simple recovery and protracted recovery or post‐concussion syndrome
• CRT
Phase 2: Sideline Assessment
“Special Juice”
• 1 qt
Omega‐3
Witch Doctor?
If you’re Not Measuring, Your Guessing
Protracted Recovery and PCS
Journal of Athletic Training 2017;52(3):160–166
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Follow‐Up Acute Assessment
Cranial Nerves
• 90% of a thorough head injury assessment
• CNN Assessment Guide
When and Where?
Directly after injury? / On Sideline?
Upon determination of concussion to document signs and symptoms?
• Graded symptom checklist at injury
• SCAT5 20+ min post‐injury
• Locker room
• Training room
SCAT 5 and Child SCAT 5
Acute signs and symptoms may not be accurate indicator of VS injury
• Within first week
• 40% report balance problems
• 30% report vision problems
• Generally recover in 3‐5 days, maybe up to 10 days.
Vestibular Signs and Symptoms
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• Smooth Pursuits
• Horizontal Saccades
• Vertical Saccades
• Near Point Convergence
• Horizontal VOR
• Vertical VOR
• Visual Motion Sensory Test
VOMS Tests
0‐10
• Headache
• Dizziness
• Nausea
• Fogginess
VOMS Recordings
The King‐Devick (KD) test is a screening tool designed to assess cognitive visual impairments, namely saccadic rhythm, postconcussion.
King‐Devick
Journal of Athletic Training 2017;52(5):439–445
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Concussion Assessment System i‐Pad Based
• Cleveland Clinic
• Combines benefits of ImPact, SCAT3, BESS, and RTP
• Completed in about 20 Min
• Cloud based application
C3 Logix
Provides for
• Graded symptom checklist
• Reaction time
• Memory & Speed processing
• Motor function
• Vision
• Balance
• Vestibular function
Concussion Assessment System
Risk Predicting
Significant predictors• amnesia, balance abnormalities, tinnitus & visual impairments at 20 min.
87% probability• headache & amnesia at 5 min
73% probability• headache, dizziness & balance abnormalities at 20 min
Epidural and Subdural hematomas and SIS are life‐threatening, but PCS is a more likely consequence of sports‐related concussion
Post‐Concussion Syndrome
Cameron KL, et al. (2000). Predicting the development of post concussion syndrome from initial signs and symptoms following mild traumatic brain injury. JAT‐S, 35(2), S‐54.
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Written concussion signs and symptoms even if there is a remote possibility that the athlete suffered a concussion
Head Injury Warning Sheet
72hrs post‐injury critical
Pass from school, homework
Full physical and cognitive rest
Yellow Card
• Signs and symptoms checklist
• Explicit diagnosis of concussion
• Physician follow‐up
• Policy overrides ER/Physician
Physician Evaluation Form
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Sports‐related head injury has a relatively high incidence rate in youth
• 15% of all ER head injuries
• 3% of all sports related injuries
• 24% of all serious head injuries
Age related difference exist between HS and college athletes
• Increased symptom severity
• Prolonged recovery
Special Consideration for Young Athletes
Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M, Putukian M, Valovich McLeod TC. National Athletic Trainers’ Association position statement: management of sports‐related concussion. J Athl Train. 2004;39(3):280‐297.
Proper Fit
Equipment Issues
Session Review
• Recording posted shortly
• Power Point link
Readings
• Hematoma vs. Concussion
• Leddy‐Neuro Rehab
• Adolescent and Pediatric Rehab Stategies
For Tomorrow