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Concussion in the EDWhat You Know, Need to Know and Better Know
to make Correct TreatmentDave Milzman, MD FACEPProfessor of
Emergency MedicineSenior Advisor for Clinical ResearchGeorgetown U
School Of MedicineProfessor of Biology Georgetown
UniversityResearch Director: Georgetown/WHC EM Residency
Clinical Director MedStar Emergency and Trauma Concussion
ProgramWash, DC
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ConcussionDiagnosis , Treatment and Follow UpDefinition: Mild
Traumatic Head Injury + LOC with any of 22 common symptoms most
common Headache, Dizzy, Fogginess, Trouble Concentrating, Trouble
Sleeping
Initial Evaluation: Good Neuro Eval, include Balance Testing,
(BESS) and Dont Image Unless you Plan to Need Admit ( < 0.3%
Positive Scan in all Sport Concussion)
Most Important Thing You Can Do On Discharge:Diagnosis, REST for
3 days, No School, No Sport and Be Re-Evaluated, 60% will Improve
in 7 days. Neuro-Psychology is your Best Consultant !!
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Ice Hockey #3 sport for mTBI
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16 year old maleInjury - Elbowed In Forehead During Hockey
GameInitially, No Symptoms, Returned to Ice for 1 shift, But Within
10 Minutes, Became Foggy With Poor Concentration, Memory,
DizzinessSubsequent Loss Of Memory For Event, Irritability,
Headaches, Reduced Energy, Sensitive To Light And Noise, Sleeping
More Than Usual, Poor Balance
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Initial Eval, RX and TX10th grade honors student Seen in the ED
and sent Home for 1 week no school, lots of sleep , Motrin and
FluidsNo texting no gaming, light TV and reading Concussion Clinic
at Day 7 & 14Neuropsychological Concussion Evaluation initially
demonstrated:Poor attentionPoor working memorySlowed processing
speedReduced reaction timeBy 14 days, excellent recovery &
return to baseline values
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What Works in Student AthletesEducate and guide the family and
patient and the primary care doctorMake recommendations for initial
accommodations in schoolKept him safe by managing his gradual
return to School and SportsThe Easy Decision and return is
SportReturn to Learn is NOT Automatic, Know This , Practice This ;
If Nothing Else, Give all 3 Day Total Rest.
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Epidemiology - ConcussionMost frequent diagnosis in injured
child is: HEAD INJURY TBIEvery 11 minutes 1 child in the US has a
brain injury resulting in permanent disabilities or 35,000
annually5,000,000 children with head injuries 3.8 million
concussions/annually Emergency Department Visits~ 90%: mild TBI/
GCS 14-15Majority with mTBI sent home from ED
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STATISTICSIncidence in HS football = 6%-8% per year.Boys + Girls
soccer = football.Girls basketball 250% greater risk than
BoysSports and recreational injuries with LOC = 300,000 per
year.Sports and recreational injuries with and without LOC = 1.6
million per year.
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DEFINITION
Complex pathophysiologic process affecting the brain, induced by
traumatic biomechanical forces.
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COMMON FEATURESCaused by a direct or indirect blow to the head,
face or neck.Results in rapid onset of short-lived impairment of
neurological function.A concussion may or may not involve LOC.The
clinical symptoms reflect a functional rather than a structural
disturbance.
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PATHOPHYSIOLOGYMechanism of InjuryRotational Much Worse than
LinearImpact decelerationChemical/Vascular1st 7-10 daysK / Ca / glc
/ glutCBFPeriod of vulnerability
- Anatomical Timeline of a ConcussionDefining the Key
FactorsLOC
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1-3 DaysDay 5-10Pre-Concussion Baseline TestingDay 12-16*Barth
et al., 2002ConcussionClinical ProtocolNeurocognitive Testing
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ConcussionPre-Concussion Baseline
TestingSymptomsCognitiveFunctions
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NEUROCOGNITIVE COMPUTERIZED TESTING
ImPACT (UPMC)
CogSport (Australia)
CRI (Headminder)
ANAM (NRH)
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OVERVIEW OF ImPACT
Proven in measures of reliability and validityProvides useful
concussion screening and management informationValidated with
multiple peer-reviewed studiesDoes not substitute for medical
evaluation and treatmentDoes not substitute for comprehensive
neuropsychological testing
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IMMEDIATE POST-CONCUSSION ASSESSMENT and COGNITIVE TESTING
(ImPACT)
8 separate testsWord memoryDesign memoryXs and OsSymbol
MatchColor MatchThree LettersInterference tests
6 composite scoresVerbal memoryVisual memoryVisual motor
speedReaction timeImpulsivityTotal symptom score
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COMPUTERIZED TESTINGFormat allows portability and
efficiency.Each vendor has their unique menu of cognitive domains
that their product measures.20 30 minutes to administer.Used as a
tool to measure recovery and not to make a diagnosis or solely
direct management.
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CONCUSSION SYMPTOM SCALEStandardized survey with 0-6 scale
rating Developed by Lovell and Collins in 1998Sensitive tool to
measure recoverySymptoms generally classified into 3 main
categories: Physical, Cognitive, and Emotional/Behavioral
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4 Symptom CategoriesPhysicalHeadacheFatigue Dizziness
Sensitivity to light and/or noiseNauseaBalance
problemsEmotionalIrritabilitySadnessFeeling more
emotionalNervousness Cognitive Difficulty remembering Difficulty
concentrating Feeling slowed down Feeling mentally foggy Sleep
Drowsiness Sleeping less than usual Sleeping more than usual
Trouble falling asleep
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GENERALMANAGEMENTMajority of injuries will recover
spontaneously.Physical and cognitive rest are required while
symptomatic.When symptom free and improved functionally graduated
return to play protocol should be utilized.Same day return to
playNEVER!!!
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PREDICTING RECOVERY TIMELINESALL ATHLETES ARE NOT CREATED
EQUALLY
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CONCUSSIONMODIFIERSThresholdRepeated concussions occurring with
less force or slower recovery.AgeChild and adolescent < 18 years
old.Co-morbiditiesMigraine, depression or other mental health
disorders, ADHD, learning disabilities and sleep
disorders.MedicationPsychoactive drugs and
anticoagulants.BehaviorStyle of play.SportContact or collision
sport, high-risk.
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RETURN TO PLAY PROTOCOLNo activity while symptomatic.Light
aerobic exercise.Sport-specific exerciseno head impact
drills.Non-contact training drills.Full contact practice.Return to
game play.
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Recovery From Concussion:How Long Does it Take?N=134 High School
athletesWEEK 1WEEK 2WEEK 3WEEK 4WEEK 5Collins et al., 2006,
Neurosurgery
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Clinicians Return to Play Decisions1008060402000ATC used GSC,
SAC, BESS (testing w/ symptom report)ATC used only GSC (player
symptom report)Marshall, Guskiewicz, & McCrea; In Review,
2006.
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NFL CONCUSSIONGUIDELINES
Established in 2009.No same day return to practice or game
play.Players encouraged to be honest and report
symptoms.Independent neurology opinion for each injury.
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CHRONIC TRAUMATIC ENCEPHALOPATHY
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CHRONIC TRAUMATIC ENCEPHALOPTHYNFL Survey> 50 = 5x risk30-49
= 19x riskComparative data from the Framingham heart study.Concept
of subconcussive trauma.Sports Legacy Institute.
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Concussions Effects on School Learning
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Return to School
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Concussions Effects on School Learning & Performance Which
specific types of problems are you experiencing in school?Students
reported an average of 4 problems below. Headaches interfering
71.3% Cant pay attn in class 62.5% HW taking much longer 59.5%
Difficulty studying for test/quiz 51.9% Too tired 50.6% Diffic
understanding material 44.0% Difficulty taking notes 28.8%
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Concussions Effects on School Learning & Performance Which
classes are you having the most trouble with?(Percent reporting
trouble in class) Parent Student Math 60.3% 73.7% Reading/LA 38.1%
46.1% Science 38.1% 47.4% Soc Stud 38.1% 40.8% Foreign Lang 38.1%
38.2% Music 6.3%17.9% PE 7.9%10.5% Art 3.2%5.3% -None25.4% 6.6%
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General Principles of RecoveryNo additional forces to head/
brain Resting the brain & getting good sleepManaging/
facilitating physiological recoveryAvoid activities that produce
symptomsNot over-exerting body or brainWays to
over-exertPhysicalCognitive! (concentration, learning,
memory)(Emotional)Even taking Neuro-Cognitive Testing is
Contra-Indicated in Symptomatic Patient
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4th International Conference on Concussion in Sport held in
Zurich, November 2012Consensus Statement on Concussion in Sport
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CURRENT BEST REVIEW TILL APRIL 2013
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Zurich CIS ConsensusConcussion ManagementPhysical AND Cognitive
Rest 48-72 HoursGraduated RTP: when asymptomatic at reststepwise
progression, proceed to next level if asymptomatic at current. Each
step take 24 hours; would take approximately one week to proceed
through the full rehabilitation protocol Same Day RTP: NEVER
appropriate in child or adolescent student-athlete (possible in
adult ONLY if within well established system)Recognized delayed
onset of symptoms 15-30 minutes is Usual
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Changing Presentation Rates For mTBI (Concussion) And Changing
Imaging Rates.
Dave Milzman, MD, FACEP Sam Frankel MS, Colin Leiu MS, Katy
Taxiera, Steve Swinford MS, Zach Hatoum.Georgetown U. School of
Medicine, Wash D.C.MedStar Sport Concussion Center; Wash, D.C.
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Results
2000-2012: Rapid rise in past 5 year with number of concussions
increased by 140% compared to ED and Trauma patient volume
increased only by 23.9%; p< 0.02.
Increases in CT for concussion: 25.8% /10 yr with less than 1.2%
of mTBI with positive Head CT ; 24% MRI have No- Therapeutic
Positive Findings MEANING None Required NeuroSurgical
Intervention.
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Concussion & Imaging 2000-2011
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Media and Medicine for Concussion
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Discussion
Media And Medicine Has Met And Increased Awareness As mTBI
Presentation And Concussion Visits are Increasing at Increased
rates Compared to All other ED and Trauma VisitsCT and MRI
Increased In Use With No Improved Treatment Intervention.
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Controversy over CT for Minor TBI Preventable
morbidity/mortality due to unrecognized TBIsCT provides visual
information about the skull and the brainPreverbal children
difficult eval.When indicated, benefit of CT greatly outweighs
risk, however
Arguments for liberal use of CT:
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InvestigationsNeuroimaging (CT, MRI)Contributes little to
concussion evaluationUse when suspicion of intracerebral structural
lesion exists:prolonged loss of consciousnessfocal neurologic
deficitworsening symptomsDeterioration in conscious stateMRI still
not proven benefit aids detection not treatment.
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Controversy over CT for Minor BHT Of the 325,000 children
evaluated with CT after BHT, fewer than 1% have significant TBI and
< 0.3% require any Neurosurgical intervention.Drawbacks of CT
include transport outside the ED, pharmacological sedation, costs
(charges $2-3K/patient)lethal malignancy risk from CT may be as
high as 1:1250
Arguments against liberal use of CT:
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Lifetime Cancer Mortality RiskNEJM, Brenner et al.Lifetime
cancer mortality risk with single CT head in year 1 of life:i-V
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PECARN Prediction Rules
Age 2 years and olderGCS < 15 or abnormal mental statusLOC
History of emesisSevere mechanism of injurySigns of basilar skull
fractureSevere headache
Kuppermann/Holmes/Dayan/Hoyle/Atabaki et al 2009
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ResultsPositive CT Proportion** Preliminary data. O.R. = 3.01
(95% CI 2.07-4.37)
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Traumatic Brain Injury ModMild Severe Severe GCS 8Moderate GCS 9
- 12Mild GCS 13 - 15
Teasdale et al Lancet 1974;Sports concussion?MinimalGlasgow Coma
Scale
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*Distribution of Head AccelerationsDiv I American Football (3
teams, 4 seasons)
20g buddy head butt300+ g recorded Crisco et al, 2012
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*
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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
varsity and junior varsity lacrosse All home contests (518) at 25
high schools (50 teams) in the Fairfax County (Va) Public Schools
during 2008 and 2009 seasons44 injuries were diagnosed by a
Certified Athletic Trainer as a concussion34 (77%) cases had
sufficient image quality for analysis
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Impact Characteristics of Concussion Injuries in Boys Lacrosse,
2008-2009 (n=34)*
CharacteristicFrequency (n)Percentage (%)Primary injury
mechanism - Bodily collision34100Striking player26Struck
player23**68Both players926Secondary impact head/body to
ground2471Impact source (striking player)Head27**79Upper
extremity/shoulder721Stick/ball00Struck player readiness for
contactUnanticipated (defenseless hit)1956Anticipated good body
position824Anticipated poor body position515
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Comparison of Concussion Injuries in Boys and Girls
Lacrosse*
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Common injury scenario (Pre-injury)*
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*
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*
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*
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Concussion Causation in LaxPlayer-to-player contact was the
mechanism for all concussions in males. > 75% --The striking
player used his head to initiate impact>50% ---The struck
players head was the initial point of impact>50% -- the struck
player was unaware and unprepared for contact These defenseless
hits represent scenarios for rule changes/enforcement to protect
vulnerable players*
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Sideline And ED Assessment of Concussion
Examine, Dont Rely on Imaging
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Sideline ToolPocket SCAT2Also Best for the ED
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Aids to sideline assessmentKnowing the patientSystematic
examinationRepeating the examination
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Components of examObservation and history Delay Assessment 10-15
min after occurrence.Mini mental status (baseline tests
ideal)OrientationMemory Concentration Symptom check
listNeurological examCranial nerveBalance - BESS (baseline tests
ideal)
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Balance Error Scoring System3 Positions Hold each with Eyes
closed for 20 seconds Mean Baseline Score is 3 ptsDouble leg,
tandem stance (dominant foot forward), single leg stance
(non-dominant foot) Hands on hips, eyes closed, 20 second trials,
count errorsHands lifted off hips, open eyes, step/stumble, hip
move > 30 degrees abduction, forefoot/heel lift, out of position
> 5 seconds
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BESS Positions ERROR PointsDouble Leg Stance 0.09Single Leg
Stance 2.45Tandem Stance 0.91Surface Total = 3.37
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Novel approaches to sideline assessmentQuantitative EEG (10-12
minutes) (Brainscope)
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Brain Sentry is an AccelerometerIt picks up a Impact Force >
70 g3. The Problem Is That You Want To Never Miss A Concussion, But
Dont Want To Have Too Many False Positive But Optimally No False
Negative.ACCURACY is Key Best Can DO : 75-80% Sensitivity
35%Specificty
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Whats the worst thing that can happen to my son?
[Father of football player with multiple concussions in one
season, 2003]
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Second Impact SyndromeDescribed by Saunders & Harbaugh,
1984RareMost commonly seen in adolescentsCan be fatalNovember 10,
2012*
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Second Impact SyndromeAthlete suffers a concussion (typically
grade 1 or 2) Most are 12-16 yoStill suffering from symptoms of
concussion and returns to playSuffers a second concussionSecond
blow may be remarkably minor, sometimes not directly to the head,
but causing the athletes head to snap which imparts accelerative
forces to the brainThe athlete may appear stunned or dazed, but
usually remains on feet for 15 seconds to a minute, similar to
someone suffering from a grade 1 concussion without loss of
consciousness*
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Second Impact SyndromeDisordered cerebral autoregulation of
cerebral blood flow vascular engorgementincreased ICPBrainstem
herniationRapid Development of coma, ocular involvement, and
respiratory failure ensueMortality 50-100% due to brainstem
herniationNever Diagnosed in ED, Always in Extremis on
Presentation, < 30 in 30 yrs.*
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November 10, 2012*
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SIS: Treatment On-field treatment of SIS requires rapid
intubation, hyperventilation (to facilitate vasoconstriction by
lowering blood carbon dioxide levels), and intravenous
administration of an osmotic diuretic (such as 20% mannitol). Needs
Immediate Decompression in 30 min.The unconscious athlete who
sustains a head injury should always be transported with his or her
neck immobilized.*
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Risk Factors for Complicated Post Concussion Syndrome9
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Medications in ConcussionThere are NO medications which are FDA
approved for concussion or mild TBIWhat are some possible
indications for medications?Existing Medication Should be
Continued.i.e. ADHD, Depression, etc. No Literature Exists Finding
Improved Outcomes in RCT*
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Medications in ConcussionWhen to startHeadache: acute, subacute,
chronicVertigo: acute if severe; unable to tolerate
therapy/functionAll other indications should only be treated with
medications if Fail therapy/non-pharmacological
managementPersistent
*
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Concussion ClinicPatients seen within 1 week of referralBrain
Injury PhysicianNeuropsychologistImPACT testing/Neuropsych
evaluationPatient/family educationReturn to sports (work, school,
etc.) recommendationsFollow up for persistent symptoms*
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ManagementCORNERSTONE = rest until asymptomatic
Rest from activityNo training, playing, exercise, weightsBeware
of exertion with activities of daily livingCognitive restNo
television, extensive reading, video games?Caution re: daytime
sleep
REST = ABSOLUTE REST!
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Sports concussionFollow-up ManagementRestRestRestExpect gradual
resolution in 7-10 daysStart graded exercise rehabilitation when
asymptomatic at rest and post-exercise challenge
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RecoveryHow long asymptomatic before exercise?If rapid and full
recovery, then 24-48 hoursOne approach is to require that they
remain asymptomatic (before starting exertion) for the same amount
of time as it took for them to become asymptomatic.
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Symptom Categories
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RTP:Graded Exertion Protocol 24 hours per step If recurrence of
symptoms at any stage, return to previous step
Rehabilitation stageFunctional exercise at each stage of
rehabilitationObjective of each stage1. No activityComplete
physical and cognitive rest. Recovery2.Light aerobic
exerciseWalking, swimming or stationary cycling keeping intensity
< 70% MPHR No resistance training.Increase HR3.Sport-specific
exercise Skating drills in ice hockey, running drills in soccer. No
head impact activities.Add movement4.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 load5.Full contact
practiceFollowing medical clearance participate in normal training
activitiesRestore confidence and assess functional skills by
coaching staff6.Return to playNormal game play
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Coach/ Player/ Parent Concern: Isnt this Concussion program
going to hold my players out longer?
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Questions?
Based on statistics from the National Pediatric Trauma Registry:
we know:The most frequent diagnosis at the time of an injury to a
child or adolescent is: HEAD INJURYThe National Pediatric Trauma
Registry gathers information regarding children admitted to
hospitals due to traumatic injuries.They have data on 50,000 injury
cases.We also know from this data base that:Every 11 minutes 1
child in the US has a brain injury resulting in permanent
disabilities (30,000 children/year)Almost 1/2 of children who
sustain winter sports injuries are diagnosed with head injury.
**12*12***Within the PECARN network, in a study recently
published in the Lancet, we developed 2 prediction rules to
identify children at very low risk of clinically important
Traumatic Brain Injury after blunt head trauma for whom CT scans
would not be routinely necessary.
*Saunders RL, Harbaugh RE: The second impact in
catastrophiccontact-sports head trauma. JAMA
1984;252(4):538-539*