Concussion in the ED What You Know, Need to Know and Better Know to make Correct Treatment Dave Milzman, MD FACEP Professor of Emergency Medicine Senior.

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

52

53

“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.”

54

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

56

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

61

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.

74

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.

76

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?