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CONCUSSIONS:A Hard Hitting Problem
Zohar Shamash, M.D. Columbia University Medical Center - Pediatrics
ANDY
17-y.o. male, no significant past medical history
Hit in head by a line drive while playing short stop on his high school baseball team
Lost consciousness for ~1 minute and had some retrograde amnesia
No vomiting or difficulty walking Now with 7/10 dull headache Normal vitals, physical exam
significant for 3x4cm boggy hematoma on R forehead, TTP
Normal neurologic exam
1/2
ANDY
What happened? How to manage this patient
acutely? What are his discharge
instructions? What to expect when he goes
home? What about returning to play? When to follow-up?
2/2
OVERVIEW
Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention
DEFINITION
a complex pathophysiological process that affects the brain, induced by traumatic biomechanical forces
International Multidisciplinary Conference on Concussion
a trauma-induced alteration in mental status that may or may not involve loss of consciousness
American Academy of Neurologyding
knock-outbell-ringer
MILD TRAUMATIC BRAIN INJURY=CONCUSSION “Clinicians may use the concussion
label because it is less alarming to parents than the term mild brain injury, with the intent of implying that the injury is transient with no significant long-term health consequences.”
“…the concussion label is strongly predictive of earlier discharge from the hospital and earlier return to school, independent of GCS and the presence of other associated injuries.”
My Child Doesn't Have a Brain Injury, He Only Has a Concussion –DeMatteo, et. al.
FEATURES
direct blow or impulsive force short-lived impairment resolves spontaneously functional rather than structural
injury may involve loss of
consciousness normal structural neuroimaging
studies
GRADING SCALES
>25 different published grading systems developed through expert opinion rely heavily on LOC
Prague, 2004, 2nd CIS symposium: classified into simple and complex groups simple concussion sxs lasting <10 days complex concussions sxs lasting >10 days or involving
prolonged LOC, seizures, prolonged cognitive impairment or a history of multiple concussions.
Zurich, 2008, 3rd CIS symposium: groups abandoned
2010 recommendation: use symptom based approach for determination of return to play
DEPRECATED GRADING SYSTEMS
OVERVIEW
Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention
A PUBLIC-HEALTH PROBLEM CDC estimates 300,000
sports related concussions occur each year Only includes LOC
(~10%) so underestimation
Children and young adults at increased risk. Possible reasons: Less force required for
same injury in child Children more
engaged in sports Developing brain more
susceptible to disruption
…EVEN BIGGER THAN WE KNOW
Under-recognition:> 1/3 athletes do not recognize their symptoms as a result of concussions
Under-reporting: athletes do not regularly report their symptoms to trained personnel
28% of athletes report continuing to play after a blow to the head that results in dizziness
61% of football players stay in the game after a hit in the head resulting in headache
YOUTH SPORT INJURY RATE
football
soccer
lacrosse
baskeball
baseball
wrestling
volleyball
0
0.2
0.4
0.6
0.8
1
1.2
boysgirls
Football has highest incidence of all youth sport
Girls have higher rate of concussion than boys in similar sports
*
*per 1,000 athlete exposures
PATHOPHYSIOLOGY
Functional disturbance without gross structural injury
Mild head injury may result in cortical contusions due to coup and contrecoup injuries
cerebral blood flow
Na+/K+ pump activity
PATHOPHYSIOLOGY
Disruption of cell
membrane
K+ efflux to extracellular
space
Release of glutamate
Further K+ efflux
Depolarization/ suppression
neuronal activity
ATP consumption and glucose utilization
lactate
Energy crisis Cell death Hypometabolic state
PATHOPHYSIOLOGY
OVERVIEW
Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention
ACUTE EVALUATION AND MANAGEMENT ABCs and stabilization
of the c-spine, especially if LOC
Can be done by a health professional on the sidelines of a game
Neurological assessment and mental status testing
MANUAL STABILIZATION OF THE PEDIATRIC C-
SPINE
Example of standardized tool for the sideline evaluation of athletes who suffer a head injury
“AAOx3” found to NOT be reliable method of screening
S.A.C.
SIGNS AND SYMPTOMS
Physical Headache Nausea Vomiting Balance
problems Visual problems Fatigue Photosensitivity Phonosensitivit
y “Dazed” “Stunned”
hallmarks are confusion, amnesia often without preceding LOC LOC occurs <10% but important sign that may herald need for
further imaging/intervention
Cognitive Mental
“fogginess” Feeling slowed
down Difficulty
concentrating Difficulty
remembering Amnesia Repeats
questions Speaks slowly
Emotional Irritability Sadness More
“emotional” Anxiety
Sleep Drowsiness Altered sleep
patterns Difficulty falling
asleep
WESTMEAD POST-TRAUMATIC AMNESIA SCALE
Measures post-traumatic amnesia and other cognitive deficits associated with mild TBI
Takes<1 minute, useful in ED
correlates with findings in more detailed neuropsychologic testing
incorrect response to one question is test for cognitive impairment after head injury
□ What is your name?
□ What is the name of this place?
□ Why are you here?
□ What month are we in?
□ What year are we in?
□ In what town/suburb are you in?
□ How old are you?
□ What is your date of birth?
□ What time of day is it?
□ Three pictures are presented for recall
TO IMAGE OR NOT TO IMAGE
CT typically normal in concussive injury, should be considered whenever suspicion of intracranial structural injury exists
Concussion rarely associated with a c-spine injury, skull fracture, or intracranial hemorrhage
Other imaging: MRI and SPECT (gamma radiation) Post-concussion syndromeabnl SPECT and
PET scans.
WARNING SIGNS severe headache seizures focal neurologic findings on
examination Repeated, prolonged emesis significant drowsiness or
difficulty awakening slurred speech poor orientation to person,
place, or time neck pain significant irritability LOC for > 30 seconds GCS <15 at 2 hours or <14 at
any time
Looking for who TO NOT scan The prediction rule for children
aged 2 years and older had a negative predictive value of 99.95% and a sensitivity of 96.8% normal mental status no loss of consciousness no vomiting non-severe injury mechanism* no signs of basilar skull
fracture ** no severe headache
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Kupperman et al
Vol 374 No 9696 October 3, 2009
•severe= motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 5 feet or head struck by a high-impact object•** haemotympanum, ‘racoon’ eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle's sign
BATTLE’S SIGN
Minor head injury is defined as witnessed LOC, definite amnesia, or witnessed disorientation in a patients with a GCS score of 13–15
Looking for who TO scan High risk (for neurological intervention)
GCS score <15 at 2 h after injury Suspected open or depressed skull fracture Any sign of basal skull fracture Vomiting ≥two episodes Age ≥65 years
Medium risk (for brain injury on CT) Amnesia before impact >30 min Dangerous mechanism (pedestrian struck by motor vehicle,
occupant ejected from motor vehicle, fall from height >3 feet or five stairs)
The Canadian CT Head Rule for patients with minor head injury Stiell et al
Vol 357 No 9266 May 5, 2001
GLASGOW COMA SCALEFeature Scale
ResponsesScoreNotation
Eye opening
SpontaneousTo speechTo painNone
4321
Verbal response
OrientedConfused conversationWords (inappropriate)Sounds (incomprehensible)None
54321
Best motor response
Obey commandsLocalize painFlexion – Normal -- AbnormalExtendNone
654321
TOTAL COMA ‘SCORE’
3/15 – 15/15
DISPOSITION
Observation (for 2-4 hours) in ED for patients with normal neurologic exam
Discharge with a responsible person—give excellent discharge instructions
Is it necessary to wake patient up every 2 hours at home? No data, but if you’re worried enough you should probably admit Might make patient worse because treatment for concussion is
sleep/relaxation Hospital admission is recommended for patients at risk for
immediate complications from head injury , patients with: GCS <15 Abnormal CT scan: intracranial bleeding, cerebral edema Seizures Bleeding risk
TREATMENT: PHYSICAL/COGNITIVE REST Physical rest Increased symptoms with cognitive
activities after concussion, so cognitive rest encouraged. May include: Temporary leave of absence from school Shortening of school day Reduction in workload Increased time to complete assignments/test
“cocoon therapy” Medication?
OVERVIEW
Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention
SO, WHEN CAN I RETURN TO PLAY?
Many "return to play" guidelines, but little scientific evidence to support them
No athlete should return to play when symptomatic at rest or with exertion
In fact, it is illegal in 11 states Most will be asymptomatic
within one week, but conservative management recommended in children Wait 7-10 days longer
No activityComplete physical and cognitive rest
Light aerobic activityWalking, swimming, stationary cycling at 70% maximum heart rate; no resistance exercises
Sport-specific activitySpecific sport-related drills but no head impact
Noncontact training drillsMore complex drills, may start light resistance training
Full-contact practiceAfter medical clearance, participate in normal training
STEP-WISE RETURN TO PLAY
Return to previous step if symptoms recur
Graduate to following step after >24 hours without symptoms
Return to play!
NEUROPSYCHOLOGICAL TESTING
Provides objective measure of brain function in athlete with concussion—validated for test retest reliability Computerized tests: ANAM,
CogState,HeadMinder, and ImPACT Vast majority of studies conducted by
developers of test Ideally compared to baseline/preinjury
test
IMPACT TEST CLINICAL REPORT
Run by Department of Neuropsychology
Departments of Neurology Neuropsychiatry Sports Medicine Physical Therapy
Uses ImPACT testing
OVERVIEW
Concussion fundamentals Epidemiology and pathophysiology Management Return to play Sequelae Prevention
SEQUELAE
second impact syndrome post concussion syndrome cumulative neuropsychologic
impairment post-traumatic epilepsy post-traumatic headaches post-traumatic vertigo other cranial nerve injuries
SECOND IMPACT SYNDROME
Occurs when an athlete who has sustained an initial head injury sustains a second head injury before the symptoms associated with the first have fully cleared Can cause severe brain injury or even death
Cause is hypothesized to be disordered cerebral autoregulation causing cerebrovascular congestion and malignant cerebral edema with increased ICP
All reported cases in athletes younger than 20 years old
VIDEO
LEGISLATION
In 2006, a 13 year old named Zackery Lystedt suffered a concussion while playing football but went back into the game.
He collapsed after the game and had a brain bleed, and suffered severe brain damage.
On May 14th 2009, Gov. Christine Gregoire of Washington state signed the “Zackery Lystedt Law,” the nation's toughest youth athlete return-to-play law.
It requires medical clearance of youth athletes suspected of sustaining a concussion, before sending them back in the game, practice or training
POST CONCUSSION SYNDROME (PCS) Constellation of physical, cognitive,
emotional, and behavioral symptoms DSM IV requires presence of symptoms in at
least 3 of 6 categories for at least 3 months after injury and evidence of neuropsychological dysfunction.
Prevalence in adults between 11-64% Limited studies done on children
P.C.S. SYMPTOMS
fatig
ue
head
ache
forg
etfu
lnes
s
slee
p di
stur
banc
e
anxiet
y
irrita
bilit
y
dizz
ines
s
noise
sens
itivity
0%
100% 91%
78%73% 70%
63% 62% 59%
46%
Prospective cohort study of epidemiology and natural history of PCS children with mild TBI compared with children with extracranial injury
Among school-aged children with mTBI, 13.7% were symptomatic 3 months after injury compared with 2.3% symptomatic after 1
year Finding could not be
explained by trauma, family dysfunction, or maternal psychological adjustment.
Epidemiology of Postconcussion Syndrome in Pediatric Mild Traumatic Brain Injury -Barlow, et. al.
SEIZURES AND CONCUSSIONS
3 different types of events: “impact seizure”
immediately following a concussive injury (w/in 2 secs)
Not associated with epilepsy, underlying brain injury, similar to convulsive syncope
Manage similar to concussions Early post-traumatic epilepsy
Within one week following injury Late post-traumatic epilepsy
After one week following injury
CUMULATIVE NEUROPSYCH IMPAIRMENT
Repeated concussions can cause cognitive impairment
“Dementia pugilistica" has been long recognized as sequelae of boxing (20% of professional boxers)
Neuropsychological symptoms Behavior Personality changes Depression Suicidality Parkinsonism Other speech/gait abnormalities
Higher incidence of dementia than in general population among NFL players with history of multiple concussions—called “chronic traumatic encephalopathy”
Neuropathological study of boxers with chronic TBI demonstrates some features of AD incuding neurofibrillary tangles, amyloid plaques
ApoE genotype and tau isoforms also may play a role
OVERVIEW
Concussion fundamentals Epidemiology and pathophysiology Management Return to Play Sequelae Prevention
PREVENTION
Mouthguards Helmets
Shown to reduce concussion in skiing and snowboarding In football, developed to reduce severe head trauma but
not concussions In soccer, protect against soft tissue injuries
Concussions usually from head-to-head or head-to-elbow contact
Heading the ball safe if done properly
Education!
As Injuries Rise, Scant Oversight of Helmet Safety
Football helmets not formally tested against the forces
believed to cause concussions, only to withstand high forces that would otherwise fracture skulls
NOCSAE standard hasn't changed since written in 1973 While bicycle helmets are designed to withstand only one
large impact before being replaced, football helmets can encounter potentially concussive forces hundreds of times a season
Helmet companies now developing helmets to specifically reduce concussion
RESOURCES/EDUCATION
cdc.gov/concussion Tons of educational resources Handouts Facebook page
iphone app “Cognit” nytimes.com: concussion
section The most important
mainstay of prevention is education of coaches, athletes, parents
ANDY
17-y.o. male, no significant past medical history
Hit in head by a line drive while playing short stop on his high school baseball team
Lost consciousness for ~1 minute and had some retrograde amnesia
No vomiting or difficulty walking Now with 7/10 dull headache Normal vitals, physical exam
significant for 3x4cm boggy hematoma on R forehead, TTP
Normal neurologic exam
1/2
ANDY
What happened? How to manage this patient
acutely? What are his discharge
instructions? What to expect when he goes
home? What about returning to play? When to follow-up?
2/2
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2001;36(3):244–248 Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375–378 Thurman DJ, Branche CM, Sniezek JE. The epidemiology of sports-related traumatic brain injuries in the United States: recent developments. J Head Trauma
Rehabil. 1998;13(2):1–8
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THE END!
THANK YOU!
The chiefs: Tom, Mithila, Yaffa
Dr. Maria Kwok and CHONY ED faculty
My family: Joey and Noa Dr. Stanberry, Dr.
Wedemeyer, Dr. Hametz Tuesday Audubon Clinic:
Christine, Annika, Omalara, Jillian, Ronny, Jason, Alanna, Josh
My class—CHONY 2011
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