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Concussions: A Hard-Hitting Problem

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  • 1. CONCUSSIONS:
    A Hard Hitting Problem
    Zohar Shamash, M.D.
    Columbia University Medical Center - Pediatrics
  • 2. Andy
    1/2
    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
  • 3. Andy
    2/2
    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?
  • 4. OvervieW
    Concussion fundamentals
    Epidemiology and pathophysiology
    Management
    Return to play
    Sequelae
    Prevention
  • 5. 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 Neurology
    bell-ringer
    ding
    knock-out
  • 6. My Child Doesn't Have a Brain Injury, He Only Has a Concussion –DeMatteo, et. al.
    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.”
  • 7. 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
  • 8. 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
  • 9. Deprecated grading systems
  • 10. OvervieW
    Concussion fundamentals
    Epidemiology and pathophysiology
    Management
    Return to play
    Sequelae
    Prevention
  • 11. 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
  • 12. …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
  • 13. Youth Sport injury rate
    *
    • Football has highest incidence of all youth sport
    • 14. Girls have higher rate of concussion than boys in similar sports
    *per 1,000 athlete exposures
  • 15. pathophysiology
    Functional disturbance without gross structural injury
    Mild head injury may result in cortical contusions due to coup and contrecoup injuries
  • 16. lactate
    cerebral blood flow
    pathophysiology
    K+ efflux to extracellular space
    ATP consumption and glucose utilization
    Energy crisis
    Disruption of cell membrane
    Na+/K+ pump activity
    Release of glutamate
    Cell death
    Further K+ efflux
    Depolarization/ suppression neuronal activity
    Hypometabolic state
  • 17. pathophysiology
  • 18. OvervieW
    Concussion fundamentals
    Epidemiology and pathophysiology
    Management
    Return to play
    Sequelae
    Prevention
  • 19. 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
  • 20. S.A.C.
    • Example of standardized tool for the sideline evaluation of athletes who suffer a head injury
    • 21. “AAOx3” found to NOT be reliable method of screening
  • Signs and Symptoms
    • hallmarks are confusion, amnesia often without preceding LOC
    • 22. LOC occurs <10% but important sign that may herald need for further imaging/intervention
    Physical
    Headache
    Nausea
    Vomiting
    Balance problems
    Visual problems
    Fatigue
    Photosensitivity
    Phonosensitivity
    “Dazed”
    “Stunned”
    Cognitive
    • Mental “fogginess”
    • 23. Feeling slowed down
    • 24. Difficulty concentrating
    • 25. Difficulty remembering
    • 26. Amnesia
    • 27. Repeats questions
    • 28. Speaks slowly
    Emotional
    Irritability
    Sadness
    More “emotional”
    Anxiety
    Sleep
    Drowsiness
    Altered sleep patterns
    Difficulty falling asleep
  • 29. Westmead post-traumatic amnesia scale
    □ 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
    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
  • 30. 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 syndromeabnlSPECT and PET scans.
  • 31. 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
  • 32. Vol 374 No 9696 October 3, 2009
    Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Kupperman et al
    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
    BATTLE’S SIGN
    • 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
    • 33. ** haemotympanum, ‘racoon’ eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle's sign
  • Vol 357 No 9266 May 5, 2001
    The Canadian CT Head Rule for patients with minor head injury Stiell et al
    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)
  • 34. Glasgow coma scale
  • 35. 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
  • 36. 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?
  • 37. OvervieW
    Concussion fundamentals
    Epidemiology and pathophysiology
    Management
    Return to play
    Sequelae
    Prevention
  • 38. 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
  • 39. Step-wise Return to play
    Graduate to following step after >24 hours without symptoms
    Return to previous step if symptoms recur
    Return to play!
  • 40. 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
  • 41. Impact test clinical report
  • 42.
    • Run by Department of Neuropsychology
    • 43. Departments of
    • 44. Neurology
    • 45. Neuropsychiatry
    • 46. Sports Medicine
    • 47. Physical Therapy
    • 48. Uses ImPACT testing
  • OvervieW
    Concussion fundamentals
    Epidemiology and pathophysiology
    Management
    Return to play
    Sequelae
    Prevention
  • 49. sequelae
    second impact syndrome
    post concussion syndrome
    cumulative neuropsychologic impairment
    post-traumatic epilepsy
    post-traumatic headaches
    post-traumatic vertigo
    other cranial nerve injuries
  • 50. 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
  • 51. VIDEO
  • 52. legislation
    In 2006, a 13 year old named ZackeryLystedt 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 “ZackeryLystedt 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
  • 53. 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
  • 54. p.C.S. symptoms
  • 55. Epidemiology of Postconcussion Syndrome in Pediatric Mild Traumatic Brain Injury -Barlow, et. al.
    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.
  • 56. 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
  • 57. 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 incudingneurofibrillary tangles, amyloid plaques
    ApoE genotype and tau isoforms also may play a role
  • 58. OvervieW
    Concussion fundamentals
    Epidemiology and pathophysiology
    Management
    Return to Play
    Sequelae
    Prevention
  • 59. 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!
  • 60. 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
  • 61. 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
  • 62. Andy
    1/2
    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
  • 63. Andy
    2/2
    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?
  • 64. references
    1/2
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    Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503
    McKeag DB. Understanding sports-related concussion: coming into focus but still fuzzy. JAMA.2003;290 (19):2604 –2605
    Shores, EA, Lammél, 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 NeurolNeurosurg Psychiatry 2008; 79:1100.
    Levin, HS, O'Donnell, VM, Grossman, RG. The Galveston Orientation and Amnesia Test. A practical scale to assess cognition after head injury. J NervMentDis 1979; 167:675.
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    Anderson V, Moore C. Age at injury as a predictor of outcome following pediatric head injury: a longitudinal perspective. Child Neuropsychol. 1995;1 :187 –202
    Cantu RC. Work-up of the athlete with concussion. Am J Med Sports. 2002;4 :152 –154
    Randolph C, McCrea M, Barr WB. Is neuropsychological testing useful in the management of sport-related concussion? J Athl Train. 2005;40 :139 –152
    Ponsford J, Willmott C, Rothwell A, et al. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001;108 :1297 –1303
    Kraus JF. Epidemiological features of brain injury in children: occurrence, children at risk, causes and manner of injury, severity, and outcomes. In: Broman SH, Michel ME, eds. Traumatic Head Injury in Children. New York, NY: Oxford University Press; 1995
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  • 66. The end!
  • 67. 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