Tackling Sports Concussions Head On


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Tackling Sports Concussions Head On

  1. 1. Tackling Sports Concussions Head On H dO Jeffrey Rosenberg MD Sports Medicine September 5 2012 5,
  2. 2. Traumatic Brain Injury j yConcussions are one type ofTBI Diffuse Injury, No Anatomic ChangesFocal Brain Injury-MoreSevere Subdural Hematoma, Epidural Hematoma, Intra- cerebral Hematoma Associated with Anatomical Change Blood, Change-Blood, Fluid, Local Damaged Tissue
  3. 3. Myth #1: Only Football Players Get Concussions>170,000>170 000 Sports and RecreationsTBI/year from birth to 19 yoER visits increased by 60%Birth to 9 yo: Playground andBicycle Related Injury y j y9% of all sports related injuriesMale 10-19 yo: Football Bicycling 10 19 Football,Female 10-19 yo: Soccer,Basketball,Basketball Bicycling
  4. 4. Silent Epidemic Up to 50% of concussions not reported Athletes hide symptoms, dont report any problems Coaches want the players to play − Athletic Trainer, not coach has the , final say Parents play down severity to let the athlete participate More d cu t to ignore in NJ as o o e difficult g oe J of 2011 regulations
  5. 5. Myth #2:Can only get Concussion if Hit in the HeadDirect blow most common− Helmet to Helmet; Head to other Body Part − G Ground dIndirect Forces Linear or rotational forces Getting hit from the side in the bodyBrain cell injury and dysfunctionNo anatomic damage
  6. 6. Brain InjuryTrauma causes brain tissue to releasechemicals: Calcium/Glutamate− Increases need for blood flow for metabolism to recover from injury− Unfortunately, the arteries are constrictedImbalance between metabolic needs andblood flow into the brain
  7. 7. Myth #3: Cant be a concussion if you arent knocked out aren tOnly 10% of concussions have LOC“Got my Bell Rung”− If any symptoms, this is a concussion as well symptomsSymptoms may not start immediately aftertheth hitSeizure activity at injury very scarey butnot permanent
  8. 8. Loss of ConsciousnessIf LOC continues need to start ABC continues,protocolAssume cervical spine injuryUsually LOC is seconds only
  9. 9. ConfusionHallmark symptom of TBI is confusionEyes glassy, loss of focusIncoherent speechI h t hGoing to wrong teams huddleMemory Loss− Loss of memory prior to event-retrograde amnesia− Loss of future memory-anterograde amnesia
  10. 10. Myth #4: Of course he can play doc next week, week he only has a concussionLoss of consciousness, Amnesia, Confusionused to be used to grade concussions− These grades would determine return to playNo data to support the grading systems− 15 different systems− No longer usedTreat each concussion individually− Symptoms must completely resolve prior to return to activitiesDing sDings matter
  11. 11. Second Impact SyndromeContinued symptoms sign thatbrainb i metabolism not yet normal t b li t t lWith additional injury (even mild)the blood vessels open wide whichincreases the pressure in the brain− Coma, Death− 10-15 die a year <19 yo− Younger the brain, more susceptibleThis is why conservative in youth y ysports, JH, HS sports
  12. 12. Myth #5: Johnny will be ready by next weekEach concussion is different, hard topredictLonger recovery with repeatedconcussions iYounger patients typically need moretimeNone the less, most better with 5-7 days ySame day return to play no longerrecommended for youth sports y p− If College athlete or Pro, maybe
  13. 13. Sideline AssessmentAssess symptoms: headache, confusion,nausea, vision i iNeurological Exam− Pupillary Response− ROM/Strength− Balance/CoordinationSCAT− Orientation− Memory y− Confusion
  14. 14. Sideline AssessmentTake HelmetDone for the dayATC or MD will re-evaluate every 15 20 ill l t 15-20mins to make sure things are worsening− If so, off to the ER f ffIn New Jersey, coaches, refs have duty tomake athletes sit if any concern
  15. 15. Red Flag Symptoms• Headaches that worsen• Look very drowsy, can’t be awakened drowsy can t• Can’t recognize people or places• Unusual behavior change g• Seizures• Repeated vomiting• Increasing confusion• Increasing irritability• Neck pain• Slurred speech• Weakness or numbness in arms or legs• Loss of consciousness
  16. 16. Myth #6: We need to go to the ERGenerally not neededIf significant LOC confusion or worsening LOC, confusion,mental state− CT and MRI are always normal by definition− If neurological status worsens must be imaged to r/o bleedNo longer recommend waking up athlete everyhour over night − Observe for unusual breathing patterns or atypical movements (jerking, tremor, convulsions)
  17. 17. Myth #7-Captain looks fine so he didnt have a concussionUnlike physical injury, its hard to see theinjuryi j− No post game activitiesTreatment of concussion− Rest, Rest, Rest− Brain Rest, Physical Rest− Quite, Dark− NSAIDs/Tylenol for headache− No electronics, phones, texting, computers, g etc
  18. 18. Brain RestIf minimal sx ok to go to school monday− Most athletes will need to miss some school− Schools finally understanding and are required to complyTake to MD on monday or tuesday for eval
  19. 19. Complications to Recovery p y Concussion History Headache History Developmental History Hi t Psychiatric History
  20. 20. Post ConcussionEvery patient has different set of symptomsPhysical− Headaches, N/V, FATIGUE, Balance, SensitivityThinking− Mentally Foggy, Concentration, Memory, SlowEmotional− Irritability, Sadness, Nervous, More EmotionalSleep− Drowsiness, Sleep more or Less, Difficult sleeping l i
  21. 21. Post ConcussionLet the child sleep, Daytime Naps p, y precommended at the beginningEat and stay hydratedLimit Activities requiring thinking orconcentrating− Read, TV, Computer, etcWatch the grass growDo not attend anything with flying objectsor potential f repeated injury t ti l for t di j
  22. 22. Post ConcussionNot much the parents can do to help otherthan provide emotional support interact support,with school nurse and administrationFrustration can kick inSchool provide tutoring > 5 daysReturning to school can be gradual− Part time− No gym or sports− Breaks in nurses station− Lunch in quiet place
  23. 23. Myth #8: There are no treatment for concussions conc ssionsInsomnia-MelatoninEmotional symptoms− Role for amitriptyline/SSRI pyPhysical symptoms− Balance can improve with vestibular therapyConcentration− ADHD medicationsAmantidineNuvigilN i il
  24. 24. Return to PlayAll physical sx must be goneIMPACT scores return tobaselineMedical clearance55-7 day return to p ay etu playprotocol− Start with minimal exertion− Progress daily− If symptoms reoccur must return to previous step
  25. 25. ImPACT TestingFocused neuropsychiatric,computer based testMemory, Coordination,Memory CoordinationConcentrationPreseason Testing Optimal@2 days post injury canprovide prognosis id iWhen symptoms are gone toconfirm brain function normal
  26. 26. Myth #9 (from the NFL/NHL) No long t N l term risk f i k from concussions iWith each concussion, repeated injuries , p joccur with less force, symptoms lastlonger, more difficult to return to sport g pSymptoms may be life longRetire from sports
  27. 27. Chronic Traumatic Encephalopathy Pathological changes in brain from multiple, b i f li l usually mild, injuries (even dings) dings ) − Deposits of protein similar to Alzheimers Alzheimer s Collision sports Substance abuse Dementia, Depression, Death Violent Suicide
  28. 28. Chronic Traumatic Encephalopathy Families of NFL players donating brain tissue after suicide/death 18/19 had CTE Huge lawsuits in future