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 Advisor for Clinical Research Georgetown U School Of Medicine Professor of Biology Georgetown University Research Director: Georgetown/WHC EM Residency Clinical Director MedStar Emergency and Trauma Concussion Program Wash, DC Concussion Diagnosis , Treatment and Follow Up •Definition: 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 Don’t 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 !! Ice Hockey #3 sport for mTBI 16 year old male Injury - Elbowed In Forehead During Hockey Game Initially, No Symptoms, Returned to Ice for 1 shift, But Within 10 Minutes, Became “Foggy” With Poor Concentration, Memory, Dizziness Subsequent Loss Of Memory For Event, Irritability, Headaches, Reduced Energy, Sensitive To Light And Noise, Sleeping More Than Usual, Poor Balance Initial Eval, RX and TX 10th grade honors student Seen in the ED and sent Home for 1 week no school, lots of sleep , Motrin and Fluids No texting no gaming, light TV and reading Concussion Clinic at Day 7 & 14 Neuropsychological Concussion Evaluation initially demonstrated: Poor attention Poor “working memory” Slowed processing speed Reduced reaction time By 14 days, excellent recovery & return to “baseline” values What Works in Student Athletes Educate and guide the family and patient and the primary care doctor Make recommendations for initial accommodations in school Kept him safe by managing his gradual return to School and Sports The Easy Decision and return is Sport Return to Learn is NOT Automatic, Know This , Practice This ; If Nothing Else, Give all 3 Day Total Rest. Epidemiology - Concussion Most frequent diagnosis in injured child is: HEAD INJURY TBI Every 11 minutes 1 child in the US has a brain injury resulting in permanent disabilities or 35,000 annually 5,000,000 children with head injuries 3.8 million concussions/annually Emergency Department Visits ~ 90%: mild TBI/ GCS 14-15 Majority with mTBI sent home from ED STATISTICS Incidence in HS football = 6%-8% per year. Boy’s + Girl’s soccer = football. Girl’s basketball 250% greater risk than Boy’s Sports and recreational injuries with LOC = 300,000 per year. Sports and recreational injuries with and DEFINITION Complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces. COMMON FEATURES Caused 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. PATHOPHYSIOLOGY Mechanism of Injury Rotational Much Worse than Linear Impact deceleration Chemical/Vascular 1st 7-10 days ↑K / ↑Ca / ↑glc / ↑glut ↓CBF “Period of vulnerability” Anatomical Timeline of a Concussion Defining the Key Factors C. Risk Factors A. Injury Characteristics B. Symptom Assessment CONCUSSION Pre-Injury Risks Retrograde Amnesia 20-35% Sec-Hrs LOC <10% Anterograde Amnesia 25-40% Sec-Min Sec-Hrs Neurocog dysfx & Post-Concuss Sx’s Hours - Days - Weeks+ Clinical Protocol Neurocognitive Testing Pre-Concussion Baseline Testing 1-3 Days Day 5-10 Day 12-16 Concussion *Barth et al., 2002 Pre-Concussion Baseline Testing Concussion Symptoms Cognitive Functions NEUROCOGNITIVE COMPUTERIZED TESTING ImPACT (UPMC) CogSport (Australia) CRI (Headminder) ANAM (NRH) OVERVIEW OF ImPACT Proven in measures of reliability and validity Provides useful concussion screening and management information Validated with multiple peer-reviewed studies Does not substitute for medical evaluation and treatment Does not substitute for comprehensive neuropsychological testing IMMEDIATE POSTCONCUSSION ASSESSMENT and COGNITIVE TESTING (ImPACT) 8 separate tests Word memory Design memory X’s and O’s Symbol Match Color Match Three Letters Interference tests 6 composite scores Verbal memory Visual memory Visual motor speed Reaction time Impulsivity Total symptom score COMPUTERIZED TESTING Format 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. CONCUSSION SYMPTOM SCALE Standardized survey with 0-6 scale rating Developed by Lovell and Collins in 1998 Sensitive tool to measure recovery Symptoms generally classified into 3 main categories: Physical, Cognitive, and Emotional/Behavioral 4 Symptom Categories Physical • • • • • • Headache Fatigue Dizziness Sensitivity to light and/or noise Nausea Balance problems • Cognitive • Difficulty remembering • Difficulty concentrating • Feeling slowed down • Feeling mentally foggy Emotional • • • • Irritability Sadness Feeling more emotional Nervousness • Sleep • Drowsiness • Sleeping less than usual • Sleeping more than usual • Trouble falling asleep GENERAL MANAGEMENT Majority 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 play—NEVER!!! PREDICTING RECOVERY TIMELINES ALL ATHLETES ARE NOT CREATED EQUALLY CONCUSSION MODIFIERS Threshold—Repeated concussions occurring with less force or slower recovery. Age—Child and adolescent < 18 years old. Co-morbidities—Migraine, depression or other mental health disorders, ADHD, learning disabilities and sleep disorders. Medication—Psychoactive drugs and anticoagulants. Behavior—Style of play. Sport—Contact or collision sport, high-risk. RETURN TO PLAY PROTOCOL No activity while symptomatic. Light aerobic exercise. Sport-specific exercise—no head impact drills. Non-contact training drills. Full contact practice. Return to game play. Recovery From Concussion: How Long Does it Take? 100 90 80 70 60 50 40 30 20 10 0 WEEK 5 WEEK 4 WEEK 1 WEEK 3 WEEK 2 1 3 5 All Athletes 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+ No Previous Concussions N=134 High School athletes 1 or More Previous Concussions Collins et al., 2006, Neurosurgery Clinicians’ Return to Play Decisions 100 80 ATC used GSC, SAC, BESS (testing w/ symptom report) 60 40 20 ATC used only GSC (player symptom report) 00 Marshall, Guskiewicz, & McCrea; In Review, 2006. NFL CONCUSSION GUIDELINES 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. CHRONIC TRAUMATIC ENCEPHALOPATHY CHRONIC TRAUMATIC ENCEPHALOPTHY NFL Survey— > 50 = 5x risk 30-49 = 19x risk Comparative data from the Framingham heart study. Concept of subconcussive trauma. 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 experiencing in school?” Students reported an average of 4 problems below. Headaches interfering 71.3% Can’t 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% Concussion’s Effects on School Learning & Performance “Which classes are you having the most trouble with?” (Percent reporting trouble in class) Math Reading/LA Science Soc Stud Foreign Lang Music PE Art -None Parent Student 60.3% 38.1% 38.1% 38.1% 38.1% 6.3% 7.9% 3.2% 25.4% 73.7% 46.1% 47.4% 40.8% 38.2% 17.9% 10.5% 5.3% 6.6% General Principles of Recovery No additional forces to head/ brain Resting the brain & getting good sleep Managing/ facilitating physiological recovery Avoid activities that produce symptoms Not over-exerting body or brain Ways to over-exert Physical Cognitive! (concentration, learning, memory) (Emotional) Even taking Neuro-Cognitive Testing is ContraIndicated in Symptomatic Patient Consensus Statement on Concussion in Sport 4th International Conference on Concussion in Sport held in Zurich, November 2012 CURRENT BEST REVIEW TILL APRIL 2013 Zurich CIS Consensus Concussion Management Physical AND Cognitive Rest 48-72 Hours Graduated RTP: when asymptomatic at rest stepwise 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 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. 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. # of Concussions Concussion & Imaging 2000-2011 200 100% 180 90% 160 80% 140 70% # Concussion 120 60% CT 100 50% MRI 80 40% 60 30% 40 20% 20 10% 0 0% 2000 2001 2002 2004 2005 2006 2007 Year 2008 2009 2010 2011 2012 Media and Medicine for Concussion Chart Title # of Articles 600 500 30 Google Hits (millions) 25 400 20 300 15 200 10 100 5 0 1995 2000 2005 Year 2010 0 2015 Journal Articles Google Query 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 Visits CT and MRI Increased In Use With No Improved Treatment Intervention. Controversy over CT for Minor TBI Arguments for liberal use of CT: • 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… Investigations Neuroimaging (CT, MRI) Contributes little to concussion evaluation Use when suspicion of intracerebral structural lesion exists: prolonged loss of consciousness focal neurologic deficit worsening symptoms Deterioration in conscious state MRI still not proven benefit aids detection not treatment. Controversy over CT for Minor BHT Arguments against liberal use of CT: • 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 Lifetime Cancer Mortality Risk NEJM, Brenner et al. Lifetime cancer mortality risk with single CT head in year 1 of life: i-V PECARN Prediction Rules Age 2 years and older GCS < 15 or abnormal mental status LOC History of emesis Severe mechanism of injury Signs of basilar skull fracture Severe headache Kuppermann/Holmes/Dayan/Hoyle/Atabaki et al 2009 Ja n1 Fe 0 bMa 10 r-1 Ap 0 rMa 10 y1 Ju 0 n1 Ju 0 lAu 10 gSe 10 p1 Oc 0 tNo 10 vDe 10 c1 Ja 0 n1 Fe 1 bMa 11 r-1 Ap 1 rMa 11 y1 Ju 1 n1 Ju 1 lAu 11 gSe 11 p1 Oc 1 tNo 11 vDe 11 c1 Ja 1 n12 Proportion of BHT Patients with CT Performed 35% Intervention 30% 25% 20% y = -0.0138x + 0.258 R2 = 0.7621 y = 0.0002x + 0.2394 R2 = 0.0002 15% 10% 5% 0% Results—Positive CT Proportion* * Preliminary data. O.R. = 3.01 (95% CI 2.07-4.37) Traumatic Brain Injury Glasgow Coma Scale “Minimal” Mod Mild Severe ? Severe Sports concussion GCS ≤ 8 Moderate GCS 9 - 12 Mild GCS 13 - 15 Teasdale et al Lancet 1974; Distribution of Head Accelerations Div I American Football (3 teams, 4 seasons) 20g – buddy head butt 300+ g recorded Crisco et al, 2012 51 52 “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.” 53 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 seasons • 44 injuries were diagnosed by a Certified Athletic54 Trainer as a concussion • 34 (77%) cases had sufficient image quality for analysis 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 Unanticipated (“defenseless hit”) 19 56 Anticipated – good body position 8 24 Anticipated – poor body position 5 15 Struck player readiness for contact 55 Comparison of Concussion Injuries in Boys’ and Girls’ Lacrosse Characteristics Boys Girls 22 (65%) 14 (100%) **32 (94%) 1 (7%) Stick (unintentional) 0 *5 (36%) Stick (intentional) 0 *3 (21%) 2 (6%) *3 (21%) Ball 0 1 (7%) Undetermined 0 1 (7%) 25 (73%) 10 (71%) Level of play Varsity Concussion mechanism Body check Collision (unintentional) Penalty called No 56 Common injury scenario (Pre-injury) 57 58 59 60 Concussion Causation in Lax • • • • • Player-to-player contact was the mechanism for all concussions in males. > 75% --The striking player used his head to initiate impact >50% ---The struck player’s 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 61 Sideline And ED Assessment of Concussion Examine, Don’t Rely on Imaging Sideline Tool Pocket SCAT2 Also Best for the ED Aids to sideline assessment Knowing the patient Systematic examination Repeating the examination Components of exam Observation and history Delay Assessment 10-15 min after occurrence. Mini mental status (baseline tests ideal) Orientation Memory Concentration Symptom check list Neurological exam Cranial nerve Balance - BESS (baseline tests ideal) Balance Error Scoring System 3 Positions Hold each with Eyes closed for 20 seconds Mean Baseline Score is 3 pts Double leg, tandem stance (dominant foot forward), single leg stance (non-dominant foot) Hands on hips, eyes closed, 20 second trials, count errors Hands lifted off hips, open eyes, step/stumble, hip move > 30 degrees abduction, forefoot/heel lift, out of position > 5 seconds BESS Positions ERROR Points Double Leg Stance 0.09 Single Leg Stance 2.45 Tandem Stance 0.91 Surface Total = 3.37 Novel approaches to sideline assessment Quantitative EEG (10-12 minutes) (Brainscope) 1. Brain Sentry is an Accelerometer 2. It picks up a Impact Force > 70 g 3. The Problem Is That You Want To Never Miss A Concussion, But Don’t Want To Have Too Many False Positive But Optimally No False Negative. ACCURACY is Key Best Can DO : 75-80% Sensitivity 35%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, 1984 Rare Most commonly seen in adolescents Can be fatal November 10, 2012 72 Second Impact Syndrome Athlete suffers a concussion (typically grade 1 or 2) Most are 12-16 yo Still suffering from symptoms of concussion and returns to play Suffers a second concussion Second blow may be remarkably minor, sometimes not directly to the head, but causing the athlete’s head to snap which imparts accelerative forces to the brain The 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 73 consciousness Second Impact Syndrome Disordered cerebral autoregulation of cerebral blood flow vascular engorgementincreased ICPBrainstem herniation Rapid Development of coma, ocular involvement, and respiratory failure ensue Mortality 50-100% due to brainstem herniation Never Diagnosed in ED, Always in Extremis on Presentation, < 30 in 30 yrs. 74 November 10, 2012 75 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. 76 Risk Factors for Complicated Post Concussion Syndrome 9 Medications in Concussion There are NO medications which are FDA approved for “concussion” or “mild TBI” What are some possible indications for medications? Existing Medication Should be Continued. i.e. ADHD, Depression, etc. No Literature Exists Finding Improved Outcomes in RCT 78 Medications in Concussion When to start Headache: acute, subacute, chronic Vertigo: acute if severe; unable to tolerate therapy/function All other indications should only be treated with medications if Fail therapy/non-pharmacological management Persistent 79 Concussion Clinic Patients seen within 1 week of referral Brain Injury Physician Neuropsychologist ImPACT testing/Neuropsych evaluation Patient/family education Return to sports (work, school, etc.) recommendations Follow up for persistent symptoms 80 Management CORNERSTONE = rest until asymptomatic Rest from activity No training, playing, exercise, weights Beware of exertion with activities of daily living Cognitive rest No television, extensive reading, video games? Caution re: daytime sleep REST = ABSOLUTE REST! Sports concussion Follow-up Management Rest Rest Rest Expect gradual resolution in 7-10 days Start graded exercise rehabilitation when asymptomatic at rest and post-exercise challenge Recovery How long asymptomatic before exercise? If rapid and full recovery, then 24-48 hours One 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. Symptom Categories RTP:Graded Exertion Protocol 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 • 24 hours per step • If recurrence of symptoms at any stage, return to previous Coach/ Player/ Parent Concern: Isn’t this Concussion program going to hold my players out longer? Questions?