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)





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


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


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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
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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
engorgementincreased ICPBrainstem
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?