Concussion in the EDWhat You Know, Need to Know and Better Know to make Correct TreatmentDave Milzman, MD FACEPProfessor of Emergency MedicineSenior Advisor for Clinical ResearchGeorgetown U School Of MedicineProfessor of Biology Georgetown UniversityResearch Director: Georgetown/WHC EM Residency

Clinical Director MedStar Emergency and Trauma Concussion ProgramWash, DC

ConcussionDiagnosis , Treatment and Follow UpDefinition: 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 Dont 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 maleInjury - Elbowed In Forehead During Hockey GameInitially, No Symptoms, Returned to Ice for 1 shift, But Within 10 Minutes, Became Foggy With Poor Concentration, Memory, DizzinessSubsequent Loss Of Memory For Event, Irritability, Headaches, Reduced Energy, Sensitive To Light And Noise, Sleeping More Than Usual, Poor Balance

Initial Eval, RX and TX10th grade honors student Seen in the ED and sent Home for 1 week no school, lots of sleep , Motrin and FluidsNo texting no gaming, light TV and reading Concussion Clinic at Day 7 & 14Neuropsychological Concussion Evaluation initially demonstrated:Poor attentionPoor working memorySlowed processing speedReduced reaction timeBy 14 days, excellent recovery & return to baseline values

What Works in Student AthletesEducate and guide the family and patient and the primary care doctorMake recommendations for initial accommodations in schoolKept him safe by managing his gradual return to School and SportsThe Easy Decision and return is SportReturn to Learn is NOT Automatic, Know This , Practice This ; If Nothing Else, Give all 3 Day Total Rest.

Epidemiology - ConcussionMost frequent diagnosis in injured child is: HEAD INJURY TBIEvery 11 minutes 1 child in the US has a brain injury resulting in permanent disabilities or 35,000 annually5,000,000 children with head injuries 3.8 million concussions/annually Emergency Department Visits~ 90%: mild TBI/ GCS 14-15Majority with mTBI sent home from ED

STATISTICSIncidence in HS football = 6%-8% per year.Boys + Girls soccer = football.Girls basketball 250% greater risk than BoysSports and recreational injuries with LOC = 300,000 per year.Sports and recreational injuries with and without LOC = 1.6 million per year.

DEFINITION

Complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces.

COMMON FEATURESCaused 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.

PATHOPHYSIOLOGYMechanism of InjuryRotational Much Worse than LinearImpact decelerationChemical/Vascular1st 7-10 daysK / Ca / glc / glutCBFPeriod of vulnerability

Anatomical Timeline of a ConcussionDefining the Key FactorsLOC

1-3 DaysDay 5-10Pre-Concussion Baseline TestingDay 12-16*Barth et al., 2002ConcussionClinical ProtocolNeurocognitive Testing

ConcussionPre-Concussion Baseline TestingSymptomsCognitiveFunctions

NEUROCOGNITIVE COMPUTERIZED TESTING

ImPACT (UPMC)

CogSport (Australia)

CRI (Headminder)

ANAM (NRH)

OVERVIEW OF ImPACT

Proven in measures of reliability and validityProvides useful concussion screening and management informationValidated with multiple peer-reviewed studiesDoes not substitute for medical evaluation and treatmentDoes not substitute for comprehensive neuropsychological testing

IMMEDIATE POST-CONCUSSION ASSESSMENT and COGNITIVE TESTING (ImPACT)

8 separate testsWord memoryDesign memoryXs and OsSymbol MatchColor MatchThree LettersInterference tests

6 composite scoresVerbal memoryVisual memoryVisual motor speedReaction timeImpulsivityTotal symptom score

COMPUTERIZED TESTINGFormat 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 SCALEStandardized survey with 0-6 scale rating Developed by Lovell and Collins in 1998Sensitive tool to measure recoverySymptoms generally classified into 3 main categories: Physical, Cognitive, and Emotional/Behavioral

4 Symptom CategoriesPhysicalHeadacheFatigue Dizziness Sensitivity to light and/or noiseNauseaBalance problemsEmotionalIrritabilitySadnessFeeling more emotionalNervousness Cognitive Difficulty remembering Difficulty concentrating Feeling slowed down Feeling mentally foggy Sleep Drowsiness Sleeping less than usual Sleeping more than usual Trouble falling asleep

GENERALMANAGEMENTMajority 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 playNEVER!!!

PREDICTING RECOVERY TIMELINESALL ATHLETES ARE NOT CREATED EQUALLY

CONCUSSIONMODIFIERSThresholdRepeated concussions occurring with less force or slower recovery.AgeChild and adolescent < 18 years old.Co-morbiditiesMigraine, depression or other mental health disorders, ADHD, learning disabilities and sleep disorders.MedicationPsychoactive drugs and anticoagulants.BehaviorStyle of play.SportContact or collision sport, high-risk.

RETURN TO PLAY PROTOCOLNo activity while symptomatic.Light aerobic exercise.Sport-specific exerciseno head impact drills.Non-contact training drills.Full contact practice.Return to game play.

Recovery From Concussion:How Long Does it Take?N=134 High School athletesWEEK 1WEEK 2WEEK 3WEEK 4WEEK 5Collins et al., 2006, Neurosurgery

Clinicians Return to Play Decisions1008060402000ATC used GSC, SAC, BESS (testing w/ symptom report)ATC used only GSC (player symptom report)Marshall, Guskiewicz, & McCrea; In Review, 2006.

NFL CONCUSSIONGUIDELINES

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 ENCEPHALOPTHYNFL Survey> 50 = 5x risk30-49 = 19x riskComparative data from the Framingham heart study.Concept of subconcussive trauma.Sports Legacy Institute.

Concussions Effects on School Learning

Return to School

Concussions 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% Cant 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%

Concussions Effects on School Learning & Performance Which classes are you having the most trouble with?(Percent reporting trouble in class) Parent Student Math 60.3% 73.7% Reading/LA 38.1% 46.1% Science 38.1% 47.4% Soc Stud 38.1% 40.8% Foreign Lang 38.1% 38.2% Music 6.3%17.9% PE 7.9%10.5% Art 3.2%5.3% -None25.4% 6.6%

General Principles of RecoveryNo additional forces to head/ brain Resting the brain & getting good sleepManaging/ facilitating physiological recoveryAvoid activities that produce symptomsNot over-exerting body or brainWays to over-exertPhysicalCognitive! (concentration, learning, memory)(Emotional)Even taking Neuro-Cognitive Testing is Contra-Indicated in Symptomatic Patient

4th International Conference on Concussion in Sport held in Zurich, November 2012Consensus Statement on Concussion in Sport

CURRENT BEST REVIEW TILL APRIL 2013

Zurich CIS ConsensusConcussion ManagementPhysical AND Cognitive Rest 48-72 HoursGraduated RTP: when asymptomatic at reststepwise 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.MedStar Sport Concussion Center; 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.

Concussion & Imaging 2000-2011

Media and Medicine for Concussion

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 VisitsCT and MRI Increased In Use With No Improved Treatment Intervention.

Controversy over CT for Minor TBI Preventable morbidity/mortality due to unrecognized TBIsCT provides visual information about the skull and the brainPreverbal children difficult eval.When indicated, benefit of CT greatly outweighs risk, however

Arguments for liberal use of CT:

InvestigationsNeuroimaging (CT, MRI)Contributes little to concussion evaluationUse when suspicion of intracerebral structural lesion exists:prolonged loss of consciousnessfocal neurologic deficitworsening symptomsDeterioration in conscious stateMRI still not proven benefit aids detection not treatment.

Controversy over CT for Minor BHT 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

Arguments against liberal use of CT:

Lifetime Cancer Mortality RiskNEJM, 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 olderGCS < 15 or abnormal mental statusLOC History of emesisSevere mechanism of injurySigns of basilar skull fractureSevere headache

Kuppermann/Holmes/Dayan/Hoyle/Atabaki et al 2009

ResultsPositive CT Proportion** Preliminary data. O.R. = 3.01 (95% CI 2.07-4.37)

Traumatic Brain Injury ModMild Severe Severe GCS 8Moderate GCS 9 - 12Mild GCS 13 - 15

Teasdale et al Lancet 1974;Sports concussion?MinimalGlasgow Coma Scale

*Distribution of Head AccelerationsDiv I American Football (3 teams, 4 seasons)

20g buddy head butt300+ g recorded Crisco et al, 2012

*

*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.

*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 seasons44 injuries were diagnosed by a Certified Athletic Trainer as a concussion34 (77%) cases had sufficient image quality for analysis

Impact Characteristics of Concussion Injuries in Boys Lacrosse, 2008-2009 (n=34)*

CharacteristicFrequency (n)Percentage (%)Primary injury mechanism - Bodily collision34100Striking player26Struck player23**68Both players926Secondary impact head/body to ground2471Impact source (striking player)Head27**79Upper extremity/shoulder721Stick/ball00Struck player readiness for contactUnanticipated (defenseless hit)1956Anticipated good body position824Anticipated poor body position515

Comparison of Concussion Injuries in Boys and Girls Lacrosse*

Common injury scenario (Pre-injury)*

*

*

*

Concussion Causation in LaxPlayer-to-player contact was the mechanism for all concussions in males. > 75% --The striking player used his head to initiate impact>50% ---The struck players 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*

Sideline And ED Assessment of Concussion

Examine, Dont Rely on Imaging

Sideline ToolPocket SCAT2Also Best for the ED

Aids to sideline assessmentKnowing the patientSystematic examinationRepeating the examination

Components of examObservation and history Delay Assessment 10-15 min after occurrence.Mini mental status (baseline tests ideal)OrientationMemory Concentration Symptom check listNeurological examCranial nerveBalance - BESS (baseline tests ideal)

Balance Error Scoring System3 Positions Hold each with Eyes closed for 20 seconds Mean Baseline Score is 3 ptsDouble leg, tandem stance (dominant foot forward), single leg stance (non-dominant foot) Hands on hips, eyes closed, 20 second trials, count errorsHands lifted off hips, open eyes, step/stumble, hip move > 30 degrees abduction, forefoot/heel lift, out of position > 5 seconds

BESS Positions ERROR PointsDouble Leg Stance 0.09Single Leg Stance 2.45Tandem Stance 0.91Surface Total = 3.37

Novel approaches to sideline assessmentQuantitative EEG (10-12 minutes) (Brainscope)

Brain Sentry is an AccelerometerIt picks up a Impact Force > 70 g3. The Problem Is That You Want To Never Miss A Concussion, But Dont Want To Have Too Many False Positive But Optimally No False Negative.ACCURACY is Key Best Can DO : 75-80% Sensitivity 35%Specificty

Whats the worst thing that can happen to my son?

[Father of football player with multiple concussions in one season, 2003]

Second Impact SyndromeDescribed by Saunders & Harbaugh, 1984RareMost commonly seen in adolescentsCan be fatalNovember 10, 2012*

Second Impact SyndromeAthlete suffers a concussion (typically grade 1 or 2) Most are 12-16 yoStill suffering from symptoms of concussion and returns to playSuffers a second concussionSecond blow may be remarkably minor, sometimes not directly to the head, but causing the athletes head to snap which imparts accelerative forces to the brainThe 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 consciousness*

Second Impact SyndromeDisordered cerebral autoregulation of cerebral blood flow vascular engorgementincreased ICPBrainstem herniationRapid Development of coma, ocular involvement, and respiratory failure ensueMortality 50-100% due to brainstem herniationNever Diagnosed in ED, Always in Extremis on Presentation, < 30 in 30 yrs.*

November 10, 2012*

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.*

Risk Factors for Complicated Post Concussion Syndrome9

Medications in ConcussionThere are NO medications which are FDA approved for concussion or mild TBIWhat are some possible indications for medications?Existing Medication Should be Continued.i.e. ADHD, Depression, etc. No Literature Exists Finding Improved Outcomes in RCT*

Medications in ConcussionWhen to startHeadache: acute, subacute, chronicVertigo: acute if severe; unable to tolerate therapy/functionAll other indications should only be treated with medications if Fail therapy/non-pharmacological managementPersistent

*

Concussion ClinicPatients seen within 1 week of referralBrain Injury PhysicianNeuropsychologistImPACT testing/Neuropsych evaluationPatient/family educationReturn to sports (work, school, etc.) recommendationsFollow up for persistent symptoms*

ManagementCORNERSTONE = rest until asymptomatic

Rest from activityNo training, playing, exercise, weightsBeware of exertion with activities of daily livingCognitive restNo television, extensive reading, video games?Caution re: daytime sleep

REST = ABSOLUTE REST!

Sports concussionFollow-up ManagementRestRestRestExpect gradual resolution in 7-10 daysStart graded exercise rehabilitation when asymptomatic at rest and post-exercise challenge

RecoveryHow long asymptomatic before exercise?If rapid and full recovery, then 24-48 hoursOne 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 24 hours per step If recurrence of symptoms at any stage, return to previous step

Rehabilitation stageFunctional exercise at each stage of rehabilitationObjective of each stage1. No activityComplete physical and cognitive rest. Recovery2.Light aerobic exerciseWalking, swimming or stationary cycling keeping intensity < 70% MPHR No resistance training.Increase HR3.Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities.Add movement4.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 load5.Full contact practiceFollowing medical clearance participate in normal training activitiesRestore confidence and assess functional skills by coaching staff6.Return to playNormal game play

Coach/ Player/ Parent Concern: Isnt this Concussion program going to hold my players out longer?

Questions?

Based on statistics from the National Pediatric Trauma Registry: we know:The most frequent diagnosis at the time of an injury to a child or adolescent is: HEAD INJURYThe National Pediatric Trauma Registry gathers information regarding children admitted to hospitals due to traumatic injuries.They have data on 50,000 injury cases.We also know from this data base that:Every 11 minutes 1 child in the US has a brain injury resulting in permanent disabilities (30,000 children/year)Almost 1/2 of children who sustain winter sports injuries are diagnosed with head injury.

**12*12***Within the PECARN network, in a study recently published in the Lancet, we developed 2 prediction rules to identify children at very low risk of clinically important Traumatic Brain Injury after blunt head trauma for whom CT scans would not be routinely necessary.

*Saunders RL, Harbaugh RE: The second impact in catastrophiccontact-sports head trauma. JAMA 1984;252(4):538-539*