concussions allyson s. howe, md major, usaf, mc. introduction definition diagnosis evaluation...
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INTRODUCTION DEFINITION DIAGNOSIS
EVALUATION GRADING
MANAGEMENT RETURN TO PLAY REFERRAL CRITERIA CURRENT
GUIDELINES PRAGUE 2004
BOARD QUESTIONS
DEFINITION OF CONCUSSION “A traumatically induced alteration of consciousness”, Robert
Cantu, 1986. A complex pathophysiological process affecting the brain,
induced by traumatic biomechanical forces. Concussion may be caused by either a direct blow to the head,
face, neck, or elsewhere on the body with an ‘impulsive’ force transmitted to the head.
It typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
It results in a graded set of symptoms that may or may not involve loss of consciousness.
Resolution of clinical/cognitive symptoms typically follows a sequential course.
Normal imaging. Prague Conference, 2004.
CONCUSSIONSEPIDEMIOLOGY
Mild traumatic brain injury (MTBI) accounts for 75% of all brain injuries
50,000-300,000 athletes per season “Ding” or “Bell-rung” = concussion but is not
always recognized as such by coaches or athletes
PHYSIOLOGY OF CONCUSSION
Functional disturbance without gross structural injury
Immediately following concussion: Altered ionic fluxes into cells of brain INCREASED brain energy demand
(hyperglycolysis) Decreased cerebral blood flow…? Calcium
mediated As mismatch corrects, symptoms abate
CASE 20-year-old hockey player
in your office on Monday morning
Sustained a hit in a game on Saturday
Had dizziness and headache after the hit for 5 hours
Denies LOC Anterograde amnesia for
15 minutes Here because his coach
wants medical clearance
CASE #1 What else do you want to know? PRIOR CONCUSSION HISTORY Clinical history from witness (Athletic
Trainer) Mechanism of injury
CASEEXAM AT 36 HOURS
On exam: CN II-XII normal Normal visual acuity but
blinks often Normal attention span Normal short term
memory Doesn’t remember hit Positive Romberg FNF, RAM intact
CONCUSSIONSDIAGNOSIS
Generally history of head trauma Direct hit Indirect impulsive force
Neurologic compromise Improves spontaneously Non-focal (usually)
No red flags
CONCUSSIONSRED FLAGS
Young age Confusion lasting > 30 minutes Loss of consciousness > 5 minutes Focal neurologic deficit Deteriorating level of consciousness
CONCUSSIONSCOGNITIVE FEATURES
Cognitive features Unaware of period, opposition, score of game Confusion Amnesia LOC
CONCUSSIONSTYPICAL SYMPTOMS
Headache Balance problem Dizziness Nausea Feeling ‘foggy’ Visual problems Hearing problems Irritability, emotional changes
CONCUSSIONSPHYSICAL SIGNS
LOC or impaired consciousness Poor conduction or balance Convulsion Gait unsteadiness Slow to answer questions, follow directions Easily distracted Emotional disturbance Slurred speech Vomiting Vacant stare
CONCUSSIONSINITIAL EVALUATION
ABCs C-spine precautions Neurologic exam:
Cranial nerves Coordination testing Romberg Strength/sensation ?
CONCUSSIONSINITIAL EVALUATION
Memory testing Attention span: months of year backwards, repeat 5
numbers forwards and backwards Short term: 3 items at 5 minutes Assess for amnesia
Retrograde Anterograde
Consider imaging for prolonged LOC, changing LOC, focal symptoms, prolonged symptoms; clinical judgment important!
CONCUSSIONSNEUROPSYCH TESTING
Objective measure of cognitive status Cognitive improvement may precede or
follow clinical improvement Computer based testing can assess for
performance variability
CONCUSSIONSGRADING
Mild:
grade I
Moderate:
grade II
Severe:
grade III
Cantu
Colorado Consortium
American Academy of Neurology
LOC= Loss of consciousness; PTA= Post-traumatic amnesia
No LOCPTA <30min
LOC <5 minPTA >30min but <24 hrs
LOC > 5 minPTA > 24 hrs
No LOCNo amnesia+ confusion
No LOC+amnesia+confusion
Any LOC
No LOCTransient confusionSymptoms <15min
No LOCTransient confusionSymptoms >15min
Any LOC
CASE Cantu grading:
Grade I concussion, grade II concussion? Colorado and AAN= Grade II concussion
Balance regained after 48 hours Able to run, skate, sprint without symptoms Returned to play (NHL playoffs) at 72 hours (Scored the winning goal in his 2nd game back)
CONCUSSIONSAMNESIA VERSUS LOC
78 athletes with sports related concussion High school (61) and college athletes ImPACT testing pre-season and 2 days
following injury Immediate Post Concussion Assessment and Cognitive Testing
Presence of amnesia more predictive of symptom and neurocognitive deficits than loss of consciousness
Collins MW, et al. On-Field Predictors of Neuropsychological and Symptom Deficit Following Sports-related Concussion. Clinical Journal of Sport Medicine. 2003. 13:222-229.
CONCUSSIONSATHLETE AWARENESS
Athletes don’t realize they have or have had a concussion
328 football, 201 soccer 70.4% football, 62.7% soccer players had
experienced symptoms of concussion in previous year
23.4% football and 19.8% soccer realized they had suffered a concussion
Coaches don’t recognize injury either Players who recognized concussion were more
likely to have had one in the past
Delaney JS, Lacroix VJ, Leclerc S, Johnston KM. Concussions Among University Football and Soccer Players. Clinical Journal of Sports Medicine. 12:331-338. 2002.
CONCUSSIONSRETURN TO PLAY
Step-wise return to activity No activity, complete rest until asymptomatic Light aerobic exercise (walking) Sport-specific training Non-contact training drills Full contact training (after medical clearance) Game play
If athlete becomes symptomatic at any level, drops back to previous level
CONCUSSIONSRETURN TO PLAY
Very clear: no return to play if symptomatic
Grade I concussion most common Remove from play that
day May return once
asymptomatic and can pass exertion drills without symptom recurrence
CONCUSSIONSRETURN TO PLAY
Return to play for Grade I concussion most commonly by 7 days Assumes this is the first
concussion for this athlete this season
Career ending? 2 or 3 grade II or III
concussions in a career
CONCUSSIONSREFERRAL CRITERIA
Acute referral Subdural/epidural
hematoma C-spine injury Deteriorating LOC Focal motor weakness Transient quadriparesis Seizure
Referral Persistent headache at 7
days Post concussion syndrome
lasting > 2 weeks Abnormal neuropsych testing History of multiple high grade
concussions over season or career
Clinical discretion
CONCUSSIONSPRAGUE CONSENSUS 2004
IIHF, FIFA, IOC Goal: create position statement on diagnosis and
treatment of concussion Recommend abandonment of grading scales in
favor of individual and functional analysis Can only determine severity in retrospect after
symptoms have resolved completely Concept of “cognitive rest” Simple versus Complex concussion Baseline evaluation at PPE recommended
McCrory P, et al. Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clinical Journal of Sport Medicine. 15(2):48-55. Mar 2005.
CONCUSSIONSPREVENTION
Regarding sports: Helmets do not prevent concussions but
probably decrease risk Soccer headgear
May transmit force to the brain Danger to other players?
Mouth guards- controversial Proven way to prevent maxillofacial injuries
CONCUSSIONSBOARD QUESTIONS
As team physician for a high school football team, you are standing on the sideline during a game when you note that one player does not rise after a play. When you reach him, he is lying on his back with his eyes closed. He is not moving.
CONCUSSIONSBOARD QUESTIONS
The first thing to do for this patient is: A. establish that the patient has a patent
airway and is breathing B. place a roll under the patient’s neck for
support C. check the pupils D. take off the patient’s helmet and pads E. place an intravenous line
CONCUSSIONSBOARD QUESTIONS
After approximately 10 seconds, the patient awakens. He is disoriented and confused but can tell you his name and what he had for breakfast. He does not, however, remember anything about the game. He denies any neck pain and is allowed to sit up. With help, he walks to the sideline and sits down again for your evaluation. He says he feels perfectly fine and wants to go back into the game. Your evaluation should include:
CONCUSSIONSBOARD QUESTIONS
A. a complete neurologic evaluation B. immediate and long-term memory recall C. balance testing D. serial subtraction testing E. all of the above
CONCUSSIONSBOARD QUESTIONS
After a few moments of evaluation, the athlete begins to complain of a severe right-sided headache. He becomes lethargic and lapses again into unconsciousness. He is immediately taken to the emergency room by the ambulance on the sideline. What injury most likely accounts for his second collapse?
CONCUSSIONSBOARD QUESTIONS
A. subdural hematoma B. epidural hematoma C. diffuse axonal injury D. second-impact syndrome E. subarachnoid hemorrhage
CONCUSSIONSBOARD QUESTIONS
Warning signs for which an athlete who has sustained a concussion should seek immediate medical evaluation include:
A. difficulty in staying awake B. seizures C. urinary or bowel incontinence D. weakness or numbness of any part of
the body E. all of the above
CONCUSSIONSBOARD QUESTIONS
Choose the following statement that is false: A. approximately 10% of college football players will
sustain a concussion each season B. multiple concussions can result in cumulative
brain damage C. there does not have to be a loss of consciousness
for there to be a diagnosis of concussion D. athletes readily admit to symptoms of a
concussion E. close observation of the athlete is of critical
importance after a head injury
CONCUSSIONSBOARD QUESTIONS
A gymnast fell off the uneven bars during a competition and hit her head on the ground. She had a 2-minute loss of consciousness and had posttraumatic amnesia for 2 hours, which completely resolved. She was sent to the emergency room and had a CT scan of the head, which was negative for any intracranial bleeding. She was discharged to home. She now comes 2 days later to your office complaining of headache and the inability to concentrate in class.
CONCUSSIONSBOARD QUESTIONS
This patient has signs and symptoms of: A. postconcussive syndrome B. continuing symptoms of a concussion C. second-impact syndrome D. epidural hematoma E. malingering
CONCUSSIONSBOARD QUESTIONS
The athlete has an important competition coming up in 2 days. She should be:
A. allowed to participate because her CT scan was negative for any bleeding
B. allowed to do any event except for the uneven bars
C. restricted from any activity until she has been asymptomatic for 1 week and has no symptoms on exertion
D. restricted until her headache goes away at rest E. readmitted to the hospital for another CT scan of
the head
CONCUSSIONSBOARD QUESTIONS
The athlete recovers and returns to competition after one week. Two weeks later, she receives a glancing blow to the head and sustains another loss of consciousness, this time less than 30 seconds. She has no amnesia and recovers quickly with no symptoms of headache or difficulty concentration. She should:
CONCUSSIONSBOARD QUESTIONS
A. return to competition as soon as she is asymptomatic
B. return to competition when she has been asymptomatic for 2 week
C. be restricted for activity for at least 1 month, then only may return if she is asymptomatic for more than one week
D. return to competition but wear a helmet E. exercise on a stationary bicycle for 2
weeks
CONCUSSIONSTAKE HOME POINTS
No return to play if symptomatic Assume cervical spine injury in unconscious players Athletes commonly do NOT recognize they have or
have had a concussion Deteriorating LOC = bleed until proven otherwise Amnesia correlates best with cognitive deficit When in doubt, err on the side of conservative
management Individualized management is best
CONCUSSIONSBOARD QUESTIONS
You are covering a college football game as a team physician. A player sustains a hard hit to the head while being tackled by two other players. He stands up directly after the play, shakes his head for a moment, and then joins the huddle for the next play. He appears confused and runs to the wrong spot. After a few more plays, one of his teammates tells the trainer that he is not remembering plays.
CONCUSSIONSBOARD QUESTIONS
When the trainer tells you this information, you: A. allow him to continue play because he had no
loss of consciousness and the game is almost over B. have the trainer check to make sure that there is
enough air in his helmet C. watch him more carefully on the next play D. remove him immediately from play for evaluation E. remind the trainer that this particular player failed
most of his classes the previous semester
CONCUSSIONSBOARD QUESTIONS
When you speak to the athlete, he states that he feels fine and wants to go back to play. He denies headache or dizziness and has a normal neurologic examination. He cannot recall three objects 2 minutes after being told them. He also cannot subtract serial 7s accurately. You should now:
CONCUSSIONSBOARD QUESTIONS
A. allow him to return to play because he has a normal neurologic exam
B. send him directly to the hospital for a computed tomography (CT) scan of the head
C. have the athlete sit down quietly and retest him in 15 minutes
D. send him to the showers E. send him home with his parents
CONCUSSIONSBOARD QUESTIONS
The most important reason for not allowing an athlete with symptoms of a concussion to play is:
A. he has not been checked for a neck injury B. the athlete may experience headache and
dizziness with exertion C. if the athlete is injured, the physician is likely to
be sued D. if the patient cannot remember the plays, the
team is likely to lose the game E. the athlete is at risk for much more severe injury
if he sustains another hit
CONCUSSIONSBOARD QUESTIONS
Which one of the following statements is not true? A. the Glasgow coma scale is a useful adjunct for
evaluating an athlete after a head injury B. despite the guidelines for return to play as compiled by
Cantu and others, the final decision should be base on the individual situation and the best clinical judgment
C. types of intracranial injuries that can be encountered in the athlete include epidural hematomas, subdural hematomas, subarachnoid hemorrhages, diffuse axonal injury and intracerebral hematomas
D. concussions can have long-lasting effects on cognitive abilities and concentration
E. Concussions can be prevented by proper helmet use