Transcript File

Concussion
SBRCSNO SPRING 2016 CONFERENCE
PRITHA DALAL, M.D.
REHABILITATION MEDICINE
CONCUSSION PROGRAM DIRECTOR
RADY CHILDREN’S HOSPITAL-SAN DIEGO
STAFF PHYSICIAN, DEPT. OF PEDIATRICS, UC SAN DIEGO
Objectives
 Initial Management of Head injury
 Normal concussion symptoms
 Concerning symptoms
 Concussion management
 Return to learn and play
 Accommodations for school
 Prolonged recovery
Concussion
 Brain injury that is defined as a complex
pathophysiological process affecting the brain and
induced by biomechanical forces.
 It can be caused by direct or indirect force to the
head, neck or face.
Concussion
 There is usually a rapid onset of short lived
impairment of neurologic function that resolves
spontaneously. In some cases signs and symptoms
may evolve over minutes to hours.
 Although this creates a complex neuro-metabolic
cascade at the cellular level within the brain, there is
no structural damage or bleed.
Sideline assessment
 Emergency management – CAB’s
 Rule out cervical spine injury
 Address first aid issues first
 Monitor player for deterioration over first 24 hours.
 Do not need to wake up in the middle of night!
Pediatric GCS Traumatic Brain Injury
Severity
GCS
Mild traumatic brain injury 13-15
Moderate TBI
9-12
Severe TBI
3-6
Imaging
 Head CT – image gently
 Focal neurologic findings
 Symptoms of increased intracranial pressure
 Seizure activity
 GCS less than 15
 Concerning findings for spinal cord injury
 Other injuries
Concussion Symptom List
Headache
Pressure in
head
Neck pain
Nausea
Vomiting
Dizziness
Blurred vision
Balance
problems
Sensitivity to
light
Sensitivity to
noise
Feeling slowed Feeling “in a
down
fog”
“Don’t feel
right”
Difficulty
Difficulty
concentration remembering
Fatigue/low
energy
Confusion
Drowsiness
Trouble falling More
asleep
emotional
Irritability
Sadness
Nervousness
Anxious
Trouble staying
asleep
Red flags that Need ED Evaluation
Progressively
Worsening confusion
worsening headache
or irritability
Focal weakness or
numbness
Increased lethargy
Continued
vomiting
Seizure
Difficulty walking
Speech changes
Unequal pupils
Concern for skull
fracture
Blood in ear
drum/canal
Disorientation
Patient that Needs ED evaluation
 Please provide as much information as possible as to
what happened and your assessment
 Most patients will appropriately not need a Head CT.
Concussion is a clinical diagnosis.
Initial instructions for Concussion
 Recommend REST
 For at least first 24-48 hours recommend physical and
cognitive rest
 Should be evaluated by Primary care provider with in
next 2-3 days
 Tylenol is ok to take for headache
 Monitor for neurologic changes for next 4-6 hours.
 SHOULD NOT WAKE UP child at night or keep
awake.
Initial instructions
 Patient should consider taking at least one day off of
school depending on symptoms
 Should not return to school until symptoms are
improved unless it has been over 2 weeks.
Concussion Assessment Tools
 ImPact testing – Computer based
 SCAT 3 – Symptom score, cognitive testing and
balance testing
 ACE- Symptom list, history and information
Physician Visit
 History
 Physical examination – full neurologic examination
 Check balance
 Cognitive testing
Cognitive examination
Cognitive Assessment
BESS
BESS
BESS
Physician Visit
 Should give recommendations for Return to Learn
 Should also give recommendations for Return to
Play
 Should give medication recommendations to take for
symptom management
Risk Factors
 Risk factors – for prolonged recovery
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History of previous concussion lasting longer than 1 week
Previous history of headaches or migraines
History learning disability, ADHD, Speech therapy
History of anxiety or depression
Treatment/Instructions
 Cognitive and physical rest
 Physical rest
 Can walk
 Stay around house
 Progress activity if asymptomatic
 Cognitive Rest
 Avoid screens
 Limiting thinking activities
 Avoid loud areas
Cognitive rest
 Initially this means being in a quiet/dark if needed room
and limiting thinking activities
 Once feeling better can start playing simple games/board
games, crafts
 If starting new activity only do it for 10-15 minutes and
monitor for increasing symptoms
 Limit screens – videogames, iPads seem to be worse
 TV and Movies- rest breaks
Treatment
 Reminders for cognitive activities
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Every day activities can cause symptoms
Grocery stores – loud, bright lights
Sitting in car- can trigger symptoms
Church – singing, loud noises can be trigger
Watching sports also not recommended
Symptom Treatment
 Headaches

Acetaminophen – first 24 hrs

NSAIDs after risk for bleed decreased

Rest
Sleep
 Reinforce normal sleep hygiene
 Can try Melatonin for sleep- helps more with
difficulty falling asleep
 Trazodone – staying asleep in more severe cases
Return to Learn
 Even if student is feeling better symptoms may worsen
with starting school
 Patient should be able to walk around for 20 minutes at
home with out significant increase in symptoms.
 If still having symptoms but improving start back at ½
days of school
 Accommodations should be put in place based on
symptoms
Return to Learn CIF
Return to Learn CIF
CIF School Accommodations
CIF School Accommodations
CIF School Accommodations
Are we overwhelmed yet?
 Communication
 Student advocate
 Help with transition
 Ask questions
 Look for red flags
Cases/Questions
Return to Play
Patients should be tolerating full days of school prior to starting
return to sport process
Ideally would like to be completely asymptomatic or at baseline
before returning to activity to prevent second injury

Return to play should ALWAYS be a graduated return to
activities
CIF rules
 California Law states that full competition for
athletes cannot be sooner than 7 days and that
progression must be supervised by a DO or MD.
Graduated Return to Sports- CIF
Graduated Return to Sports- CIF
Graduated Return to Sports- CIF
Sport Specific
Sport Specific
Return to Play
 Questions?
Prolonged Recovery Considerations
 Once patient has had symptoms for over 2 weeks
complete rest no longer appropriate
 Start physical activity- gentle and gradual – still NO
contact
 Aggressively treat symptoms
Prolonged Recovery Treatments
 Physical symptoms
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Headaches
Long term headache medications
 Rebound headache concerns
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Neck pain
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Dizziness
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Physical therapy
Vestibular therapy
Blurry vision
Nausea
Fatigue
Increase activity
 Monitor sleep
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Prolonged Recovery Treatments
 Balance difficulties
 Physical therapy
 Sleep
 Medications
 Good Sleep Hygeine
 Cognitive difficulties
 Strongly consider 504 plan
 Consider setting up meeting
Prolonged Recovery considerations
 Emotional/mood symptoms
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Concussion symptoms similar to anxiety/depression
symptoms
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Recommend talking to school counsellor or psychologist
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Normalize symptoms
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Help with plan for stressors
Prolonged Symptom Recovery
 Activity
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Progress to non-contact activity that does not increase
symptoms (subthreshold)
Recommend physical activity daily
Encourage athletes to find new activities until symptoms
improve
Prevention
 Helmets/headbands
 Prevent against skull fracture and worse head injury but do not
prevent concussion
 Should they stay out of sport?
 Risks vs Benefit of sports
Concussion Clinic Information
 Dr. Pritha Dalal – [email protected]
 Rehabilitation Medicine
 858-966-1700 ext 2661
 Fax – 858-966- 6721
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Administrative Assistant- Gina Luna
References
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McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the
4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J
Sports Med 2013;47:250-258.
Halstead ME, Walter KE. Report—Sport-Related Concussion in Children and Adolescents.
Pediatrics 2010;126:596-615.
SCAT3 Sports concussion Assessment Test. Br J Sports Med 2013 47: 259
Child SCAT 3. Br J Sports Med 2013, 47: 263
Heads Up: Concussion http://www.cdc.gov/HeadsUp/index.html Page last updated February
16, 2015. Accessed April 4th, 2016.
Giza CC and Hovda DA. The Neurometabolic Cascade of Concussion. Journal of Athletic
Training. 2001;36(3):228-235.
Maugans TA, Farley C, Altaye M, Leach J, Cecil KM. Pediatric Sports-related Concussion
Produces Cerebral Blood Flow Alterations. Pediatrics. 2012 January; 129(1) 28-37.
Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent Postconcussion
Symptoms Among Children With Acute Concussion in the ED. JAMA. 2016;315(10):1014-1025
BESS http://knowconcussion.org/wp-content/uploads/2011/06/BESS.pdf
Accessed – April 4th, 2016
May KH, Marshal DL, Burns TG, Popoli DM, Polikandroitis JA. Pediatric Sport Specific Return
to Play Guidelines Following Concussion. Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255
California Interscholastic Federation Concussion. http://cifstate.org/sportsmedicine/concussions/index Accessed April 4th, 2016.