Transcript Concussion Management - Texas Children`s Hospital

Concussion Management in Pediatric Patients
Amanda Jones, MSN, RN, CPNP-PC
Blue Bird Circle Clinic for Pediatric Neurology
Texas Children’s Hospital
Baylor College of Medicine
Objectives
• Define concussion and identify common symptoms
• Understand appropriate evaluation of patients with
suspected concussion
• Management of concussion symptoms and
comorbidities
• Determine when to refer to Neurology and other
specialties
Concussion Statistics
• It is estimated that between 1.6 and 3.6 million
people are affected by concussion annually
• 80-90% of athletes will rec0ver within 7-10 days
(McCrory 2005)
CDC, McCrory
Who is at greatest risk for concussion
• Sport – football, rugby, hockey and soccer
• Gender – females greater in soccer and basketball
• Prior concussion – hx of concussion/mild traumatic
brain injury (mTBI)
• Helmet reduces risk in hockey, rugby and football
• Age – no clear correlation has been determined
• Position – insufficient evidence to determine risk
Strong evidence
Giza et al 2013
Moderate evidence
Insufficient evidence
WHAT IS A CONCUSSION?
Definition – Zurich Guidelines
Concussion in Sport: The 3rd International Conference on Concussion in Sport
Concussion is defined as the complex pathophysiological process affecting
the brain, induced by traumatic biomechanical forces. Several common
features that incorporate clinical, pathologic and biomechanical injury
constructs that may be utilized in defining the nature of a concussive head
injury include:
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Concussion may be caused either by a direct blow to the head, face, neck or
elsewhere on the body with an “impulsive” force transmitted to the head.
Concussion typically results in the rapid onset of short-lived impairment of
neurologic function that resolves spontaneously. However in some cases, symptoms
and signs evolve over a number of minutes to hours.
Concussion may result in neuropathological changes, but the acute clinical
symptoms largely reflect a functional disturbance rather than a structural
injury and, as such, no abnormality is seen on standard structural neuroimaging
studies.
Concussion results in a graded set of clinical symptoms that may or may not
involve loss of consciousness. Resolution of the clinical and cognitive symptoms
typically follows a sequential course; however it is important to note that in a
small percentage of cases however, post-concussive symptoms may be prolonged.
McCrory 2013
Definition – American Medical Society for
Sports Medicine
A concussion is defined as a traumatically induced
transient disturbance of brain function and is caused
by a complex pathophysiological process. Concussions
have also been referred to as mild traumatic brain
injuries (MTBI). While all concussions are MTBIs, not
all MTBIs are concussion. Concussions are a subset of
MTBIs, on the less-severe end of the brain injury
spectrum and are generally self-limiting in duration
and resolution.
Harmon 2012
Definition – American Academy of
Neurology
A clinical syndrome of biomechanically induced
alteration of brain function, typically affecting
memory and orientation, which may involve loss
of consciousness (LOC).
Evaluation of Concussion
Approach to Child with Suspected Concussion
1. Emergency management of the athlete with
caution of cervical spine
2. Following first aid, use assessment tool for
evaluation of severity of concussion
3. Thorough H&P in Emergency Center or in
office (PCP or Sport’s Medicine)
AAN 2013
Checklists/Screening Tools
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Post Concussion Symptom Scale
Graded Symptom Checklist (GSC)
Standardized Assessment of Concussion (SAC)
Balance Error Scoring System (BESS)
Sport Concussion Assessment Tool 3 (SCAT3)
Additional Screening Tools
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Military Acute Concussion Evaluation
King-Devick Test
Clinical Reaction Time Test
Sensory Organization Test
Acute Concussion Evaluation – CDC
Concussion Symptom Inventory
Health and Behavior Inventory
Rivermead Post-Concussion Symptoms Questionnaire
Several Computerized Testing programs – ImPACT
(Immediate Post-Concussion Assessment and
Cognitive Testing)
Graded Symptom Scale
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Blurred vision
Dizziness
Drowsiness
Sleeping More Than Usual
Easily Distracted
Fatigue
Feeling “In a Fog”
Feeling “Slowed Down”
Headache
Unusually Emotional
Irritability
Loss of Consciousness
Loss of Orientation
Preseason
Baseline
Time of
Injury
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Memory Problems
Nauseous
Nervousness
Personality Changes
Poor Balance/Coordination
Ringing in the Ears
Sadness
Seeing Stars
Sensitivity to Light
Sensitivity to Noise
Sleep Disturbances
Vacant Stares/Glassy Eyes
Vomiting
24 Hours
Post-Injury
Day 3 PostInjury
Day 4 PostInjury
Day 5 PostInjury
Standardized Assessment of Concussion
(SAC)
Evaluation of SIX key areas
1. Orientation
4. Concentration
2. Immediate Memory
5. Exertional Maneuvers
3. Neurological Screening 6. Delayed Memory Recall
Recollection of injury
Sensation
Coordination
Strength
SCAT3
• Combines Maddocks Side
Lines Questions and SAC
• Also includes GCS, neck
evaluation and balance
assessment and a
symptom checklist
• Takes about 15-20
minutes
• For children 13 and older
• Child SCAT3 (5-12 yo)
• Pre-assessment is
recommended for
accurate results
BESS – Balance Error Scoring System
• Evaluate 3 stances on 2 surfaces
for 20 seconds each
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Double leg
Single leg
Tandem
Firm and foam surfaces
• Count each error
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Hands off hips
Opening eyes
Step, stumble or fall
Abduction or flexion of hip beyond
30 degrees
▫ Lifting of forefoot or heel off testing
surface
▫ Remaining out of the proper testing
position for > 5 seconds
Neuroimaging
• CT – selective use to rule out more serious TBI
▫ Specifically intracranial hemorrhage or fracture
• MRI – may be helpful to evaluate persistent or
worsening symptoms
▫ Chiari malformations, arteriovenous
malformations, causes for seizures (focal cortical
dysplasia or mesial temporal sclerosis)
• fMRI – shows delay in recovery after
improvement in symptoms
• Unhelpful at this time: PET, DTI, MRS, SPECT,
functional connectivity
AAN 2013; Harmon et al 2013
Symptoms of Concussion
Suspect concussion if 1 or more of
the following are present:
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Symptoms – somatic, cognitive and/or emotional
Physical signs
Behavioral changes
Cognitive impairment
Sleep disturbances
McCrory 2013
Common Symptoms Associated
with Concussion
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Blurred vision
Dizziness
Drowsiness
Sleeping More Than Usual
Easily Distracted
Fatigue
Feeling “In a Fog”
Feeling “Slowed Down”
Headache
Unusually Emotional
Irritability
Loss of Consciousness
Loss of Orientation
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Memory Problems
Nauseous
Nervousness
Personality Changes
Poor Balance/Coordination
Ringing in the Ears
Sadness
Seeing Stars
Sensitivity to Light
Sensitivity to Noise
Sleep Disturbances
Vacant Stares/Glassy Eyes
Vomiting
Management of Concussion
Returning to Activities
Return to Learn – Commonly Used Terms
• May include an IEP (Individualized Educational Plan) –
formal plan under Individuals with Disabilities Education Act, allows for
modifications or special education
• 504 Plan – under Section 504 of the Rehabilitation Act and the American with
Disabilities Act, provides accommodations in regular education for those not eligible
for special education
• Individualized health care plan – document created by school nurse
based upon recommendations by Pediatrician to address specific health care needs
• Family Education Rights and Privacy (FERPA) – protects the
privacy of “education records” including school health records
Return to Learn
• *INDIVIDUALIZED*
Practice Recommendations
• Pre-participation Counseling
• Return to Play (RTP)
▫ No same day return to play EVER
• Retirement from Play
Return to Play
• 4th International Conference on Concussion in Sport
(Nov. 2012) – graduated protocol
• American Medical Society for Sports Medicine
position statement: concussion in sport – confers
with graduated protocol
• CDC also endorses a 5 step return to play protocol
• American Academy of Neurology – recommends no
return to play until asymptomatic off medications
which could mask s/s of concussion; it may be
beneficial to use graduated approach to return to
play
Retirement from Play
• Overall poor consensus on this topic
• 4th International Conference on Concussion
provides no guidance
• AAN – athletes with multiple concussion should
have neurological/neuropsychological evaluation
which can provide guidance on recommendations
for retirement; counsel on the risk for permanent
neurobehavioral or cognitive impairments in
athletes with a history of multiple concussions or
persistent neurobehavioral impairments
Management of Concussion
Treating the Symptoms
Common Comorbidities
Physical
Cognitive
Emotional
Sleep
Headache
Concentration
Irritability
Hypersomnia
Vestibular
Autonomic
Memory
Depression
Insomnia
Blurry vision
Feeling slowed
down
Mood lability
Trouble falling
asleep
Loss of energy
Inability to
multitask
Anxiety
Trouble staying
asleep
Starling 2015
Multidisciplinary Approach
• Sports Medicine Clinic
• Physical Therapy
• Occasionally, Neurology or Neuropsychology for
persistent symptoms
Supplements/Medications
• Sleep – melatonin
• Anxiety - anxiolytics
Headache Types in PTH
Headache Type
Description
Migraine
Moderate-severe, photo/phonophobia, or
nausea/vomiting, worse with movement
Tension Type
Mild-moderate
Cervicogenic
Worse with neck movement
Cluster
Unilateral, retro-orbital, cranial autonomic symptoms
Orthostatic
Secondary to change in position, associated with
lightheadedness/dizziness, can be short-lasting
Vestibular
Triggered by eye and body movement, associated with
dizziness/vertigo, can be short-lasting
Treatment of headache
• Topamax “dopamax”
• Amitriptyline
• Beta blockers
Risk Factors for Prolonged PostConcussive Symptoms
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History of mood disorders in patient
Family history of mood disorders
Personal history of migraine
Family history of migraine
History of prior concussion
Delayed symptom onset
ALL associated with >3 month duration of
symptoms
Morgan 2015
Management of Prolonged Symptoms
• After initial period of physical and cognitive rest,
other therapies should be considered
Cognitive
Physical
Vestibular
Psychological
• Also consider assessment of other causes of
prolonged symptoms – HEADSS Exam
Helpful Handouts
• CDC HEADS UP –
▫ Online training course
http://www.cdc.gov/concussion/headsup/clinicians/
▫ Fact sheets for parents, coaches, athletes and
sport’s officials
Moving Forward with Concussion
• President Obama requested $5 million in 2017
budget for a National Concussion Surveillance
System which would help provide more accurate
information about the actual number of children
and adults affected by concussion each year.
References
Giza, C.C., Kutchner, J.S., Ashwal, S., Barth, J., Getchius, T.S.D., et al. (2013). Summary
of Evidenced-based Guideline Update: Evaluation and Management of
Concussion in Sports. Neurology, 80:2250-7.
doi: 10.1212/WNL.0b013e31828d57dd
Halstead, M.E., McAvoy, K., Devore, C.D., Carl, R., Lee, M., et al. (2013). Returning to
Learning Following a Concussion. Pediatrics, 132, 948-57.
doi:10.1542/peds.2013-2867
Harmon, K.G., Drezner, J.A., Gammons, M., Guzkiewicz, K.M., Halstead, M., et al.
(2013). American Medical Society for Sports Medicine position statement:
Concussion in Sport. British Journal for Sports Medicine, 47, 15-26.
doi:10.1136/bjsports-2012-091941
McCrory, P., Johnston, K., Meeuwisse, W., Aubry, M., Cantu, R., Dvorak, J.,et al.
(2005). Summary and agreement statement of the 2nd International
Conference on Concussion in sport, Prague 2004. British Journal of Sports
Medicine, 39(4):196-204.
McCrory, p., Meeuwisse, W., Aubry, M., Cantu, B., Dvorak, J., et al. (2013). Consensus
Statement on Concussion in Sport – The 4th International Conference on
Concussion in Sport held in Zurich, November 2012. British Journal of Sports
Medicine, 47, 250-258.
References Continued
Morgan, C.D., Zuckerman, S.L., Lee, Y.M., King, L., Beaird, S. et. al. (2015).
Predictors of Postconcussion Syndrome After Sports-Related Concussion
in Young Athletes: a matched case-control study. Journal of Pediatric
Neurosurgery, 15:589-598.doi: 10.3171/2014.10.PEDS14356
Resch, J.E. & Kutcher, J.S. (2015). The Acute Management of Sport Concussion in
Pediatric Athletes. Journal of Child Neurology, 1-9.
doi:10.1177/0883073815574335
Starling, A. (2015). Treatment of TBI, Concussion, PTH Cases and Thoughts on
Current and Future Research [Powerpoint Slides]. Presented at American
Headache Society 2015 Scottsdale Headache Symposium.American
Academy of Neurology (2013). Summary of Evidence-based Guideline for
Clinicians, Update: Evaluation and Management of Concussion in Sports.
Retrieved from http://www.neurology.org/content/80/24/2250.full
QUESTIONS?