Transcript Concussion Management

Put Me In Coach:
I Want a Hat Trick
Understanding the Dynamics of Concussion
AnnMarie Papa, DNP,RN,CEN,NEBC,FAEN,FAAN
HAT TRICK!!!!
Definitions
 Trauma-induced alteration in mental status that may or may not
be associated with Loss of Consciousness
AAN
 Type of mild traumatic brain injury (TBI) caused by an impact or
jolt to the head
AAP
 A complex pathophysiologic process affecting the brain, induced
by traumatic biomechanical forces
CISG
 Concussion is a complex pathophysiological process affecting the
brain, induced by traumatic biomechanical forces.
Third International Conference
Consensus Statement on
Concussions in Sports
 2001
 1st International Conference on Concussion in Sport,
Vienna
 2004
 2nd International Conference on Concussion in Sport,
Prague
 2008
 3rd International Conference on Concussion in Sport,
Zurich
 Sport Concussion Assessment Tool (SCAT2)
Consensus Statement
Zurich, 2012
Centre for Health, Exercise and Sports Medicine, University of Melbourne,
Australia
Sport Medicine Centre, Faculty of Kinesiology and Department of Community
Health Sciences, Faculty of Medicine, University of Calgary, Alberta, Canada
Sport Concussion Clinic, Toronto Rehabilitation Institute, Toronto, Ontario,
Canada
FIFA Medical Assessment and Research Center and Schulthess Clinic, Zurich,
Switzerland
Ottawa Sport Medicine Centre, Ottawa, Canada
Huguenot House, Dublin, Ireland
Emerson Hospital, Concord, Massachusetts, USA
Purpose
 Develop conceptual understanding of concussion in
sport using a formal consensus-based approach
 Develop guidelines for use by physicians, therapists,
athletic trainers, health professionals, coaches and
other individuals involved in the care of injured
athletes, whether at the recreational, elite or
professional level
Results
 Concussion may be caused by a direct blow to the head,
face, neck, or elsewhere on the body with impulsive force
transmitted to the head.
 Concussion typically results in the rapid onset of shortlived impairment of neurologic function that resolves
spontaneously.
 Concussion may result in neuropathological changes, but
the acute clinical symptoms largely reflect a functional
disturbance rather than structural injury.
More Results
 Concussion may result in a graded set of clinical
syndromes that may or may not involve LOC.
 Resolution of the clinical and cognitive symptoms
typically follows a sequential course.
 Post-concussive symptoms may be prolonged in a
small percentage of cases.
 Concussion shows no abnormality on standard
structural neuroimaging studies.
Traumatic Brain Injury
 Caused by a blow to the head or a penetrating
head injury that disrupts the normal function of the
brain
 A brief change in mental status or consciousness to
“severe,” an extended period of unconsciousness
or amnesia after injury”
 Centers for Disease Control & Prevention
Mild TBIs are Concussions
 Each year, more than 1.5 million people experience some
form of traumatic brain injury (TBI)
 85% of people with mild TBI have no long-term symptoms
 15% of people with mild TBI have lingering or long-term
symptoms
 Many people don’t realize they have sustained a mild TBI
Common Signs of Mild TBI
 Headaches
 Nausea
 Confusion
 Length of time can vary, depending on the severity of the
injury
 Could last a few seconds, minutes, or even hours
 Slow thinking
 Sleep changes
 Mood changes
 May result in depression due to the dysfunction of the brain
 Depression may go away, but some need help in counseling
or medications
 Dizziness
Common Causes of Mild TBI
 Motor vehicle collisions
 Falls
 Toddlers learning to walk
 Elderly who are beginning to experience
coordination problems
 Contact sports
 More common amongst 15 – 25 year old males
Mechanism of Injury in Ice Hockey
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Body checking
86% of all injuries in 9 – 15 year old
Contact leagues 4x injury rate, 12x fracture rate
45% legal body checks, 8% illegal body checks
Direct fatality and injury rates for football are half of
hockey
 Spinal cord injury and brain injury rate
 2.6 per 100,000 high school hockey players
 .7 per 100,000 high school football players
Challenges
 Athletes may not report symptoms or head injury for fear of
being excluded from participation
 In a study of high-school football players with concussion:
47.3% reported their injury
52.7% did not report their injury because:
66% did think their injuries were serious enough to
36% did not realize their symptoms were consistent with
concussion.
41% did not want to be held out of play.
 Athletes who have ever had a concussion are at increased risk
for another concussion.
Resources
Your Brain
What is Happening?
 Impact shakes the brain inside the skull
 A wave through brain tissue causes discharge of
damaging chemicals
 Nerve cells can shear
 Microscopic damage can affect the anatomy and
function of brain cells
Management
. First
Steps
 If there is loss of consciousness – Initiate
Emergency Action Plan. Call 911 to get an
ambulance. Assume possible neck injury.
 Assess ABCs: Airway, Breathing and
Circulation
 Important acute management principles
More Management
1. Remove the player from the current game or
practice (if event occurred during sport)
2. Do not leave the player alone; monitor signs
and symptoms
3. Do not administer medication
4. Inform parent or guardian
5. The player should be evaluated by a medical
doctor
6. The player must not return to play in that
game or practice
Later Management
Later Management
 The 6-step Graduated Return to Play Protocol
 Step 1 - physical and mental rest.
No return to activity until all symptoms have
resolved, and do not recur even after provocative
exercise during Steps 2-5.
If any Symptoms or Signs Return, Stop the
Process, and Return to Step 1
.
Continued
 Step 2 - Light aerobic exercise, such as
walking or stationary cycling. Monitor for
symptoms and signs. No resistance training or
weight lifting.
 Step 3 - Sport specific activities and training
(e.g. skating).
 Step 4. Drills without body contact. May add
light resistance training and progress to
heavier weights.
 Step 5. Begin drills with body contact.
 Step 6. Game play.
Concussion Management:
Return to Activity Guidelines
Step 1: No
concentration,
light aerobic
exercise < 10 min
Step 2: Mild
concentration,
light aerobic
exercise < 20 min
Step 3: Moderate
concentration,
add light strength
training < 30 min
Concussion Management:
Return to Activity Guidelines
Step 4: Sports
performance
training < 60 min,
full concentration
Step 5: Progress
to full activities
including contact
under observation
Full Return
to Play
The time needed to progress
from non-contact to contact
exercise (45) will vary with
the severity of the concussion
and the player. Only go to step
5 after medical clearance.
Again, go back to Step 1 if
symptoms recur.
Recovery
 Most ‘recover’ in 1 – 2 weeks, 95% recover in 3 months
 Longer in younger athletes and in female compared
to male
 Post-concussion syndrome is the presence of
symptoms for at least 3 months post injury
 Deficits in balance resolve in 5 days
 Cognitive tests return to baseline in 5 – 10 days
 Abnormalities in metabolic balance, oxygen
consumption, and electrical responses persist for
several months
Post Concussion Syndrome
 Re-injury before complete recovery
 Over-exertion early after injury
 Significant stress
 Unable to participate in sports
 Medical uncertainty
 Academic difficulties
 Prior or comorbid condition
 Migraine
 Anxiety
 ADHD, LD
Multiple Concussions
 Second Impact Syndrome
 A concussion prior to recovery from a
prior concussion
 Athlete is still symptomatic
 Mostly males < 21 years old
 Rapid increase in intracranial pressure
 Rare but almost always fatal
Multiple Concussions
 Cumulative effects
 Risk of concussion is 4-6 times greater after
one concussion
 Risk is 8 times greater after sustaining two
concussions
 Prolonged or incomplete recovery
 Increased risk of later depression or dementia
HOW MANY IS TOO MANY?
Diagnosis and Management
On-Field Diagnosis
“If In Doubt - Sit Them Out”
Then have the player assessed by a
physician with expertise in
concussions
Sideline Evaluation
Sport Concussion Assessment Tool
 SCAT: developed by combining
existing tools into a new standardized
tool for
 Patient education
 Physician assessment of sports
concussion
Concussion Management: Acute Injury
 ANY signs or symptoms of a concussion:
 Should not be allowed to return to play in the
current game or practice
 Should not be left alone; regular monitoring for
deterioration
 Should be medically evaluated
 Return to play must follow a medically supervised
stepwise process
 “When in doubt, sit them out!”
Neuroimaging
 Conventional modalities usually normal
 Head CT (or MRI) contributes little to concussion
evaluation except whenever suspicion of an intra-cerebral
structural lesion exists:
 Prolonged disturbance of conscious state
 Focal neurologic deficit
 Worsening symptoms
 Newer structural MRI modalities (gradient echo, perfusion,
and diffusion weighted) have greater sensitivity for
structural abnormalities but limited use currently
How Long do Cumulative Effects Last?
 If there is another risk or exposure soon after a concussion,
the likelihood of experiencing a repeated concussion is great
 With athletes who have had at least two or three
concussions, a decade, two, or even a lifetime of increased
risk of concussion is possible
 Statistically the risk is greater if people have a history of
concussions
Ways to Make Sports Safer
 Wear the proper helmet for each sport
 Reduce risk of injury by changing some of the rules in
certain sports
 banning intentional hitting from football and ice hockey
 Ban boxing entirely
 Stop players from taking unnecessary risks in sports
when it comes to repeat concussions
Conclusions
 Repetitive concussions increase the risk of second impact
syndrome and post-concussive syndromes
 NO athlete should return to sport until all concussive
symptoms have resolved at rest and with exertion
 Goal: to prevent catastrophic outcomes of acute structural
brain injury, second impact syndrome, and cumulative
brain injury due to repetitive trauma.
 All athletes suspected of having sustained concussions
should undergo thorough evaluation, including neurologic
screening exam, neuropsychological testing, and
exertional provocative maneuvers.
Resources
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www.Parachutecanada.org
www.aftertheinjury.org/concussions
www.aftertheinjury.org/concussions
www.popwarner.com
www.cdc.com/concussion
Questions?