Meyering - Concussion 4 _PPTminimizer_ by wuyunyi


									  Concussion: When
  Return To Play Is
       Christopher Meyering, DO
             MAJ MC USA
        Director Sports Medicine
DD Eisenhower Family Medicine Residency
   The views expressed in this lecture are those of
    the presenter and do not reflect official policy or
    position of the Department of the Army, the
    Department of Defense, or the US Government
   The naming of specific neuropsychological
    products does not constitute endorsement of any
   Review and understand the signs and symptoms
    of concussion
   Review evaluation tools and treatment prior to
    return to activity
   Discuss the complications of concussion
   Discuss the military implications and guidance
    for mild traumatic brain injury (mTBI)
Case Presentation
             Case Presentation
   28 year old male was performing a clearing
    mission in a downtown location when an IED
    exploded at the front of the squad
   One soldier killed instantly by explosion
   Our patient was knocked backwards and others
    reported he was not moving for a “short while”
             Case Presentation
   Able to get back to evac point walking with rest
    of squad
   Feels “dazed” and dizzy when walking though
   Recalls starting the clearing operation but not
    the incident
   Also complains of some nausea but has not
   Has few small superficial injuries but otherwise
             Case Presentation
   You are at the evac point as the Battalion
   You have a senior medic and a junior medic plus
    your ambulance along with escort units
   Your Aid Station is 15 minutes away, Level 2
    facility is 25 minutes away
   CASH is 45 minutes away, AirEvac can be
    present in 10 minutes
   There is heavy enemy activity in the area
   Evacuate immediately?
   Watch and wait?
   Send soldier back out with squad to continue
   Concussion or mTBI is a pathophysiological process
    affecting the brain induced by direct or indirect
    biomechanical forces
   Rapid onset of short-lived neurological impairment
    which usually resolves spontaneously
   Usually a functional rather than a structural disturbance
   Wide range of clinical symptoms which may or may not
    include loss of consciousness (LOC)

    Herring et al: ACSM Concussion (Mild Traumatic Brain Injury) and the Team
    Physician: A Consensus Statement. Med Sci Sports Exerc 2005, 39:196-204.
     Acute Signs and Symptoms
      Suggestive of Concussion
 Cognitive
 Somatic

 Affective
        Acute Signs and Symptoms
         Suggestive of Concussion
   Cognitive
     Post-traumatic amnesia (PTA)
     Retrograde amnesia (RGA)

     Loss of Consciousness (LOC)

     Disorientation

     Delayed verbal and motor responses

     Excessive drowsiness
        Acute Signs and Symptoms
         Suggestive of Concussion
   Somatic
     Headache
     Fatigue

     Dizziness

     Nausea/Vomiting

     Visual disturbances

     Phonophobia
        Acute Signs and Symptoms
         Suggestive of Concussion
   Affective
     Emotional lability
     Irritability
Additional Military Considerations
                            mTBI should be suspected
                             for all patients exposed to or
                             involved in a blast, fall,
                             vehicle crash, or direct head
                             impact that lose
                             consciousness, have amnestic
                             event or become dazed or
                            Significant association
                             between barotrauma TM
                             perforation and concussion
            Pyne S. Concussion. 2008 USAFP Annual Meeting
            Xydakis et al. Tympanic-membrane perforation as a marker of
            concussive brain injury in Iraq; N Engl J Med 357;8, 2007
              Warning Signs
   Inability to awaken
   Severe or worsening headaches
   Persistent vomiting
   Weakness/ Numbness/ Focal neuro signs
   Vision difficulty
   Worsening confusion
   Persistent or Recurrent seizures
Grading Systems
           Concussion Grading
   At least 25 described concussion grading
   Most commonly used were the Cantu criteria,
    American Academy of Neurology parameter and
    the Colorado Medical Society guidelines
   Current recommendation for grading is to use
    an individualized symptom-based concussion
    management utilizing frequent reassessment
   Severity determined after symptoms have
              Concussion Categories
   Simple
   Complex
Summary and Agreement Statement of
the 2nd International Conference on
Concussion in Sport, Prague 2004. Clin J
Sport Med Vol 15 (2), 2005, pp48-55.

    No concussion
    Concussion with LOC
    Concussion without LOC
             Concussion Categories
   Simple
     Most common
     Progressive resolution without complication over 7-
      10 days
     No intervention required

     No advanced neuroimaging or neuropsychological
      testing needed
     Typically resumes activity without further problem

    Summary and Agreement Statement of the 2nd International Conference on
    Concussion in Sport, Prague 2004. Clin J Sport Med Vol 15 (2), 2005, pp48-55.
               Concussion Categories
   Complex
      Persistent symptoms (or recurrence with exertion)
      Specific sequelae such as concussive convulsions,
       LOC> 1 min, or prolonged cognitive deficits after
       the injury
      Repeated concussions

      Additional evaluation with neuroimaging and
       neuropsychological testing advised

    Summary and Agreement Statement of the 2nd International Conference on
    Concussion in Sport, Prague 2004. Clin J Sport Med Vol 15 (2), 2005, pp48-55.
Management Principles
         Management Principles
   Brief LOC (seconds, not minutes) associated
    with specific early deficits, but does not predict
    concussion severity and time to recovery
   RGA, PTA and prolonged confusion are better
    predictors of severity of mTBI, but should not
    be used alone
   Symptom duration guides activity advancement
    and defines severity
   Individualize treatment and recovery
             Case Presentation
   Our soldier returns to the Aid Station for
    evaluation on the following day (24 hours)
   Feels improved with walking around, but still
    with some dizziness
   Remembers more of the mission but not
    immediately prior to the blast
   Continue to monitor at Aid Station?
   Evacuate to higher level care?
   Allow to return to duty?
Assessment Tools
   Developed as a sideline assessment tool
   Able to differentiate between concussed and
    nonconcussed at time 0 but not thereafter
   One-third of patients able to improve their score
    despite remaining symptomatic
   Should not be used exclusively to make a
     Putukian M. Repeat Mild Traumatic Brain Injury: How to Adjust Return
     to Play Guidelines. Current Sports Med Reports. 2006, 5:15-22
   Proposed in the Prague Guidelines
   Clear supportive data not evident
   Patient answers questions about multiple
    symptoms associated with concussion
   Clinician asks about clinical signs of concussion
    and evaluates memory and cognition
   Assesses orientation, immediate memory,
    concentration, and delayed recall
   Contains components of the SAC and SCAT
   Gives guidance to clinician on scoring
     Max score is 30
     Score of 25 or less likely significant

   Assessment cards available to order at or
When and What To Image?
               Diagnostic Imaging
   Cervical Spine
       Symptom based
   Skull X-ray
       Not helpful
       Consider facial bone x-rays if indicated
   CT Scan or MRI
       Usually normal for simple concussions
       Use if clinically suspicious of intracranial hemorrhage
       Nearest MRI in theater is Kuwait
Back To Our Case
             Case Presentation
   Our soldier returns to the Aid Station for
    evaluation on the following day (24 hours)
   Feels improved with walking around, but still
    with some dizziness
   Remembers more of the mission but not
    immediately prior to the blast
What Do You Want To Do Doc?
   Continue to monitor at Aid Station?
   Evacuate to higher level care?
   Allow to return to duty?
Current Guidelines
             Current Guidelines
   Assess for Red Flags
     Decreased LOC
     Seizures

     Pupil asymmetry

     Progressive worsening of function

     Focal neurological dysfunction

     GCS < 15

   If any Red Flags present, evacuate to Level 3
                 Current Guidelines
   Assess symptoms of concussion
   Physical examination with detailed neurological
    and cognitive evaluations
   Give MACE exam
   If concussed begin primary care management
     Removal from stimulus environment
     Information sheet to service member
           Available at in PDF file
     Duty restrictions
     Physical and Cognitive rest
              Current Guidelines
   Can observe at Primary Care level for 7 days
       Recommend this only if improving
   Evaluate every 1-3 days
     Rely on your medics/corpsmen to watch for
     Involve command to ensure soldier is restricted

   If no symptoms at rest, perform exertion and
    repeat testing
   If any signs or symptoms with exertion then still
              Current Guidelines
   Serial neurological assessment helps determine
    the need for more advanced intervention
       Gradual improvement or worsening may be subtle
   Oral and written instructions should be given to
    the patient and a responsible party with focus on
    worsening symptoms and specific follow-up
     Need to avoid alcohol
     Regular diet
         Headache Management
   Acetaminophen for the first 48 hours
   Can switch to NSAID after 48 hours
   For persistent headaches over 7 days can use
    nortriptyline or amitriptyline 25 mg qhs but only
    give a 10 day prescription
   Avoid narcotics and tramadol
Back to the
Case Again
             Case Presentation
   Our soldier is at the Level 2 facility
   Still c/o headaches, dizziness and nausea
   Difficulty focusing on computer screen and
    having difficulty with sleeping

   Now What?
Additional Testing
Neuropsychological (NP) Testing
                Civilian
                    Immediate Postconcussion
                     Assessment and Cognitive Testing
                    Headminder
                    CogSport
                Military
                    Automated Neuropsychological
                     Assessment Metrics (ANAM)
                    Currently using ANAM 4
      Neuropsychological Testing
   Detailed assessment and quantification of
    cognitive function
   Evaluates information processing, memory
    recall, attention and concentration, reaction
    time, scanning and visual tracking ability, and
    problem solving abilities
        Neuropsychological Testing
   Few studies with published data on sensitivity
    and specificity
     Sensitivity of 80% and specificity of 77% for an NP
      test battery when athletes compared to their own
      baseline NP test
     Sensitivity dropped to 75% if preinjury test not
     ImPACT sensitivity and specificity has been 81.9%
      and 89.4%
        Putukian M. Repeat Mild Traumatic Brain Injury: How to Adjust Return
        to Play Guidelines. Current Sports Med Reports. 2006, 5:15-22
Military Neurocognitive Assessment
   Automated Neuropsychological Assessment
    Metrics (ANAM)
     Developed by Army, comprised of 30 tests for
      neuropsychological domains
     Includes a 15 minute ANAM TBI battery and
      assesses processing speed, learning, delayed memory,
      working memory, and spatial memory
     Computerized system with pre-test, post-test and
      assessment and treatment algorithms
     Validity still being evaluated
        Neuropsychological Testing
   Concerns with NP testing
     Stress, fatigue and sleep deprivation result in
      decreased performance on NP testing
     Research and commercial interest in testing may
      skew testing utility and validity
     Correlation with symptoms of mTBI
           Can see continued deficits in cognitive function with NP
            testing after symptoms resolved
        Neuropsychological Testing
   Additional concerns
     Original plan after April 2008 was to test every
      soldier going to and returning from theater
     Logistical issues for getting testing done
          Not available at all levels
          Evaluation teams used to try and capture all injuries

       Fellows from WRAMC deploying for short term
        intervals to collect data
              Case Presentation
   Our soldier was evacuated to CSH after 1 week
    of observation due to persistent symptoms
   Still complains of headaches, dizziness, difficulty
    sleeping, and difficulty concentrating on tasks
   He remembers more, but not all, of the day
    when his squad member was killed in front of
   He keeps having recurrent, intrusive images of
    those events which affect his ability to function
Prolonged Concussion Symptoms
   Majority of patients with concussion will have
    complete resolution of symptoms
   Small percentage have symptoms lasting over 4
     Physical
     Behavioral/Emotional

     Cognitive
Prolonged Concussion Symptoms
Physical Symptoms
     Nausea & Vomiting      Headache
     Vision problems        Fatigue
     Transient neuro        Phono/Photosensitivity
      abnormalities          Sleep disturbance
     Seizures               Drowsiness
     Balance problems       Dizziness
Prolonged Concussion Symptoms
   Behavioral/ Emotional
     Problems controlling emotions
     Irritability

     Anxiety

     Depression
Prolonged Concussion Symptoms
   Cognitive
     Problems with memory
     Difficulty concentrating

     Limitations in functional status
         Risk Factors for Prolonged
   Pre-existing mental health conditions such as
    depression, anxiety, or PTSD
   Co-occurrence of psychiatric disorders
   Lack of support system
   History of malingering
  Current Guidelines
for Referral from Level
        I or II
            Current Guidelines
   Confirm TBI screen
   Review all records
   Comprehensive exam
     Neurological
     Psychological

     Consider ENT, Ophthalmology and/or balance
                Current Guidelines
   CT scan if:
     Positive findings on exam
     Evidence of trauma above the clavicles

     Seizure

     Vomiting

     Headache

     Short-term memory deficits

     Coagulopathy
             From Jagoda et al 2008.
             Current Guidelines
   If negative CT scan continue with treatment trial
    as previously mentioned
   Neurocognitive assessment
   Refer to other available specialists as needed
   Repeat evaluation every 72 hours up to 14 days
   If still not improving or still having symptoms
    with exertion consider evacuation to Level IV
   Consider MEB if symptoms persist in garrison
    setting for 6 months
    Additional Military Implications
   Need to weigh the relative costs of removal
    from the unit vs. utilizing an impaired service
   Multiple factors can lead to under-diagnosis
      Ignorance of the diagnosis and its impact
      Distrust of the medical system by the service
      Cheating by memorizing the answers to assessment
                   For the Future
   Working on data capture to ensure continuity of
    communication and care
   Working on clarifying the role of automated
    neurocognitive testing in theater
   Revising the MACE
             From DVBIC Consensus Conference
             Guidelines Recap
   Red Flags, Evac to Level 3
   Concussed service member can remain under
    Primary Care unless concerning findings or not
    showing signs of improving
   Rely on consultants through if any concerns
   Increase awareness of severity of these injuries
       Go to for MACE cards for medics;
   Need to recognize and begin treatment early
   Understand when a patient needs additional care

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