Sports Related Concussion amnesia

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					  Sports Related
   Concussion
   Current Trends and
Evidence Based Medicine
                    Objectives
   Defining and Recognizing Concussion
       Latest evidence
   Management of Concussions
       Clinical Evaluation – Sideline/AT Clinic
 Referral Decisions
 Concussion Assessment Tools
 Return to Play
 Home Care
     International Conference on
         Concussion in Sport
   Complex pathophysiological process
    affecting the brain, induced by traumatic
    biomechanical forces.
     Struck player more likely to receive
     Functional disturbance rather than a structural
      injury
         Biochemical,   metabolic, and gene expression
       Symptom cluster
         Somatic,   Emotional, Cognitive, Sleep Disturbances
            Symptom Cluster
                            Emotions
                     •More Emotional
                     •Sadness
                     •Nervousness
                     •Irritability                  Cognitive
      Somatic
                                             •Attention Problems
•Visual
                                             •Memory Dysfunction
•Dizziness
                                             •Fogginess
•Balance Problems
                                             •Fatigue
•Headaches
                                             •Cognitive Slowing
•Light Sensitivity     Sleep Disturbances
•Nausea              •More sleep
                     •Less sleep
                     •Can‟t fall asleep or
                     stay asleep
            Research about S/S
 LOC only in 9%, Amnesia only in 27%
 No association between LOC and amnesia
  and the duration of S/S
 Significant association between S/S
  severity and total duration
 Can have lucid period followed by S/S
       15-20 minutes athlete should sit
     International Conference on
         Concussion in Sport
   Simple vs. Complex Concussion
       SIMPLE
         Injuryprogressively resolves without complications
          over 7-10 days.
         Management = rest until all S/S resolved, graded
          return to sport, and evaluated by physician.
       COMPLEX
         Injuryresults in persistent symptoms
         Athlete receives multiple concussions
         Management = same as above with more formal
          evaluation by team of specialists
         To grade or not to grade?
    Current approaches
    1.   Time of injury
    2.   Based on Presence and duration of
         symptoms
    3.   NOT to grade at all – focus on recovery
    The medical community does not agree
     on a system – but is leaning towards #3
              Grading Scales (#1)
Cantu Grading System American Academy of
 Grade 1 (mild)      Neurology
       No LOC; PTA < 30 mins        Grade I
   Grade 2 (moderate)                   No LOC; S/S < 15 mins
       LOC < 5 min or PTA > 30      Grade 2
        mins                             No LOC; S/S > 15 mins
   Grade 3 (severe)                 Grade 3
       LOC > 5 min or PTA > 24          Any LOC
        hrs
          Most recent grading (#2)
                  Note: Takes place after symptoms have resolved


    Cantu Evidence Based Grading System
   Grade 1 (mild)
        No LOC; PTA < 30 mins; PCS < 24 hrs
   Grade 2 (moderate)
        LOC < 1 min or PTA > 30 mins but < 24 hrs or PCS > 24 hrs but
         < 7 days
   Grade 3 (severe)
        LOC > 1 min or PTA > 24 hrs or PCS > 7 days
                        #3




     MOI, Amount of Damage, # of previous
      injuries can vary. How does grading the
      concussion change the outcome?
     Severity of symptoms and total duration
     Focus on whether the athlete is symptom
      free, posture/balance is restored, and normal
      cognitive functioning.
    Cornerstones of Management
 Removal of symptomatic athletes from
  play
 Restriction from play while symptomatic
 Graduated return to play
 Recognition of differences in children
     Brains don‟t absorb shock the same
     Be more conservative

   Neurocognitive testing is recommended
   Management of Concussions

 Stepwise    Process
   Immediate  history/palpation
   Rule out immediate life threatening
    injuries
   Clinical Evaluation of Symptoms
     S/Sscales
     Neuropsychological Testing
   Obtain   detailed concussion history
                  Clinical Evaluation
   Where do you begin? Just Observe!
       AVPU Scoring– alert, verbal, pain, or unresponsive
            Level of consciousness
       Oriented X 3 – person, place, and time
            Do you know where you are and what happened?
            Is there a blank or vacant stare? Can the athlete keep their
             eyes open?
       Is there slurred speech or incoherent speech?
       Are there delayed verbal and motor responses?
       Gross disturbances to coordination?
Decision Tree
    Immediate History/Palpation
   Common questions
         Can  you remember who we played last week?
          (retrograde amnesia)
         Can you remember walking off the field?
          (anterograde amnesia)
         Does your head hurt?

       Palpate head, face, neck vertebrae
         Doyou have pain in your neck?
         Can you feel and move your hands and feet?
    Rule out these injuries before
             proceeding
   Most head injuries in athletics are mild:
                  However, …
       Breathing or Heart Malfunction
          Don‟t   respond to questions
       C-Spine Fracture/Dislocation
          Pain   in neck, inability to feel or move hands and
          feet
       Skull Fracture
          Head    hurts at site of impact
       Intracranial Bleeding
          Memory    issues/Lucid and then rapid deterioration
                    Skull Fractures
   Fx. at trauma site or away from site
     General S/S: skin cool and moist, pulse and
      breathing changes, and pupil discrepancies
     Specific S/S: „raccoon eyes‟, „battle‟s sign‟,
      goose egg, cerebrospinal fluid – otorrhea or
      rhinorrhea
     Testing for Cerebrospinal fluid (CSF)
         Bull‟s   eye test/Halo test
                 Cranial Bleeding
   Intracranial Bleeding        Signs of increasing
       Progressive decline       cranial pressure from
   Epidural Hematoma             bleeding
                                     Progressive headache
       Rapid deterioration
                                     Excessive drowsiness
   Subdural Hematoma                Nausea/vomiting
       Slow deterioration           Unequal/Unreactive pupils
                                     Disorientation
                                     Cranial Nerve Dysfunction
                                     Increase BP
                                     Decrease in pulse
    Medical                          Loss of Consciousness
    Emergency
                  Cranial Bleeding
   Intracranial Bleeding              Epidural Hematoma
       Bleeding in sinus                  Between dura mater and
        separating two                      skull
        hemispheres                        Arterial bleeding – rapid
       Progressive decline – 24-           accumulation of blood
        48 hours                           Lucid period followed by a
                                            rapid deterioration
                                                10-60 mins.
                                           Unilaterally dilated pupil is
                                            most common early sign
                     Cranial Bleeding
   Subdural Hematoma
       Between the dura and archnoid
        mater
       Arterial and venous bleeding
            Within 48 hours
       Slow venous bleeding
            Days to weeks
       Lucid period followed by gradual
        deterioration
             Headaches, confusion, and
             declining consciousness
            This is why home instructions are
             so important
         Clinical Evaluation

 If new signs and symptoms appear OR
 If any of these signs and symptoms are
  severe or persist OR
 Begin to deteriorate then this warrants
  immediate…
              REFERRAL
               Referral Decisions
   When do you refer a concussion?
       Day of referral and Delayed referral
   KEYS:
       LOC or deterioration of consciousness
       Amnesia longer than 15 mins
       Eye signs
       Vasomotor signs
       Mental status changes
       Cranial nerve deficit
       Motor, Balance, or Sensory deficit
       Normal life is adversely affected.
              Clinical Evaluation
   Special Tests
     Eyes
     Neurological Status

   Concussion Assessment Tools
       Cognition
          Standardized   Concussion Assessment (SAC)
       Balance
          Balance   Error Scoring System (BESS)
                      Special Tests
   “Eyes are the great revealer”
       Eye function
          Pupils   equal and reactive to light (PEARL)
               Dilated or irregular pupils
               Ability of pupils to accommodate to light variance
          Eye  tracking - smooth or unstable (nystagmus,
           which may indicate cerebral involvement)
          Dynamic Visual Acuity
          Blurred vision
          Photophobia
          Diplopia
    Standardized Assessment of
        Concussion (SAC)
   5 - 10 minute test; 30 point scale
     Orientation
     Immediate memory
     Concentration
     Delayed recall


     Neurological Screening – not scored
     Exertional Manuevers – not scored
www.upmc.com and www.impacttest.com
        Balance and Coordination
   Rhombery Sway and Tandem Rhomberg
   Singleton‟s Test
   Finger to Nose
   Balance Error Scoring System
    (BESS)
       Two surfaces – firm and foam
       Three positions – double, single, tandem
       Errors committed in 20 seconds with eyes closed.
            Eyes open, hands off, foot down, moving too much
       Reliable and Valid
              Neurological Status
   What does a diminished reflex indicate?
   How about hypo- or hypersensitivity of the skin
   Cranial Nerves
       I-XII
       On Old Olympic Towering Tops A Finn And German
        Vault and Hop
       Olfactory(I), Optic (II), Oculomotor(III), Trochlear(IV),
        Trigeminal(V), Abducens(VI), Facial(VII), Auditory(VIII)
        (Vestibulococchlear), Glossopharyngeal(IX), Vagus(X),
        Accessory(XI), Hypoglossal(XII)
       http://www.gwc.maricopa.edu/class/bio201/cn/cranial.
        htm
Cranial Nerves
CNN #   Name                Function

I       Olfactory           Special Sensory: Smell

II      Optic               Special Sensory: Sight

                            Somatic Motor: Superior, Medial,
                            Inferior Rectus, Inferior Oblique
III     Oculomotor
                            Visceral Motor: Sphincter
                            Pupillae

IV      Trochlear           Somatic Motor: Superior Oblique

                            Somatic Sensory: Face
V       Trigeminal          Somatic Motor: Mastication,
                            Tensor Tympani, Tensor Palati

VI      Abducens            Somatic Motor: Lateral Rectus

                            Somatic sensory: Posterior
                            External Ear Canal
                            Special Sensory: Taste (Anterior
                            2/3 Tongue)
VII     Facial
                            Somatic Motor: Muscles Of Facial
                            Expression
                            Visceral Motor: Salivary Glands,
                            Lacrimal Glands

VIII    VestibuloCochlear   Special Sensory: Auditory/Balance

                            Somatic Sensory: Posterior 1/3
                            Tongue, Middle Ear
                            Special Sensory: Taste (Posterior
IX      Glossopharyngeal
                            1/3 Tongue)
                            Somatic Motor: Stylopharyngeus
                            Visceral Motor: Parotid Gland

                            Somatic Sensory: External Ear
                            Somatic Motor: Soft Palate,
                            Pharynx, Larynx (Vocalization and
X       Vagus               Swallowing)
                            Visceral Motor:
                            Bronchoconstriction, Peristalsis,
                            Bradycardia, Vomitting

                            Somatic Motor: Trapezius,
XI      Spinal Accessory
                            Sternocleidomastoid

XII     Hypoglossal         Somatic Motor: Tongue
        Immediate RTP Decisions
   Any LOC, neurological changes, or
    persistent symptoms
       NO play that day!
   Golden rules:
     “If you were out, you are out”
     “If you sway you do not play”
     “When in doubt, sit them out”

   15-20 minute “rule”
    Immediate RTP Decisions
 Must NOT have extensive concussion
  history
 Must be symptom free at rest and exertion
    Athlete must meet 4 criteria
     Normal   neurological - – physiological and cognitive
     Normal vasomotor – BP and pulse
     Free of headaches, dizziness, fatigue, & impaired
      orientation
     Increase in activity doesn‟t make S/S worse
          40 yd dash, sit-ups, push-ups, deep knee bends
        Immediate RTP Decisions
   Statistics
     30% of concussions RTP on same day
     70% = 4 or more days
   Why is it important to continue to monitor
    symptoms even when they return to play
    that day?
     33% of same day returners experienced
      delayed onset of symptoms
     12% of non-returners experienced delayed
      onset of symptoms
   Importance of Concussion
            History
 Must   get a DETAILED History
   Previous   head injuries
     Number
     Characteristics – MOI
     All S/S and deficits
     Time out of practice
     Time out from competition
          Neurocognitive Testing
   Inability to focus attention and easily distracted?
   Memory deficit?
       Retrograde vs. Anterograde
       Short term and Long term
   Does the athlete have normal concentration?
   Normal emotional response?
       How long were the athlete‟s emotions abnormal?
ImPACT™ Testing
Immediate Post-Concussion Assessment and Cognitive
Testing
           Computerized Testing
   NOT to diagnose but to measure recovery
   There are varieties
       Need interpretation and norms
       Risk of False Negatives
       Cost
   ImPACT™ Testing (www.impacttest.com)
       Verbal Memory
       Visual Memory
       Information Processing Speed
       Reaction Time
       Impulse Control
Neurocognitive Testing
Neurocognitive Testing
               Return to Play (RTP)
•   Athletes should complete the following step-wise process prior to
    return to play following concussion.
     •   Removal from contest following any signs / symptoms of concussion
     •   No return to play in current game
     •   Medical evaluation following injury
     •   Rule out more serious intracranial pathology
•   Step-wise return to play
     •   No activity - rest until asymptomatic
     •   Light aerobic exercise
     •   Sport-specific training
     •   Non-contact drills              Prague Concussion
     •   Full-contact drills             Conference
     •   Game play
                                     Recommendations
Future Return to Play Decisions
   Depends on both the athlete‟s current condition
    and the athlete‟s past concussions.
       Should follow a progression that begins once the
        athlete is fully symptom free
       No magic number of concussions – After
        3…significant changes in neurocognitive function
   Current recommendations:
       Fully symptom free for at least 7 days at rest and
        during exertion
            Why 7 days?
                 Research studies
            Remember time frame gets bigger if athlete has had more
             than one concussion
Threat of Multiple Concussions
   This is your brain:      This might be your
                              brain after multiple
                              concussions:
                 Reassessment
   What timeline should you use?
       Who is involved?
   This may be the time to grade the
    concussion
     You have more data – severity of symptoms
      and total duration
     HOWEVER, do not place too much
      emphasis on the grading system…FOCUS
      on whether the athlete is symptom free
          Use   the 4 criteria of RTP
          Home Care Instructions
   Instructions on medicine, rest, food, alcohol, S/S
    monitoring, and when to be reassessed.
       Why are these so important?
       What should an athlete know about their concussion?
   Should a concussed athlete be awakened
    throughout the night?
   What would you write on your athletic training
    room‟s Home Care Instructions?
        Second Impact Syndrome
   Second Impact Syndrome (SIS)
       Athlete returns to play while still experiencing S/S of
        previous concussion, then receives another blow
        (even minor).
            Loss of vascular autoregulation causes vascular
             engorgement
                 Catastrophic swelling in brain with increase in intracranial
                  pressure
    Second Impact Syndrome
   May initially display S/S of Grade I concussion
    but then quickly collapses into a
    semicomatose state
      Dilated   pupils, Unresponsive pupils, Loss of eye
       motion
      Responsiveness diminishes – eyes open but
       unresponsive to commands
      Respiratory distress secondary to phrenic nerve
       disruption
    Second Impact Syndrome
   DON’T push for early return to play.
      Concussions     are cumulative!!
           The previous one is NOT erased
   Permanent damage
      50%chance that SIS will result in death or
      vegetative state
   How do you prevent if athlete doesn‟t report
    lingering symptoms?
      Neuropsychological     and cognitive testing is
      important
Post Concussion Syndrome
     Post-concussion Syndrome
   Continued disability due to one or more
    concussions.
           i.e. Al Toon, Meryl Hodges, Chris Miller, Brett Lindros, Pat
            LaFontaine, Stan Humphries, Steve Young, Troy Aikman

   S/S:
     Early: disorientation, headaches, dizziness,
      nausea, sleep disturbances, light sensitivity,
      and blurred vision.
     Late: Poor memory, lack of concentration,
      depression, irritability, anxiety, fatigue,
      headaches, and sleep disturbances
                  In Conclusion
   Work as a sports medicine team
       ATC, Dr., athlete (parents), coach
   No 2 concussions are the same !!!
       Each athlete should be considered
        individually
   The negative consequences of early return
    by far outweigh the inconvenience of time
    lost in a season