Closed Head Injury New Guidelines

Transcription

1 Outreach Education Online Video Library Closed Head Injury New Guidelines.... Program Handouts This information is provided as a courtesy by Children's Health Care System and its related organizations (CHCS). Persons accessing this information assume full responsibility for the use of the information and understand and agree that CHCS is not responsible or liable for any claim, loss or damage arising from the use of the information. The views and opinions of the document authors do not necessarily state or reflect those of CHCS. Neither the authors nor CHCS nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information. Marianne Gonterman - Outreach Education (206) or (800) ext. 2 marianne.gonterman@ seattlechildrens.org

2 Closed Head Injury- New Guidelines Monique S. Burton, MD Interim Chief, Sports Medicine Program Clinical Assistant Professor Dept of Pediatrics, Dept of Orthopedics & Sports Medicine VTC Disclosure I do not have any conflict of interest or will be discussing any off-label product use. This class has no commercial support or sponsorship, nor is it co-sponsored. Concussion: Definition 1966 Committee on Head Injury Nomenclature of Neurological Surgeons Concussion is a clinical syndrome characterized by immediate and transient post-traumatic impairment of neural function such as alteration of consciousness, disturbance of vision or equilibrium, etc, due to brain stem dysfunction

3 Concussion: Definition American Academy of Neurology (AAN) any trauma induced alteration in mental status that may or may not include loss of consciousness Concussion: Definition International Conference on Concussion in Sport Vienna 2001, Prague 2004, Zurich 2008 Previous definition (AAN) fails to include common symptoms of concussion Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Concussion: Definition Direct blow to head, face, neck or elsewhere on body with an impulsive force transmitted to the head Rapid onset of short-lived impairment of neurological fxn that resolves spontaneously May result in neuropathological changes, but acute clinical syx reflect functional disturbance rather than structural injury Graded set of clinical symptoms +/- LOC Resolution typically follow sequential course Small % have prolonged post-concussive symptoms Neuroimaging studies usually negative

4 Dings Defined as a stunned confused state that resolves within minutes Do they exist? Probably not Avoid use of this term Treat as a concussion May be a more serious injury Symptoms may not be evident for minutes to hours later Pathophysiology Immediately after brain injury Abrupt indiscriminate neurotransmitter release & unchecked ionic fluxes occur Excitatory neurotransmitter binding to NMDA receptor Neuronal depolarization K efflux & Ca influx Acute & subacute changes in cellular physiology Pathophysiology In effort to restore neuronal membrane potential Na/KATP-ase activation hyperglycolysis Hypermetabolism in setting of CBF Disparity btwn glucose supply demand cellular energy crisis Brain less able to respond adequately to second injury & potentially leading to longer lasting deficits

5 Pathophysiology After initial accelerated glucose utilization: Depressed metabolism in brain Persistent Ca Impair mitochondrial oxidative metabolism Worsens energy crisis Directly activate pathways leading to cell death Intra-axonal Ca flux disrupt neurofilaments & microtubules, impairing posttraumatic neural connectivity Concussion: Epidemiology million children in nonscholastic sports annually ~ million sports & recreation related concussions in US each year children and youth ages 5-18 yrs accounted for 2.4 million sports related ED visits annually 6% (135,000) involved concussion Concussion: Epidemiology High School Reporting Information Online & NCAA Injury Surveillance System ( ) 8.9 % all high school athletic injuries 5.8 % all collegiate athletic injuries 16.8% had previous concussion (that season or prior season) Concussion Rates Football Girls soccer Boys soccer Girls basketball Girls had higher rate of concussions J Athl Train 2007 Gessel, et al

6 Evaluation VTC Evaluation: Signs & Symptoms Symptoms Somatic, cognitive, &/or emotional Physical Signs Behavioral Changes Cognitive Impairment Sleep Disturbances Evaluation: Signs Appears dazed/stunned Confused Forgets plays Unsure of game, score, opponent Clumsy Answers questions slowly LOC Change in behavior/personality Unable to recall events prior to hit Unable to recall events after hit

7 Evaluation: Symptoms Headache Pressure in head Nausea or vomiting Balance problems Dizziness Double vision Blurred vision Photophobia Phonophobia Feeling sluggish Feeling like in a fog Don t feel right Difficulty with memory or concentration Fatigue Confusion Drowsiness Difficulty with sleep More emotional Irritability Sadness Nervous/Anxious Evaluation: Sideline Who do you evaluate? ANYONE with concern for concussion What to do? Remove immediately from play Evaluate Standard emergency management, C- spine precautions Sport Concussion Assessment Tool Serial monitoring No Return to Play Sport Concussion Assessment Tool SCAT 2 Developed from International Conference on Concussion in Sport Zurich 2008 Ages 10 yrs & older

8 SCAT 2 Symptoms score Symptoms with physical &/or mental activity? Physical signs score +/- LOC, how long? Balance problem/unsteadiness? Glasgow Coma Scale (GCS) Sideline Assessment Maddocks Score At what venue are we today? Which half is it now? Who scored last in this match? What team did you play last week/game? Did your team win the last game? SCAT 2 Standardized Assessment of Concussion (SAC) Cognitive Assessment Orientation Immediate memory Concentration Delayed recall Balance Examination Coordination Examination Evaluation: Office Comprehensive History Include symptoms scale Detailed Neurological Exam Mental Status Assessment Cognitive Function Gait & Balance Determine Clinical Status Improvement, deterioration, no change Further Evaluation Neuroimaging Neuropsych testing

9 Mental Status LOC relatively rare (<10%) Usually very brief Prolonged LOC very infrequent Confusion & amnesia more common Confusion Impaired awareness to surroundings, memory systems not affected Appear stunned, dazed, glassy-eyed Difficulty w/ appropriate play calling, answer questions slowly or inappropriately, repeat oneself Amnesia Anterograde amnesia Loss in memory from point of injury until return of a full ongoing memory process Can be difficult to distinguish confusion from anterograde amnesia Assess when confusion cleared & lucid memory returns Can recall specific events just subsequent to injury Highly predictive of neurocognitive & symptom deficit Amnesia Retrograde amnesia Inability to recall events occurring during period immediately preceding trauma Difficulty with questions re: events just prior to trauma Length of amnesia usually shrinks w/ time Even seconds may be predictive of outcome

10 Amnesia v. LOC Collins, et al Clin J Sport Med athletes (61HS/17college) Preseason & postconcussion ImPACT w/in 5d (mean 1.7 d) Good (no baseline change)/poor ( syx, memory fxn) Results: (Poor group) 10x more retrograde amnesia 4x more PTA & >= 5 min of mental status change No diff btwn good and poor groups in terms of LOC Conclusion: Presence of amnesia, not LOC, appears predictive of syx & neurocognitive deficits following concussion Evaluation: Neuroimaging Controversial Not typically needed unless Worsening symptoms Prolonged symptoms Focal deficit What study? Brain CT or MRI Contribute little for concussion but appropriate if suspect intra-cerebral structural lesion Other Imaging Gradient echo, perfusion & diffusion imaging More sensitive, limited studies to support Evaluation: Neuropsychological Testing Assists with return to play decision making Should only be used to assist decision-making When to perform? For assistance with RTP when symptom free Prolonged Symptoms consult with neuropsychologist

11 Evaluation: Computerized Neuropsychological Testing ImPACT 20 minute neurocognitive battery test Formal Neuropsychology Testing Evaluation: Classifications/Grading Guideline Grade 1 Cantu 1. No LOC 2. Posttraumatic amnesia <30 min Colorado 1. Confusion w/out amnesia 2. No LOC Grade 2 1. LOC > 5 min OR 2. Posttraumatic amnesia > 30 min 1. Confusion w/ amnesia 2. No LOC Grade 3 1. LOC > 5 min OR 2. Posttraumatic amnesia >24 1. LOC (of any duration) AAN 1. Transient confusion 2. No LOC 3. Concussion syx, ms change resolve w/in 5 min Cantu 1. No LOC OR (Revised) 2. Posttraumatic amnesia signs/syx > 30 min 1. Transient confusion 1. LOC 2. No LOC (brief or prolonged) 3. Concussion syx, ms change >15 min 1. LOC < 1 min 1. LOC > 1min OR OR 2. Posttraumatic 2. Posttraumatic amnesia >30 min, <24 amnesia >24 OR 3. Post concussion signs/syx > 7d Evaluation: Classification/Grading No method universally accepted or consistently followed

12 Management VTC Management: Return to Play Physical Rest No physical activity beyond necessary daily routine No sports No running, PE class, weight lifting, excessive play Management: Return to Play Cognitive rest School work modifications Extra time for homework Postpone test Frequent breaks, short durations Avoid extra mental stimulation Video games Excessive computer use Excessive txt messaging

13 Management: Return to Play Graduated Return to Play Protocol Stepwise progression of exertion Only progress to next level if completely asymptomatic at current level Each step should take 24 hrs ~ 1 week to complete protocol once asymptomatic If symptoms recur at any point Rest until asymptomatic x 24 hrs Return to last asymptomatic step successfully completed Graduated Return to Play Rehab Stage Functional Exercise Objective 1. No activity 2. Light aerobic exercise 3. Sport-specific exercise 4. Non-contact training drills 5. Full contact practice 6. Return to play Complete physical & cognitive rest Walking, swimming or stationary bike; no resistance training Running drills; no head impact activity Progression to more complex training drills; start progressive resistance training After Medical Clearance Only; Restores confidence & Normal activity assess functional skills Normal game/competition Recovery HR Add movement Exercise, coordination, cognitive load Management: Other Psychological/Mental Health Monitor for depressive symptoms Treat accordingly Pharmacological For specific prolonged symptoms Sleep disturbance Anxiety, depression Careful RTP considerations to masking of symptoms

14 Children & Adolescents VTC Concussions High school athletes recovery times are longer than college athletes 3x more likely to sustain a 2 nd concussion Concussions: Children & Adolescents Physiological differences in children & adolescents May have prolonged diffuse cerebral swelling after TBI? risk for 2 injury Brain may be 60x more sensitive to glutamate (neurotransmitter in metabolic cascade of concussion) May lead to longer recovery period likelihood for permanent/severe neurological deficit if reinjury occurs

15 Second Impact Syndrome Schneider 1973: When an athlete who sustains a head injury- often a concussion or worse injury, such as a cerebral contusionsustains a second injury before syx associated with the first have cleared 1st head injury: postconcussive syx 2nd head injury (may be minor) Often no LOC, collapse to ground, semicomatose rapidly dilating pupils, loss of eye movement, resp failure Second Impact Syndrome Pathophysiology Loss of autoregulation of brain s blood supply Cerebral vascular congestion Vascular engorgement within cranium Markedly ICP Herniation of uncus of temporal lobe or lobes below tentorium of cerebellar tonsils through foramen magnum Animal research- brainstem failure very rapid (2-5min) Second Impact Syndrome Rare No athletic participation until symptoms completely resolve Monitor postconcussive symptoms closely Further research needed

16 Management Recommendations designed for > = 10 yrs Considerations for Young Athletes Age appropriate symptoms check list Include parent input, teacher/school input, if appropriate Age appropriate neuropsych testing when indicated More gradual RTP protocol Extend asymptomatic rest & graded exertion Legislation VTC Zackery 13 yrs old Football game Head trauma during play Returned to play Minor event Collapsed Significant brain hemorrhaging Devastating brain damage

17 Zackery Lystedt Law May 14, 2009 Governor Christine Gregoire signed House Bill 1824 Youth athlete suspected of sustaining a concussion or head injury in practice or game Remove from competition at that time May not return to play until: Evaluated by a licensed health care provider trained in the evaluation and management of concussions and Receive written clearance to return to play from that person Zackery Lystedt Law Information & policies by schools districts & WIAA Educate coaches, youth athletes and parents Nature & risk of concussion Dangers of returning to practice or competition after a concussion or head injury Concussion & head injury information Youth athlete and parent/guardian required to sign sheet yearly, prior to participation in athletic activity Private, nonprofit youth sports using public playfields Comply with this law New Directions Considerations in multiple other states ACSM Call to Action Possible nationwide policy

18 Concussion in Sports Physical & Cognitive Rest Healthy Diet Supportive measures Graduated return to play Medical clearance before return to play Avoid prolonged symptoms Avoid devastating brain injuries Healthy, safe environment for sports and play Helpful Resources Consensus Statement on Concussion in Sport; 3 rd International Conference on Concussion in Sport, Zurich 2008 SCAT 2 Graduated Return to Play Zackery Lystedt Law CDC Heads Up Tool Kit WIAA website- Coaches video Seattle Sports Concussion Program Harborview, UW, Seattle Children s THANK YOU! monique.burton@seattlechildrens.org VTC