Concussion Management. Michael Reardon, M.D. April 24,2016

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1 Concussion Management Michael Reardon, M.D. April 24,2016

2 Objectives Understand what a concussion is Know how to recognize it Understand the differential diagnosis Know how to manage and treat symptoms Know when to refer for more comprehensive evaluation

3 What is a Concussion? Trauma to the head Does not have to be direct blow to head Pathophysiological Changes Neuro-metabolic cascade Clinical Syndrome Signs and symptoms

4 What Causes a Concussion? Impact or acceleration/deceleration forces Helmets do not prevent concussions

5 What is a Concussion? Pathophysiological Changes Neuro-metabolic cascade

6 Clinical Syndrome Observable Signs Loss of consciousness (only 10-15%) Amnesia or confusion Dazed, slowed down, sluggish, sleepy Mood or Behavioral changes Balance problems Vomiting

7 Clinical Syndrome Subjective symptoms Headache or pressure in head Vision changes: blurry, fuzzy, spots/stars Nausea Sensitivity to light and noise Dizziness Feeling slowed down, like in a fog Trouble remembering and concentrating Irritable, anxious, or depressed mood Sleepy or trouble sleeping

8 Common Features of Concussion Onset relatively immediate, though may go unrecognized Tends to improve with rest, and worsen with exertion or over-stimulation With good management, usually resolves over days to weeks

9 Differential Diagnosis Moderate to severe TBI Non-TBI causes of symptoms Dehydration, heat exhaustion, migraine Side effects or complications of treatment Deconditioning, anxiety, somnolence or altered circadian rhythm Psychological disorders

10 How to differentiate concussion from GCS >13 more severe TBI Amnesia/disorientation resolves within 1-2 hours No focal deficits Able to walk independently Normal Head CT or MRI

11 Features suggesting some other problem Significant delay in onset of symptoms/signs Displaying profound memory impairment Continued somatic complaints after several weeks Very specific or peculiar triggers for symptoms Significant emotional or behavioral symptoms

12 Management of Concussion Immediately remove from game/event Never return to sport/activity on same day Medical evaluation prior to return to sports or high-risk activities Gradual, step-wise return to sports after symptoms and signs have resolved

13 Management of Concussion Avoid repeat injury Education Treatment of symptoms Relative rest Gradual return to activities as tolerated

14 Management of Concussion Education Full recovery can range from days to several weeks; cannot be predicted at onset Repeat head trauma before full recovery can damage the brain; highest risk in first 1-2 weeks Light exercise as tolerated will NOT harm the brain, and will likely help Attempting cognitive/academic activities as tolerated will NOT harm the brain Treating headaches and other symptoms is helpful for recovery; not just masking symptoms

15 Treatment of Symptoms Headaches Nausea Dizziness Sleep disorder Anxiety or depressed/irritable mood Cognitive impairment

16 Treatment of Headaches First line Naproxen 15mg/kg/day divided BID Magnesium mg BID May add benedryl + phenergan mg/kg/dose q 6-8 hr as needed May add imitrex 25-50mg q 8 hr x 2-3 days

17 Treatment of Headaches Second line Cyproheptadine 4-12mg qhs; may add smaller dose in AM as tolerated or Amitriptyline 25-50mg qhs Consider hospitalization for IV meds if severe and not improving

18 Treatment of other Symptoms Nausea Phenergan, compazine, or reglan better than zofran for migraine Dizziness No medication works for dizziness (including Meclizine) Time, rest, gradual increase in movement Vestibular Therapy when not improving

19 Treatment of other Symptoms Sleep disorder Sleep hygiene; maintain normal circadian rhythm; exercise Melatonin 3-6mg; up to if helpful; benedryl mg Cyproheptadine, amitriptyline, or gabapentin (esp if headaches) Anxiety or depressed/irritable mood Psychotherapy Consider SSRI and/or psychiatry Cognitive impairment Omega 3: fish oil mg/day; or Vayarin 2 capsules/day

20 Management of Concussion Relative rest, as tolerated At least one day at home; a few days if needed; plan to return to school with adjustments Encourage light, relaxing activities as tolerated Encourage short trials of school work as tolerated Return to school when tolerating moderate activities without significant worsening of symptoms

21 Management of Concussion Recommended School Adjustments Encourage flexibility based on symptoms Avoid noisy, crowded environments Bus, cafeteria, gym; change classes before bell rings Reduce the amount of work; allow more time Delay testing or adjust tests Shorter tests; multiple choice or open note Allow rest breaks and extra time

22 Management of Concussion Gradual return to exercise Start very light, low impact exercise, even if still having symptoms; walking or stationary bike Find pace that does not cause worsening of symptoms; suggest 5-15 minutes Gradually increase pace and/or duration over several days as tolerated When symptoms have cleared, can advance to more strenuous, higher impact exercise

23 Management of Concussion When to clear for full return to sports All symptoms have cleared, without medication, and with full participation in school and vigorous non-contact exercise School performance is back to baseline Neurological exam is normal If pre-injury baseline tests were performed, postinjury scores are within range of baseline

24 Management of Concussion When to refer for further evaluation Complex past history Multiple concussions; other neuro issues Unusual symptoms or signs Severe headaches or other symptoms Symptoms are not improving in 1-2 weeks with first-line management

25 Far West Clinic Physician Back-line: Fax: Cedar Park Clinic Physician Back-line: Fax:

Signs and Symptoms of Concussion

Signs and Symptoms of Concussion These signs and symptoms following a witnessed or suspected blow to the head or body are indicative of probable concussion. Signs (observed by others) Appears dazed or