Concussion in Children

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1 S306- Management of Concussion in Children John Kuluz, MD Neurorehabilitation Miami Children s Hospital

2 Disclosure of Relevant Relationship Dr. Kuluz (or spouse/partner) has not had (in the past 12 months) any conflicts of interest to resolve or relevant financial relationship with the manufacturers of products or services that will be discussed in this CME activity or in his presentation. Dr. Kuluz will support this presentation and clinical recommendations with the best available evidence from medical literature. Dr. Kuluz does not intend to discuss an unapproved/investigative use of a commercial product/device in this presentation.

3 Epidemiology of Pediatric TBI >600,000 ED visits/yr in US <18 years Many TBIs go undiagnosed and unreported 60,000 admissions/yr; 7,400 deaths (US, 2006) Good news Prevention works! - CDC data (from ; April, 2012) show 29% decrease in mortality from accidents in children 0-19 y: MVA 41% Falls 19% Drowning 28% Fire/Burns 45% Infant suffocation 54% Teen drug deaths 91% All accidental mortality by age

4 Classification of TBI Based on Glasgow Coma Scale (GCS): Mild (80-85%) (10-20% GCS 13 will have + CT) Moderate 9-12 (5-10%) Severe 3-8 (8-12%

5 Sign GCS Pedi GCS Score Motor Obeys commands Spontaneous 6 Response Localizes pain Withdraws to touch 5 Withdraws Withdraws to pain 4 Flexion Flexion 3 Extension Extension 2 None None 1 Verbal Oriented Age-appropriate 5 Response Confused Cries/irritable 4 Inappropriate Cries only to pain 3 Incomprehensible Moans only to pain 2 None None 1 Eye Spontaneous Spontaneous 4 Opening To command To sound 3 To pain To Pain 2 None None 1 Best possible score 15

Definition of Concussion Concussion is a mild brain injury (GCS 14-15) with brain dysfunction caused by direct or indirect mechanical force to the head A functional disturbance rather than structural

6 Definition of Concussion Concussion is a mild brain injury (GCS 14-15) with brain dysfunction caused by direct or indirect mechanical force to the head A functional disturbance rather than structural injury Rapid onset of neurological symptoms and cognitive impairment. May or may not have LOC, Amnesia, Seizures, Vomiting, HA Almost all have normal neuroimaging CT and MRI. Dysfunction typically resolves spontaneously and is usually followed by characteristic post-concussive symptoms.

7 Headache Signs and Symptoms of Concussion Physical Cognitive Emotional Sleep Feeling mentally foggy Irritability Nausea, Vomiting Feeling slowed down Sadness Balance problems Visual problems Fatigues easily Sensitivity to light Sensitivity to noise Dazed, Stunned Difficulty concentrating Difficulty remembering Forgetful of recent information Confused about recent events Answers questions slowly Repeats questions More emotional Nervousness Affective disorders Impulse control Aggressiveness Drowsiness Sleeping more than usual Sleeping less than usual Difficulty falling asleep

8 LOC known or suspected Clinical Presentation Kupperman/PECARN study, 2009 Findings < 2 years 2-18 years 5% (> 1 min in 1.6%) 18% (> 1 min in 3.7%) Headache % (severe 3.1%) History of Vomiting 15% 12% GCS 14 (remainder 15) 4.3% 2.7% Altered mental status 11.6% 13.6% Not normal per parents 14.3% 16.4% Palpable Skull Fx 3.4% 2.1% Signs Basilar Skull Fx 0.5% 0.7% Scalp Hematoma 44% (63% frontal) 38% (48% frontal)

9 Epidemiology of Pediatric Concussions Meehan, et al. Pediatric concussions in US emergency departments in the years J Pediatr 2010;157: Concussions: 3,800,000 recreation/sports-related conc/ year (all ages) 144,000 concussions present to pediatric ED annually ( ) 69% Males Age distribution: (depends on population studied) < 1 year 4% % % % % (Data collected from the National Hospital Ambulatory Medical Care Survey from 600 randomly selected EDs and clinics.)

10 Epidemiology of Pediatric Concussions Geographic: South 38%, Northeast 19%, Midwest 22%, West 21% Mechanism: Sport s/rec 30% Falls 21% MVA 20% Bicycle 6% Assault 4% Hit by car 2% Other 13% Meehan, et al. Pediatric concussions in US emergency departments in the years J Pediatr 2010;157:

11 Injury Mechanism in Pediatric Concussions Comparison of 2 different studies Mechanism: Sports/Rec 30% Falls 21% MVA 20% Bicycle 6% Assault 4% Ped hit by car 2% Other 13% Age 0-19y, only 20% <5y Meehan, et al. CT rate 69% Mechanism: Fall from height 27% Fall ground vs collision 17% MVA 9% Fall stairs 7 % Sport-related 7% Head struck 7% Assault 7% Bicycle 4% Ped hit by car 3% Other 8% Age < 18y, 25% < 2y Kupperman, et al. CT rate 35%

12 Sports-Related Concussions in Children and Adolescents High Risk Low Risk Sport Football Girls' soccer Boys' lacrosse Boys' soccer Girls' basketball Wrestling Girls' lacrosse Softball Boys' basketball Boys' and girls' volleyball Baseball Injury Rate/1000 Athlete Exposures a,b 0.36 a c,d 0.22 a 0.21 a 0.18 a c,d 0.07 a 0.07 a 0.05 a 0.05 a

include: Behavioral, Social ADHD, Learning disorders

13 Most pediatric concussions are NOT sports-related Pre-morbid factors that affect risk for mtbi and recovery include: Behavioral, Social ADHD, Learning disorders Genetic, Family functioning Medical/Neurological diagnoses Migraine hx

14 Linear Example: A child falls to the ground and hits his forehead. The falling motion propels the brain (frontal lobes) in a straight line downward. Rotational Example: When a football player is tackled, his head may be struck at an angle and spin in the horizontal plane, causing a rotational injury.

15 Pathological Mechanisms of Concussion/mTBI Dirnagl et al., 2003 Global CBF : Pediatric Sports-Related Concussion Produces Cerebral Blood Flow Alterations. Maugans, et al. Pediatrics 2012;129; Global CBF remained below normal 2-3 days (79%) and 1-2 months (83%) post-injury

16 Management of Concussions

17 Goals of ED/Office Management of Concussion/mTBI Rule out something BAD (brain, other injuries) Document Hx, findings, symptom severity Treat symptoms/provide supportive care Educate, reassure patient and family Observation period Discharge plan with follow up

18 Rule out BAD things - Brain, other injuries Careful history Mechanism of injury, height of fall, LOC, vomiting, HA, Sz Prior brain injury Physical exam Dehydration is common in athletes esp with vomiting Other traumatic injuries Complete neuro exam Focal deficits motor and sensory Cerebellar Vestibular/Balance/Nystagmus Dix-Hallpike Special attention to the C-spine follow clearance protocol Cognitive assessment Orientation, ST memory, processing speed, simple math (Serial 7s)

What predicts intracranial lesions in children with mild TBI? CHALICE rule: Children s Head Injury Algorithm for prediction of Important Clinical Events. Dunning, et al. Arch Dis Child 2006.

19 What predicts intracranial lesions in children with mild TBI? CHALICE rule: Children s Head Injury Algorithm for prediction of Important Clinical Events. Dunning, et al. Arch Dis Child ,772 pts, 3.3% had CTs Abnormal CT in 281=1.2% Admitted 1,461 (6.4%) 12 pts not scanned sent home/deteriorated/7 NSGY 27 pts not scanned admitted /deteriorated/ 24 NSGY Study weakness: Enrolled all severities of TBI

20 Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Kuppermann N, et al. Lancet Oct 3;374(9696): ,412 children 0-18y (<18) with mtbi at 25 Pedi EDs 25% < 2 years; excluded very mild TBI, eg, scalp lacs 35% had brain CT as per physician s discretion 9% of patients were admitted Clinically important TBI (citbi) defined as: Death from TBI Intubation for > 24 h Hospital stay 2 days Neurosurgical intervention

21 Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Kuppermann N, et al. Lancet Oct 3;374(9696): Predictors of citbi in < 2y Altered mental status LOC >5 seconds Mechanism of injury severe Palpable skull Fx Scalp hematoma (not frontal) Not normal per parent TBI on CT 8.5% citbi 0.9% Neurosurgery 0.2% Predictors of citbi in 2-18 y Altered mental status LOC (any LOC) Mechanism of injury severe History of vomiting Clinical signs basilar skull Fx Severe headache TBI on CT 4.3% citbi 0.9% Neurosurgery 0.1%

22 Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Kuppermann N, et al. Lancet Oct 3;374(9696): Severe mechanism: Fall from >3 ft (<2y), >5 ft (2-18y) MVA: Pt ejected, roll over, death of another passenger Pedestrian or bicyclist hit by car Struck with high velocity object Mild: Fall from ground height or ran into something Medium: Inbetween mild and severe

23 Children < 2 years Authors imply that infants < 3 months should be managed more conservatively due to the well known difficulty in picking up brain injuries using physical exam alone in this age group.

24 Children 2-18 years Study weakness: definition of clinically important. In the ED we have to decide who stays or is discharged, and a child with a positive CT needs to be admitted.

25 Total PCS Interview score Recovery trajectories of Post-Concussive Symptoms (PCS) in mtbi (GCS 13-15) (Keith Yeates, PhD) No PCS Moderate Persistent PCS High Acute/Resolved PCS High Acute/Persistent PCS Days post-injury

26 Timeline of a Concussion/ mtbi C. Risk Factors A. Injury Characteristics B. Symptom Assessment CONCUSSION Pre-Injury Risks Retrograde Amnesia 20-35% LOC <10% Anterograde Amnesia 25-40% Neurocog dysfx & Post-Concuss Sx s Sec-Hrs Sec-Min Sec-Hrs Hours - Days - Weeks+

27 Cognitive Recovery From Concussion: How Long Does it Take? WEEK 5 WEEK 4 WEEK 1 WEEK 3 WEEK All Athletes No Previous Concussions 1 or More Previous Concussions N=134 High School athletes Collins et al., 2006, Neurosurgery

28 Keys to Recovery Resting the Brain and the Body Not over-exerting (over-using) it Not interfering with physiological recovery Ways to over-exert Physical Cognitive! (concentration, learning, memory) Emotional

29 Follow-Up Plan: Multi-Visit Model Pre-Concussion Baseline Testing 1-3 Days Day 7 Day 14 Concussion *Barth et al., 2002

30 H.S.

31 Intervention & Management Monitor for neurological changes Management of post-concussive symptoms Concussion education, reassurance Evaluate & manage risks - home, school, sports/ recreation Management of activity Physical exertion Mental/ cognitive exertion

32 Acute and Post-Concussion Symptom Relief Psychopharmacology Headaches Pain Nausea/Vomiting Vestibular Sleep problems Attention Anxiety Depression Psychology Sleep problems Anxiety Depression Headaches NOTE: Athletes should not return to play until athlete is no longer taking medication because medication can mask symptoms.

33 Heads Up: Brain Injury in Your Practice Information for Physicians Facts for Physicians booklet [PDF 4.58MB] Acute Concussion Evaluation (ACE) form [PDF 79KB] ACE Care Plan Work version [PDF 88KB] School version [PDF 91KB] Concussion in Sports palm card [PDF 138KB]

34 Acute Concussion Evaluation (ACE)

35 Managing Exertion Managing physical and cognitive activity Risk for increase or re-emergence of postconcussion symptoms following significant exertional activity Pay attention to symptom exacerbation with activity Managing school demands and physical activities

36 ACE Care Plan Linking Diagnosis With Treatment

37 Facilitating Recovery in the School Return to School +/- Accommodations Full vs. Partial Day Modified Day: Classes w/ rest breaks Shortened classes Test taking Monitoring function/ performance fatigue, headache, concentration, memory, etc.

38 Stepwise Return to Play The express elevator is broken you ll have to take the steps! Rehabilitation Stage Functional Exercise 1. No activity Complete physical and cognitive rest 2. Light aerobic activity Walking, swimming, stationary cycling at 70% maximum heart rate; no resistance exercises 3. Sport-specific exercise Specific sport-related drills but no head impact 4. Noncontact training drills More complex drills, may start light resistance training 5. Full-contact practice After medical clearance, participate in normal training 6. Return to play Normal game play

Clinicians may use the concussion label because it is less alarming to parents than the term mild brain

39 ''My Child Doesn't Have a Brain Injury, He Only Has a Concussion'' DeMatteo, et al. Pediatrics 2010;125;327. Clinicians may use the concussion label because it is less alarming to parents than the term mild brain injury, with the intent of implying that the injury is transient with no significant long-term health consequences. That which we call a rose, by any other name would smell as sweet? William Shakespeare

40 Concussions are Serious Brain Injuries! Second Impact Syndrome (Very rare- 2-4 cases/yr): When an individual who has sustained a mtbi/concussion sustains a second head injury before fully recovering from the first, and as a result develops severe TBI, malignant brain swelling and severe neurological devastation or death. Thought to be more common in young adults/adolescents. Zachary Lystedt: 13 yo RB/CB injured 1 st half, sat out 15 min then played second half. Multiple hits. Collapsed after game, SIS, emergent neurosurgery. Town settled lawsuit $14.6 million.

41 Concussions are Serious Brain Injuries! (and the Florida Legislature agrees) Zackery Lystedt Law (Washington State): Prohibits young athletes who show signs of having sustained a concussion from returning to play without a licensed healthcare provider s written approval. Florida SB 256: (goes into effect July, 2012) Requires that a youth athlete who is suspected of sustaining a concussion or head injury in a practice or competition be immediately removed from that activity, and may not return to practice or competition until the youth receives written clearance to return from a physician

42 Concussions are Serious Brain Injuries!

43 Concussions are Serious Brain Injuries! Chronic Traumatic Encephalopathy (CTE) Dave Duerson

44 Association Between Recurrent Concussion and Late-Life Cognitive Impairment in Retired NFL Players ( 50 yrs) Guskiewicz et al. Neurosurgery, : * Questionnaire study of 2,552 former players. 61% had at least 1 concussion, 24% 3 or more. (MCI mild cognitive impairment)

45 Concussions are Serious Brain Injuries! From the pigskin to the bacon - Lawsuits by >1200 ex-players claim negligence by NFL in their handling of head injuries Tom McHale

ImPACT Testing Immediate Post-Concussion Assessment and Cognitive Testing A timed 20-minute computer-based cognitive testing program Requires monitored standardized test conditions

46 ImPACT Testing Immediate Post-Concussion Assessment and Cognitive Testing A timed 20-minute computer-based cognitive testing program Requires monitored standardized test conditions $600/year school fee to use; $1200 for physicians plus per test fee Results on line and available to brain injury clinicians Age 16 and up but some pedi centers use down to age 10y

47 Pediatric ImPACT Gerry Gioia, PhD DC Children s Computerized cognitive testing system Adaptation of ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing - for adolescents/ adults) Subtests measure same constructs (e.g., memory, attention, speed) Developmentally-appropriate Task instructions Test stimuli (pictures, words) Developed for age subtests, 5 alternate forms

55 Internet Resources: Computerized neuropsychological tests US Army Medical Department, Automated Neuropsychological Assessment Metrics (ANAM): CogState: Headminder: ImPACT: Information on head injury Centers for Disease Control and Prevention Heads Up Toolkit for High School Sports: Centers for Disease Control and Prevention Heads Up Toolkit for Schools: Centers for Disease Control and Prevention Heads Up Toolkit for Physicians:

58 Summary Concussions in children are very common Concussions are serious brain injuries ED goals are primarily: Diagnostic R/O more severe injuries (Kupperman algorithm) Supportive treat acute symptoms Education patient and family Discharge planning A comprehensive follow-up plan is mandatory for children with concussion to prevent secondary complications: Repeat brain injuries Persistence of post-concussive symptoms School peformance Family functioning

59 Concussions are Serious Brain Injuries!

60 Questions? Thank You!

Disclosure Statement. Dr. Kadish has no relevant financial relationships with any commercial interests mentioned in this talk.

Disclosure Statement. Dr. Kadish has no relevant financial relationships with any commercial interests mentioned in this talk. Disclosure Statement Dr. Kadish has no relevant financial relationships with any commercial interests mentioned in this talk. Head Trauma Evaluation Primary and secondary injury Disposition Sports related