Flawless 2/20/2018. All rights reserved. Sports Medicine Concepts, Inc. Concussion Management Specialist Program 1. The CMS Resources Page

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1 Sports Medicine Concepts Concussion Management Specialist On Field Management and Differential Diagnosis The CMS Resources Page Session Recordings Pre Recorded Sessions Seminal Readings Open Quizzes Case Study / Essay RFQ Must NOT Be Without EAP Represent A Standard of Care Position statements Peer Review 2Min Drill Specialist Program 1

2 The Medical Timeout Perhaps the most critical element of an EAP Eyes on The Field at All Times Obvious vs. Subtle Follow the ball Scan the sideline, back field, and court Watch players coming off the field Consider an Injury Spotter I really like this! Phase I: On Field Management Gain and Maintain Control of Scene Initial CABin Check LOC / Responsive Determine extent of injury and likelihood of transport Safe handling Level of service required Specialist Program 2

Head Trauma and The Unconscious Athlete Spreading depression LOC and Transport Brief vs.

Grade 2 (moderate) LOC <1 min or PTA >30 min <24 h or PCSS >24 h <7 d Grade 3 (severe) LOC

trauma Protect from further injury during seizure Prepare for airway management once

3 Head Trauma and The Unconscious Athlete Spreading depression LOC and Transport Brief vs. Prolonged Cantu Evidence Based Grading System Grade 1 (mild) No LOC PTA <30 min PCSS <24 h Grade 2 (moderate) LOC <1 min or PTA >30 min <24 h or PCSS >24 h <7 d Grade 3 (severe) LOC >1 min or PTA >24 h or PCSS >7 d Seizure and Airway Management Seizure secondary to head trauma Protect from further injury during seizure Prepare for airway management once seizure subsides MJT OPA/NPA 2 Person BVM Manual suction Secure ALS Service RSI Specialist Program 3

4 Acute Central Neuro Hyperventilation Working Definition Diffuse axonal injury disrupts brain stem centers resulting in vicious cycle: Totally unresponsive GCS =3 Cardiac Strong, rapid carotid pulse, tachycardic (> 100bpm) Airway Jaw may be clenched Breathing Tachypnea or Hyperventilation After 30 seconds breathing stops, pulse weakens/slows As CO2 rises, reflex initiates breathing Tachypnea/hyperventilation and tachycardia ACNH Management Activate EMS Prepare for HQ CPR Monitor vital signs Be very diligent with carotid pulse checks prior to arrival of EMS; Only apply AED if there is NO pulse Prepare for safe handling during transfer and prep for transport ACNH Prognosis May wake up and be stable prior to or during transport; May be stable, but remain unresponsive for period of time Long term consequences? Specialist Program 4

Progressive Transition SMC s Progressive Algorithm Reposition CABiN Apprehension Reassess in seated position Reassess in standing Support Initial Vital Signs Vital Sign Triad Sure CABiN, but what

5 Progressive Transition SMC s Progressive Algorithm Reposition CABiN Apprehension Reassess in seated position Reassess in standing Support Initial Vital Signs Vital Sign Triad Sure CABiN, but what else can we get from vital signs? Pulse rate Systolic blood pressure Body temperature Radial Pulse Check Screen for accelerated heart rate Screen for regular pulse pattern Rates > 140 may indicate abnormal heart rhythm Specialist Program 5

6 Temperature If elevated heart rate or low systolic blood pressure Electronic oral or tympanic Initial temperature readings > 100 occur during heat stress Vital Sign Trending Rule of 100 Pulse >100 Temperature > 100 Systolic BP <100 Trending Serial measurements at 10 minute intervals for 30 minutes Differentiate between serious and minor injury Specialist Program 6

Trending Pulse Rate Conditioned athletes normalize within 20 30 minutes Pulse rate >100 Anxiety Temperature Blood Pressure Initial readings of 140 170mmHg Normalize to 120/70 Persistent systolic

7 Trending Pulse Rate Conditioned athletes normalize within minutes Pulse rate >100 Anxiety Temperature Blood Pressure Initial readings of mmHg Normalize to 120/70 Persistent systolic pressure elevations significant head trauma Post Concussion Blood Pressure Widened pulse pressure with bradycardia increased intracranial pressure = pp 50 Serial Temperature Readings Performed to confirm initial readings Useful in assessing heat illnesses Internal injury Specialist Program 7

consultation SMC s Enhanced Vital Signs Trending Report Interpretation of Signs / Symptoms Lucid Interval Intermittent

8 SpO2 Pulse Oximetry Rule of 100 Applied again following vital sign trending 30 min normalization for majority of injured athletes Persistent triad abnormalities referred to ED Normal vitals following trending sent for physician consultation SMC s Enhanced Vital Signs Trending Report Interpretation of Signs / Symptoms Lucid Interval Intermittent improvement / deterioration of level of consciousness and other s/s More typical of hematoma than concussion Specialist Program 8

Intracranial Pressure Body s compensatory reflexes will accommodate small rises in ICP Initial inc may not be readily observable When ICP reaches MAP there is a decrease in CBF

vasoconstriction Lucid interval Hyperventilation Sluggish or dilated pupils Widened pulse pressure Second Impact Syndrome Relatively minor blow loss of auto regulatory centers

9 Intracranial Pressure Body s compensatory reflexes will accommodate small rises in ICP Initial inc may not be readily observable When ICP reaches MAP there is a decrease in CBF Inc systolic blood pressure to compensate for deccbf Vicious cycle with devastating consequences Hematoma Bradycardia Hypo hypertension Respiratory depression Systemic vasoconstriction Lucid interval Hyperventilation Sluggish or dilated pupils Widened pulse pressure Second Impact Syndrome Relatively minor blow loss of auto regulatory centers of the brain cerebral hyperemia and edema that is virtually impossible to control Elevated ICP w/herniation Adverse affects on CNN within minutes Death in 50% of cases Specialist Program 9

Acute Signs & Symptoms of SIS Acute S/S Resemble SRC Loss of coordination Rapid LOC Coma Dilating pupils that are motionless Respiratory distress a minor concussion, but readily deteriorate due to

10 Acute Signs & Symptoms of SIS Acute S/S Resemble SRC Loss of coordination Rapid LOC Coma Dilating pupils that are motionless Respiratory distress a minor concussion, but readily deteriorate due to pressure on CNN Children and Risk Children appear to more vulnerable to cerebral swelling and subdural hematoma Increased sensitivity and more conservative approach Indications for Transport Level 1 Trauma Center Cannot rule out CSI Hematoma S/S Increased intra cranial pressure When to Refer Monitor vitals and LOC every 5 min Lucid interval Deteriorating S/S Inc number of Inc graded symptom score Specialist Program 10

11 Phase 2: Sideline Assessment Protect immediate health / Prevent protracted recovery / PCS What you do from minute 1 could make the difference between simple recovery and protracted recovery or post concussion syndrome CRT Witch Doctor? Special Juice 1 qt Omega 3 Protracted Recovery and PCS If you re Not Measuring, Your Guessing Journal of Athletic Training 2017;52(3): Specialist Program 11

Follow Up Acute Assessment Cranial Nerves 90% of a thorough head injury assessment CNN Assessment Guide SCAT 5 and Child SCAT 5 When and Where? Directly after injury? / On Sideline?

12 Follow Up Acute Assessment Cranial Nerves 90% of a thorough head injury assessment CNN Assessment Guide SCAT 5 and Child SCAT 5 When and Where? Directly after injury? / On Sideline? Upon determination of concussion to document signs and symptoms? Graded symptom checklist at injury SCAT5 20+ min post injury Locker room Training room Vestibular Signs and Symptoms Acute signs and symptoms may not be accurate indicator of VS injury Within first week 40% report balance problems 30% report vision problems Generally recover in 3 5 days, maybe up to 10 days. Specialist Program 12

VOMS Tests Smooth Pursuits Horizontal Saccades Vertical Saccades Near Point Convergence Horizontal VOR Vertical VOR Visual Motion Sensory Test VOMS Recordings 0 10 Headache Dizziness Nausea Fogginess

13 VOMS Tests Smooth Pursuits Horizontal Saccades Vertical Saccades Near Point Convergence Horizontal VOR Vertical VOR Visual Motion Sensory Test VOMS Recordings 0 10 Headache Dizziness Nausea Fogginess King Devick The King Devick (KD) test is a screening tool designed to assess cognitive visual impairments, namely saccadic rhythm, postconcussion. Journal of Athletic Training 2017;52(5): Specialist Program 13

C3 Logix Concussion Assessment System i Pad Based Cleveland Clinic Combines benefits of ImPact, SCAT3, BESS, and RTP Completed in about 20 Min Cloud based application Concussion Assessment System

are life threatening, but PCS is a more likely consequence of sports related concussion Cameron KL, et al. (2000).

14 C3 Logix Concussion Assessment System i Pad Based Cleveland Clinic Combines benefits of ImPact, SCAT3, BESS, and RTP Completed in about 20 Min Cloud based application Concussion Assessment System Provides for Graded symptom checklist Reaction time Memory & Speed processing Motor function Vision Balance Vestibular function Post Concussion Syndrome Risk Epidural and Subdural hematomas and SIS are life threatening, but PCS is a more likely consequence of sports related concussion Cameron KL, et al. (2000). Predicting the development of post concussion syndrome from initial signs and symptoms following mild traumatic brain injury. JAT S, 35(2), S 54. Predicting Significant predictors amnesia, balance abnormalities, tinnitus & visual impairments at 20 min. 87% probability headache & amnesia at 5 min 73% probability headache, dizziness & balance abnormalities at 20 min Specialist Program 14

Head Injury Warning Sheet Written concussion signs and symptoms even if there is a remote possibility that the athlete suffered a concussion Yellow Card 72hrs post injury critical Pass from school,

15 Head Injury Warning Sheet Written concussion signs and symptoms even if there is a remote possibility that the athlete suffered a concussion Yellow Card 72hrs post injury critical Pass from school, homework Full physical and cognitive rest Physician Evaluation Form Signs and symptoms checklist Explicit diagnosis of concussion Physician follow up Policy overrides ER/Physician Specialist Program 15

Special Consideration for Young Athletes Age related difference exist between HS and college athletes Increased symptom severity Prolonged recovery Sports related head injury has a

JP, McCrea M, Putukian M, Valovich McLeod TC. National Athletic Trainers Association position statement: management of sports related concussion. J Athl Train. 2004;39(3):280 297.

16 Special Consideration for Young Athletes Age related difference exist between HS and college athletes Increased symptom severity Prolonged recovery Sports related head injury has a relatively high incidence rate in youth 15% of all ER head injuries 3% of all sports related injuries 24% of all serious head injuries Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M, Putukian M, Valovich McLeod TC. National Athletic Trainers Association position statement: management of sports related concussion. J Athl Train. 2004;39(3): Equipment Issues Proper Fit For Tomorrow Session Review Recording posted shortly Power Point link Readings Hematoma vs. Concussion Leddy Neuro Rehab Adolescent and Pediatric Rehab Strategies 48 Specialist Program 16

17 Conclusion Assessment Interpretation of signs and symptoms Vital signs trending Rule of 100 Pulse pressure Pulse rate Predicting PCS / Protracted Recovery Concussion vs. Hematoma Rising ICP Widened pulse pressure Bradycardia Specialist Program 17

Flawless. Mike Cendoma, MS, ATC. Athletic Trainer. Sports Medicine Concepts. Get Your Coffee and Get Comfy. We ll Start in Just A Few!

Flawless. Mike Cendoma, MS, ATC. Athletic Trainer. Sports Medicine Concepts. Get Your Coffee and Get Comfy. We ll Start in Just A Few! Sports Medicine Concepts Get Your Coffee and Get Comfy. We ll Start in Just A Few! Mike Cendoma, MS, ATC Sports Medicine Concepts, Inc Suite of Services Since 1995 Founder, Program Director In 2Min or