Brain Concussion: A Stealth Injury. Christine Schulman, RN, MS, CNS, CCRN Trauma & Critical Care CNS Legacy Health, Portland, Oregon Director, AACN

Transcription

1 Brain Concussion: A Stealth Injury Christine Schulman, RN, MS, CNS, CCRN Trauma & Critical Care CNS Legacy Health, Portland, Oregon Director, AACN

2 Legacy Emanuel Medical Center Portland, Oregon

3 Disclosures No disclosures related to this presentation

4 Objectives Identify the mechanism and pathophysiology of concussion Explore the neurologic sequelae of cerebral concussion Describe symptoms and initial management of concussion and post-concussion syndrome.

5 Close to Home On the Skykomish

6 Skiing at Chamonix

7 Barkley Sound

8 February 2001

9 February 2001

10 February 2001

11 Cerebral Concussion: What Is It? A complex pathophysiological process Direct blow, to the head, face, or neck, or transfer of force from elsewhere to the brain Rapid onset of short-lived, spontaneously resolving neurologic impairment Symptoms due to a functional disturbance rather than structural injury May or may not involve loss of consciousness McCrory P, et al., Consensus statement on concussion in sport: the 4 th International Conference on Concussion in Sport. Br J Sports Med. 2013;47:250.

12 Severity Severity determined by the DURATION and NUMBER of postconcussion symptoms Not LOC Not amnesia The severity of concussion should not be determined on the day of concussion, but only after all symptoms have resolved

13 Concussion Classifications in 2004 Simple Most common form of concussion Resolves without complication over 7-10 days Cornerstone of management is rest until all symptoms resolve Can be managed by primary care MD or certified athletic trainers

14 Concussion Classification in 2004 Complex Persistent symptoms Specific sequelae Concussive convulsions Prolonged LOC > 1 minutes Prolonged cognitive impairment following injury Neuropsychological testing Managed by multidisciplinary team with experience in concussion (sports neurologist or neurosurgeon)

15 Mechanism of Concussion Front-to-back Side-to-side Top-to-bottom Rotational Blast injury?

16 Pathophysiology

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19 Pathophysiology Neurochemical Cascade For days to weeks after concussion: Release of excitatory amino acids Increase in glucose demand Altered cerebral autoregulation to meet energy demands Alters chemical and ionic environment of the brain BBB disruption Neural tissue susceptible to further injury

20 Theoretical Concussion Pathophysiology Concussion Hyperexcitation Depolarization Depolarization Increased excitatory amino acids (EEA), glutamate NMDA receptors Severe or repeat injury? Spreading Depression? Lactate accumulation K+ efflux Ca++ influx Na+/K+ activity Hyperglycolysis For ATP (30min) Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. Journal of Athletic Training (3) Mitochondria Impaired oxidative metabolism Decreased glucose Cell damage? Decreased CBF Glucose-CBF Uncoupling Shaw, NA The Neurophysiology of concussion. Progress in Neurobiology. 2002, 67,

21 At Risk Populations Traditional Trauma Patients

22 Sports Concussion More than 300,000 sports related concussions per year

23 Football 5 th most prevalent injury between in NFL 184 incidents per year Quarterbacks have highest risk, followed by wide receivers Highest risk plays are kickoffs and punts Youth, high school, and college players are at greater risk than professional players

24 So Are Concussions Clinically Significant?

25 Concussion Sequelae Post-Concussion Syndrome Second-Impact Syndrome Dementia Pugilistica Alzheimer s Dementia Chronic Traumatic Encepahlopathy (CTE)

26 Post-Concussion Syndrome Persistence of concussion symptoms beyond a normal recovery period Persist weeks to months following injury Affect return to normal ADL

27 Second Impact Syndrome Second head injury sustained before symptoms of the first injury resolve May occur days to weeks after initial injury May be more likely to cause devastating brain swelling and death Younger patients at greater risk

28 Concussion #1 Concussion #2, still recovering from #1 failure of cerebral vascular autoregulatory mechanism Vasogenic and cytotoxic edema cerebral blood volume Posttraumatic brain swelling McRory, P. Does Second Impact Exist? Clin J Sports Medicine; 2001; 11:

29 Dementia Pugilistica Punch Drunk More commonly seen in boxers (20% incidence) Parkinsonian movement pattern Risk associated with increased exposure and number of concussions

30 Alzheimer s Dementia Concussions lower the age of onset of dementia Deficiency/dysregulation of brain acetylcholine

31 Chronic Traumatic Encephalopathy (CTE) Progressive degenerative disease Repeated concussive & subconcussive blows to the head Symptoms begin 8=10 years after injury Difficult to diagnose and predict Imaging Bio-markers

32 Guiding Principles of Concussion Management: Recognition, Respect & Paranoia

33 Field Assessment Tools

34 Symptoms- Physical Signs Loss of consciousness/impaired LOC Poor coordination, balance, gait unsteadiness Concussive convulsions/impact seizure Vacant stare/glassy eyed

35 Symptoms Somatic Headache or pressure in the head Balance problems or dizziness Nausea & vomiting Visual problems Hearing problems Numbness & tingling

36 Symptoms Cognitive Feeling slow or in a fog Confusion Amnesia Slow to answer questions Easily distracted, poor concentration Inappropriate playing behavior Unaware of game period, opposition, or game score

37 Symptoms Neurobehavioral Inappropriate emotions Drowsiness Fatigue/lethargy Sadness/depression Nervousness/irritability Excess sleep, insomnia

38 Management of Acute Concussion Mental and physical rest Observation with wake-ups CT scan with worsening sx Sx management Headaches: acetominophen Light diet Written discharge instructions What to do if sx worsen What to do if sx don t resolve in 5-10 days

39 Management of PCS Identification 3 or more of the following that do not resolve within appropriate time period Headache Fatigue Sleep disturbance Vertigo Hearing Loss Irritability Anxiety Depression Apathy Difficulty with concentration Personality change

40 Prevention Restriction from play/work while symptomatic Protective equipment Rule changes Rule enforcement Weight training to strengthen neck muscles Education of athletes, coaches, family members, and health care team

41 Legislative & Litigation Measures

42 Trauma Patients Remember mechanism of injury Pursue explanation for inappropriate behavior Assess multiple times On acute care unit At time of discharge During clinic visits At school Instruct families and patients to be alert for sx of PCS

43 Close to Home The Rest of the Story

44 comcast.net lhs.org