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Concussion: Evidence-Based Blueprint for Success Aaron Vaughan, MD MAHEC Sports Medicine Director MAHEC/Mission Primary Care Sports Medicine Fellowship.

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Presentation on theme: "Concussion: Evidence-Based Blueprint for Success Aaron Vaughan, MD MAHEC Sports Medicine Director MAHEC/Mission Primary Care Sports Medicine Fellowship."— Presentation transcript:

1 Concussion: Evidence-Based Blueprint for Success Aaron Vaughan, MD MAHEC Sports Medicine Director MAHEC/Mission Primary Care Sports Medicine Fellowship Director Pediatric Grand Rounds 16 July 2014

2 Objectives Local, Regional, National Pulse/Resources Diagnosis of Concussion/PCS In-Office Framework/Algorithm ▫Vestibular-Ocular Motor System (VOMS) Evidence-based Pertinent, Practical

3 Teaching Points Know your guidelines ▫NC: Gfeller Waller Concussion Act Know what you don’t know (and where/who to look for info) ▫CDC, BIANC, Local Providers/Referral Sources Know your bonus prizes/red flags ▫Cerebral bleeds, Orbital Floor Know your exam ▫Vestibular-Ocular*** Know your Options ▫School is Key: Accommodate

4 Local, Regional, National

5 “Preliminary Approval in NFL Concussion Lawsuit” Original settlement ▫$675 M for players with neurologic symptoms ▫$75 M for baseline testing ▫$10 M for medical research ▫$112 M lawyers fees No cap

6 Local/Regional: WNC >60,000 seen in ER/yr (2007) Sport-Related: 607/yr (1996-99) Football: 33/100k athlete exposures

7 National ED Visits Hosp Deaths Total 2001 420.6 82.7 18.5 521.0 2002 433.9 85.6 18.3 537.2 2003 423.3 94.6 18.2 535.4 2004 486.3 97.6 18.1 601.3 2005 505.0 92.8 18.6 615.7 2006 478.9 98.7 18.2 595.1 2007 457.5 91.7 18.2 566.7 2008 616.4 95.5 17.7 728.9 2009 677.4 98.0 17.2 791.9 2010 715.7 91.7 17.1 823.7 CDC Rates of TBI-related Emergency Department Visits, Hospitalizations, and Deaths — United States, 2001–2010 Per 100,000 National Hospital Ambulatory Medical Care Survey — United States, 2001–2010 (Emergency Department Visits)

8 Rates of TBI-related Emergency Department Visits, Hospitalizations, and Deaths----US, 2001-2010 National Hospital Ambulatory Medical Care Survey — United States, 2001–2010 (Emergency Department Visits) National Hospital Discharge Survey — United States, 2001–2010 (Hospitalizatio ns) National Vital Statistics System Mortality Data — United States, 2001– 2010 (Deaths)

9 Rates of TBI-related Emergency Department Visits by Age Group — United States, 2001–2010 National National Hospital Ambulatory Medical Care Survey — United States, 2001–2010 (Emergency Department Visits)

10 Case JA is a 16 year old women’s soccer player who goes up for a header and instead knocks heads with an opposing player. She has initial dizziness and a headache as well as a left occipital contusion. These symptoms last for 1 hour and by the time she presents to the ER her symptoms have totally resolved. Her parents push for a CT for “clearance” which is normal. She presents to your clinic the next day because her athletic trainer her told her to. She remains subjectively symptom free.

11 Case (cont) Was this a concussion ▫Y▫Yes ▫N▫No Concussion = Clinical Diagnosis Mechanism + Symptoms

12 Algorithm: In-Office Concussion Algorithm: In-Office

13 ▫A complex vascular and neurochemical process affecting the brain, caused by direct or indirect traumatic forces to the head Case (cont) Keys: Not a Structural, but a Functional Problem Loss of consciousness only occurs in only 10% of concussions. What is a Concussion ?

14 Signs/Symptoms of a Concussion Physical ▫Headache ▫Nausea ▫Dizziness ▫Impaired Balance ▫Phonophobia/Photophobia ▫Tinnitus ▫Cervicalgia Cognitive ▫Confusion ▫Mental “fogginess” ▫Feeling slowed down ▫Concentration difficulties ▫Memory Impairment Emotional ▫Irritability ▫Sadness ▫Anger ▫Nervousness/Anxiety ▫Mood lability Sleep ▫Drowsiness ▫Sleeping more than usual ▫Restless sleep ▫Increased sleep latency/Trouble falling asleep Case (cont)

15 Concussion Types ▫Executive ▫Psychogenic ▫Cervicogenic ▫Vestibular ▫Ocular ▫Migrainous

16 Objective #1: Rule out ‘Badness’ ▫ie: When to send to ER or Need for Imaging  Signs of increasing pressure on brain  Loss of consciousness > 30 seconds  Convulsions / seizures  Deteriorating level of consciousness or behavior  Headache that is rapidly worsening or becoming severe  Late onset of or persistent vomiting  Late onset of or worsening amnesia / memory loss  Focal neurological signs (motor function, vision, speech) Case (cont) Keys: Do not interrupt sleep to check for symptoms

17 Case (cont) An appropriate evaluation in your office would include which of the following? ▫A▫A review of her symptoms; a neurologic exam and send her for a stat MRI ▫A▫A review of her symptoms; a neurologic exam and a concussion assessment tool ▫A▫A review of her symptoms; a few memory questions and a balance test ▫A▫A review of her symptoms; order a stat MRI and blood sample checking for elevated levels of S100 calcium binding protein B (S100B)

18 Algorithm: In-Office Concussion Algorithm: In-Office

19 Exam Symptom Evaluation ▫SCAT3/Child SCAT3SCAT3Child SCAT3 Exam ▫Physical  Orbits  Dental  Cervical  Other distracting injuries ▫Neurologic  CN II-XII  Gross Motor/Sensory

20 Exam (cont) Vestibular-Ocular ▫VOMSVOMS  Smooth Pursuits  Saccades: Horizontal  Saccades: Vertical  Convergence (near point)  VOR: Horizontal  VOR: Vertical  Visual Motor Sensitivity Test

21 VOMS ▫Vestibular-Ocular injury: Rotational/Occipital blow  Symptoms:  Migraine presentation  On-field ‘dizziness’  Vision complaints (blurred, focus issues)  Balance problems  Motion sickness  Anxiety in busy environments  Problems with math/screen time/reading

22 Exam (cont) Neurocognitive

23 Exam (cont) Neurocognitive: ImPACT ▫What is It?  One piece of the overall concussion evaluation and management process.  A sophisticated test of cognitive abilities.  A tool to help health care professionals track recovery of cognitive function  A tool that helps health care professionals and educators make decisions about academic needs following concussion ▫What isn’t It?  A cure-all for concussion. Concussions still happen.  A substitute for medical evaluation and treatment.  Not a tool to “Diagnose”  The only tool out there

24 Case (cont) Which of the following recommendations do you have for her care? ▫H▫Have her go into “cocoon therapy” and go to complete bed rest avoiding all electronic devices ▫S▫She can warm up tonight at 50 % effort and if that goes well, she can compete without any restrictions ▫A▫Avoid any physical activities that raise her heart rate and limit cognitive activities that “tire” her brain ▫A▫Allow her to briskly walk the dog and do basic tumbling moves and limit her Facebook time to less than 1 hour a day

25 Algorithm: In-Office Concussion Algorithm: In-Office

26 Rest Gfeller Waller Accommodations Physical Rest Avoid activities that elevate heart rate Applies to all activities: practice, competition, physical education, dance, non-school based activities, household chores Avoid further trauma / injury to the brain Sleep is essential Hydration/nutrition 20-30 mins/light aerobic activity Cognitive Rest Limit concentration effort ▫Homework, school work, job-related work ▫Texting, computer, video games or television use ▫May require changes to a normal academic day Bottom Line: Don’t do anything that makes symptoms worse! Use symptom score

27 Case (cont) Once she is asymptomatic, has a normal exam and passes a concussion assessment tool, what level of exercise are you going to allow her first day back? ▫A▫Allow her to briskly walk the dog and do basic tumbling moves ▫L▫Light aerobic exercise (e.g. stationary cycle or walking laps for 30 minutes) ▫S▫Sport-specific exercises at moderate effort for less than 1 hour (e.g. moderate jog, moderate footwork drills, shooting drills) ▫S▫Start out light for about ½ hour and if she tolerates that, allow her to progress to a full workout that first day

28 Algorithm: In-Office Concussion Algorithm: In-Office

29 Return to Play PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION Keith H. May, David L. Marshall, Thomas G. Burns, David M. Popoli, John A. Polikandriotis Int J Sports Phys Ther. 2014 April; 9(2): 242–255.

30 Case (cont) What are you going to do for her if her symptoms plateau at 3-4 weeks? ▫Arrange a referral to a concussion specialty clinic ▫Arrange for a brain MRI and if it is normal she never really had a concussion anyway ▫Arrange for more extensive testing such as an ImPACT test or CogState test ▫Have her initiate a return to play protocol to see if it aggravates her symptoms; if not, allow her to return to full activities once completing the protocol

31 Be suspicious when: ▫A concussion seems to be stalling out after one week ▫Concussion symptoms continue after three weeks ▫Concussion symptoms come back shortly after increasing activities Is it still a concussion or is it something else (Bonus Prize)? ▫Inner ear problems ▫Cervical spine trigger points or facet problems ▫Migraine cluster ▫Post traumatic stress disorder ▫Something more serious?  Seizure disorder  New presentation of brain mass/tumor  Subdural hematoma How do you evaluate someone for Post Concussive Syndrome?

32 Algorithm: In-Office Concussion Algorithm: In-Office

33 Be suspicious of a concussion/PCS. “If in doubt hold them out” Be familiar with your algorithm; Know your exam (VOMS) Signs/symptoms change. Evaluate the athlete looking at: Cervicogenic, Psychogenic, Vestibular, Ocular, Migrainous, Executive dysfunction There are many tools to help you on the sidelines and in the office. The law recommends that you use one. Initial treatment is based on both physical and cognitive rest until the symptoms resolve. Returning to activities is gradual process once asymptomatic. RTP Protocols vary Work closely with all of the health care providers involved (athletic trainers, school nurses, consulting neurologist or neuropsychologists) to provide the best care for this complex problem. Review

34 Other web based Resources: ▫CDC Heads Up: Brain Injury in Your Practice  http://www.cdc.gov/concussion/headsup/physicians_t ool_kit.html http://www.cdc.gov/concussion/headsup/physicians_t ool_kit.html ▫North Carolina High School Concussion Paperwork  http://www.nchsaa.org/health-and-safety http://www.nchsaa.org/health-and-safety ▫North Carolina Concussion Clearance Form  http://gfellerwallerlaw.unc.edu/GfellerWallerLaw/gwla w.html http://gfellerwallerlaw.unc.edu/GfellerWallerLaw/gwla w.html ▫Brain Injury Association of North Carolina  http://bianc.net/ http://bianc.net/ ▫Zurich Concussion in SportZurich Concussion in Sport Resources

35 Aaron Vaughan, MD MAHEC/Mission Sports Medicine aaron.vaughan@mahec.net http://mahec.net/patient-information/family-health/sports-medicine 330-904-9273 @DrAJVaughan aaron.vaughan@mahec.net


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