concussion for pediatricians

Slide 1: 

Concussion Blythedale Children's Hosp 1

New Blythedale Children’s Hospital Opening December 2011: 

New Blythedale Children’s Hospital Opening December 2011

TRAUMATIC BRAIN INJURY in Children and Adolescents Pediatric Grand Rounds: BLHC: 

TRAUMATIC BRAIN INJURY in Children and Adolescents Pediatric Grand Rounds: BLHC Jay E. Selman, MD Chief of Neurology Blythedale Children’s Hospital

Slide 4: 

Concussion Blythedale Children's Hosp 4

Overview: 

Overview Epidemiology Burden of TBI Concussions Biomechanics Etiology Management Return to play Catastrophic head injuries Summary Concussion Blythedale Children's Hosp 5

Epidemiology : 

Epidemiology 63 TBI / 100,000 hospitalizations at <14 yo < 2 yo: 24-32% are non - accidental 6 Concussion Blythedale Children's Hosp

Mean Hospitalization Rates for TBI over time: 

Mean Hospitalization Rates for TBI over time Bowman S. et al., 2008 7 Concussion Blythedale Children's Hosp

TBI in the US: 0 – 21 yo: 

TBI in the US: 0 – 21 yo 1,300,000 medically attended TBI visits per year 8 Concussion Blythedale Children's Hosp

TBI by Gender: 

TBI by Gender 9 Concussion Blythedale Children's Hosp

Leading Causes of Death, 2006: 

Leading Causes of Death, 2006 RANK < 1 yo 1 – 4 yo 5 – 9 yo 10 – 24 yo 1 Congenital Non - TBI Non TBI Non - TBI 2 Short Gestation TBI Neoplasm TBI 3 SIDS Congenital TBI Neoplasm 4 Pregnancy Complications Neoplasm Congenital Cardiac 5 Non TBI Cardiac Cardiac Congenital CDC and National Vital Statistics Data, 2006 10 Concussion Blythedale Children's Hosp

Burden of TBI: 

Burden of TBI Concussion Blythedale Children's Hosp 11

Post Hospitalization Mortality: 

Post Hospitalization Mortality Age at admission N Observed Deaths Expected Deaths SMR < 1 yo 406 6 3 2.0 1 - 19 yo 4,156 41 11 3.7 Ventura, T. 2010 12 Concussion Blythedale Children's Hosp

% of Cases in TBI Series: 

% of Cases in TBI Series Concussion Blythedale Children's Hosp 13 Kraus, J, 1995

% TBI Patients Discharged Alive: 

% TBI Patients Discharged Alive Concussion Blythedale Children's Hosp 14 Kraus, J, 1995

% TBI Patients Disabled: 

% TBI Patients Disabled Concussion Blythedale Children's Hosp 15 Kraus, J, 1995

Concussions: 

Concussions 16 Concussion Blythedale Children's Hosp

Concussion = MILD TBI: 

Concussion = MILD TBI Concussion Blythedale Children's Hosp 17

A Concussion by Any Other Name…: 

A Concussion by Any Other Name… Ding Having the bell rung Seeing stars Bang etc Concussion Blythedale Children's Hosp 18

Concussion Myths: 

Concussion Myths You have to lose consciousness You can return to play the same day No problems after concussions The CT / MRI has to be abnormal Concussion Blythedale Children's Hosp 19

What Is A Concussion?: 

What Is A Concussion? Force to brain Change in brain function A mild TBI (traumatic brain injury) 20

Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. ✪: 

Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. ✪ Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an "impulsive" force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. 3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however it is important to note that in a small percentage of cases however, post-concussive symptoms may be prolonged. 5. No abnormality on standard structural neuroimaging studies is seen in concussion. 21

Concussion: Key Elements – 1: 

Concussion: Key Elements – 1 = “Mild” traumatic brain injury (mTBI) “Complex pathophysiological process affecting the brain…” Direct or indirect blow to the head International Conference on Concussion in Sports (ICCIS) 22 Concussion Blythedale Children's Hosp

Concussion: Key Elements - 2: 

Concussion: Key Elements - 2 = Rapid onset / Short duration of symptoms Functional rather than structural changes +/- LOC International Conference on Concussion in Sports (ICCIS) 23 Concussion Blythedale Children's Hosp

Concussion: Key Elements - 3: 

Concussion: Key Elements - 3 Variable severity of symptoms “Standard” neuro-imaging = normal CT MRI International Conference on Concussion in Sports (ICCIS) 24 Concussion Blythedale Children's Hosp

Biomechanics of Concussion: 

Biomechanics of Concussion Concussion Blythedale Children's Hosp 25

Mechanics of Concussion: 

Mechanics of Concussion 26 Concussion Blythedale Children's Hosp

Torque Increases Shearing of Axons: 

Torque Increases Shearing of Axons Concussion Blythedale Children's Hosp 27

Biomechanics of Concussion - 1: 

Biomechanics of Concussion - 1 Significant forces transmitted to brain Differential physical properties of brain v skull Amplification by torque +/- use of protection 28 Concussion Blythedale Children's Hosp

Biomechanics of Concussion - 2: 

Biomechanics of Concussion - 2 Stretching / tearing / shearing of neural and supporting tissues Functional impairment Changes in Energy metabolism Autoregulation 29 Concussion Blythedale Children's Hosp

Axonal Shearing: 

Axonal Shearing Concussion Blythedale Children's Hosp 30 www.tbilawyers.com/images/axon-shear.jpg

Slide 31: 

Concussion Blythedale Children's Hosp 31

Diffuse Axonal Shearing on MRI: 

Diffuse Axonal Shearing on MRI 32 Concussion Blythedale Children's Hosp ntnu.edu

Diffusion Tensor Imaging: 

Diffusion Tensor Imaging Left-Right Anterior- Posterior Cranial- Caudal 33 Concussion Blythedale Children's Hosp

DTI and Concussion : 

DTI and Concussion Cubon V et al. J Neurotrauma 2011 34 Concussion Blythedale Children's Hosp

Etiology of Concussions: 

Etiology of Concussions Concussion Blythedale Children's Hosp 35

Why the Increasing Incidence?: 

Why the Increasing Incidence? 16.5% annual rate of increase over 10 years Better detection Larger body mass? No change in sports per se Concussion Blythedale Children's Hosp 36 Lincoln, AE 2011

Trends in Incidence of Sports Injury: 

Trends in Incidence of Sports Injury Concussion Blythedale Children's Hosp 37 Concussions / 1000 athletic exposures School Year Girls Boys

Which Sports: 

Which Sports Girls: soccer (in adolescents) Boys: football 38 Concussion Blythedale Children's Hosp

Trends in Incidence of Concussion : 

Trends in Incidence of Concussion Concussion Blythedale Children's Hosp 39 Similar Sports All Sports Helmet Boys’ Sports No Helmet Lacrosse Girls Boys Boys Girls

Injury Rates by Sport: 

Injury Rates by Sport Sport Injury Rate Football ~ 1 per 1,000 exposures Girls’ Soccer ~ 1 per 3,600 exposures Boys’ Lacrosse ~ 1 per 3,000 exposures Boys’ Soccer ~ 1 per 2,000 exposures Girls’ Basketball Wrestling Girls Lacrosse ~ 1 per 10,000 exposures Softball ~ 1 per 50,000 exposures Boys Basketball Boys and Girls Volleyball Baseball Adapted from Halstead et al. (2010) 40 Concussion Blythedale Children's Hosp

Sports with High Risk but Little Data: 

Sports with High Risk but Little Data Concussion Blythedale Children's Hosp 41 Skateboarding ATV Skiing (water / snow) Snowboarding Climbing Home wrestling Stupidity (ADHD)

Stupidity?: 

Stupidity? Concussion Blythedale Children's Hosp 42

Management of the Patient with Acute Concussion: 

Management of the Patient with Acute Concussion Concussion Blythedale Children's Hosp 43

Evaluation of Concussion: 

Evaluation of Concussion On the scene In the office 44 Concussion Blythedale Children's Hosp

Brief Neurological Examination on the Sideline: 

Brief Neurological Examination on the Sideline Cognitive Orientation Short term recall Short term memory Speech Pupillary reactions Gait and stance Romberg and Regular Tandem Coordination (F-N) 45 Concussion Blythedale Children's Hosp

Provocative Testing at the Sidelines: 

Provocative Testing at the Sidelines IF the patient has no definite symptoms, then vigorous exercise (40 yd sprint, 5 pushups or knee bends) IF any associated symptoms appear, then + and NO return to play 46 Concussion Blythedale Children's Hosp

Referral to the ER after Acute Trauma: 

Referral to the ER after Acute Trauma LOC > 2 minutes Any focal findings Worsening mental status Significant gait or coordination problems Clinical judgment 47 Concussion Blythedale Children's Hosp

CHALICE Guidelines for CT in Children: 

CHALICE Guidelines for CT in Children C hildren’s H ead injury A lgorithm for the P rediction of I mportant C linical E vents Developed in the UK Over 30 months w 22,000+ pediatric ER visits Sensitivity 98% ; specificity 87%; w 14% CT rate Concussion Blythedale Children's Hosp 48 Tang, PH, 2009

CHALICE Guidelines: 

CHALICE Guidelines Witnessed LOC > 5 min Amnesia > 5 min Abnormal drowsiness >2episodes of vomiting Suspicion of non-accidental injury Post traumatic epilepsy w/o hx of seizures GCS < 14 in child GCS < 15 in infant ? Open/depressed skull fx or tense fontanel ? Basilar skull fracture Focal neuro deficit Bruise, swelling, laceration > 5 cm – infant High impact head trauma Concussion Blythedale Children's Hosp 49 Tang, PH, 2009

Referral to a Neurologist: 

Referral to a Neurologist Persistent or worsening symptoms Decrease in school performance Abnormalities on neurological examination 50 Concussion Blythedale Children's Hosp

Johnny M - 1: 

Johnny M - 1 15 yo boy complained of headache, dizziness, and fogginess the day after the Friday football game. He had difficulty completing his homework assignments that weekend. During the week his teachers complained about decreased attentiveness. His coach said he had difficulty remembering and following plays in practice. Concussion Blythedale Children's Hosp 51

Johnny M - 2: 

Johnny M - 2 What happened? What would you do? Concussion Blythedale Children's Hosp 52

Post Concussion Syndrome: 

Post Concussion Syndrome Concussion Blythedale Children's Hosp 53

Post Concussion Symptoms: 

Post Concussion Symptoms Physical Behavioral Cognitive Concussion Blythedale Children's Hosp 54

Physical Post Concussion Symptoms: 

Physica l Post Concussion Symptoms Headaches Dizziness Insomnia Fatigue Ataxia Nausea Blurred vision Tinnitus Concussion Blythedale Children's Hosp 55

Behavioral Post Concussion Symptoms: 

Behavioral Post Concussion Symptoms Irritability Depression Anxiety Emotional lability Eating disorder Sleep disturbance Personality changes Concussion Blythedale Children's Hosp 56

Cognitive Post Concussion Symptoms: 

Cognitive Post Concussion Symptoms Slowed mentation Inattention Poor concentration Emotional lability Memory loss Sleep disturbance Personality changes Concussion Blythedale Children's Hosp 57

Returning to Play: 

Returning to Play 58 Concussion Blythedale Children's Hosp

Overview: 

Overview Absolute prohibition Delayed return 59 Concussion Blythedale Children's Hosp

Absolute Prohibition of Contact Sports: 

Absolute Prohibition of Contact Sports Cerebral contusion Intraparenchymal / intraventricular hemorrhage Focal deficits Cognitive deficits Seizure? 60 Concussion Blythedale Children's Hosp

Relative Restrictions on Return to Play: “Guidelines”: 

Relative Restrictions on Return to Play: “Guidelines” Proposed by different organizations Not entirely consistent Limited use in real life 61 Concussion Blythedale Children's Hosp

Bases of Guidelines: 

Bases of Guidelines LOC: +/- and duration Confusion and cognitive changes: +/- and duration Cannot really predict full return to normal function 62 Concussion Blythedale Children's Hosp

Graduated Return to Play: 

Graduated Return to Play Rehab Stage Exercise Purpose No Activity Physical/Cognitive Rest Recovery Light Aerobic Walking/swimming/ Stationary bike Increase heart rate Sport-specific exercise Running/skating skills Add movement Non-contact training activities Progression to more complex activities Coordination, increasing cog load Full contact training activities After medical clearance Restore confidence, skill assessment Return to play 63 Concussion Blythedale Children's Hosp Br J Sports Med 2009

Graduated Return to Play (RTP): 

Graduated Return to Play (RTP) Minimize short and long term cognitive impairments Prevent 2 nd Impact Syndrome Problems with time based Individualized approach is essential 64 Concussion Blythedale Children's Hosp

Is Being Asymptomatic Sufficient?: 

Is Being Asymptomatic Sufficient? In a group of high and college athletes with concussion, QEEG abnormalities persisted longer than Neurocognitive impairments Post-concussion symptoms How long is long enough? McCrea M et al. J Head Trauma Rehabil 2010 65 Concussion Blythedale Children's Hosp

DTI and Concussion : 

DTI and Concussion Cubon V et al. J Neurotrauma 2011 66 Concussion Blythedale Children's Hosp

What is considered cognitive rest?: 

What is considered cognitive rest? 67 Concussion Blythedale Children's Hosp

Accommodations in Post Concussion Syndrome: 

Accommodations in Post Concussion Syndrome Increased sleep time Reduced school day Modified homework assignments More frequent breaks Concussion Blythedale Children's Hosp 68

Catastrophic Brain Injuries: 

Catastrophic Brain Injuries Concussion Blythedale Children's Hosp 69

Catastrophic Brain Injuries: 

Catastrophic Brain Injuries 1989 – 2002 football seasons Many had symptoms of prior head injury at time of catastrophic event 71% had sustained injury in current season ~40% playing with residual neuro symptoms Amer J Sports Medicine, 2009 70 Concussion Blythedale Children's Hosp

Second Impact Syndrome (SIS): 

Second Impact Syndrome (SIS) Concussion Blythedale Children's Hosp 71

Case Report: 

Case Report 17 yo M sustained concussion in game HA for next week 1 wk later: concussion # 2 and continued to play Collapsed almost immediately, becoming comatose CT brain: severe swelling w/o hematoma Concussion Blythedale Children's Hosp 72 Wetjen, N, 2010

Case Report – cont’d: 

Case Report – cont’d Concussion Blythedale Children's Hosp 73

Diffuse Cerebral Edema: 

Diffuse Cerebral Edema Concussion Blythedale Children's Hosp 74 springerimages.com

Case Report – cont’d: 

Case Report – cont’d ER could not resuscitate Autopsy: Massive cerebral edema No mass No hemorrhage Concussion Blythedale Children's Hosp 75 Wetjen, N, 2010

Second Impact Syndrome (SIS): 

Second Impact Syndrome (SIS) VERY rare Controversial re: existence (or not) Concussion Blythedale Children's Hosp 76 Wetjen, N, 2010

Possible Mechanisms of SIS: 

Possible Mechanisms of SIS Failure of cerebral autoregulation Catecholamine induced hypertension Leading to malignant brain swelling Concussion Blythedale Children's Hosp 77 Wetjen, N, 2010

Possible Mechanisms of SIS: 

Possible Mechanisms of SIS Loss of cerebral autoregulation In 20-30% of patients with mild TBI Can last hours to weeks Loss of cerebral autoregulation in up to 80% of patients with severe TBI Concussion Blythedale Children's Hosp 78 Wetjen, N, 2010

Possible Mechanisms of SIS: 

Possible Mechanisms of SIS Catecholamine surge present in all mammalian models of head trauma Confirmed in clinical series Dose dependent response Concussion Blythedale Children's Hosp 79 Wetjen, N, 2010

Sympathetic Surge in SIS: 

Sympathetic Surge in SIS Concussion Blythedale Children's Hosp 80 Arterial BP ICP

Treatment of SIS: 

Treatment of SIS All standard methods Almost always fatal Concussion Blythedale Children's Hosp 81 Wetjen, N, 2010

Slide 82: 

Concussion Blythedale Children's Hosp 82

New Blythedale Children’s Hospital: 

New Blythedale Children’s Hospital

Blythedale is Unique: 

Blythedale is Unique Licensed as a hospital New York State’s only specialty children’s hospital Has the expertise and resources to care for medically complex patients

Blythedale: Complex Medical Problems: 

Blythedale: Complex Medical Problems Ventilator Weaning Traumatic and Acquired Brain Injury High Tech Nutritional Support and Feeding Therapy Pre- and Post Organ Transplants Complicated Pain Syndromes Genetic and Neuromuscular Disorders Burn Rehabilitation and Wound Care Complicated Trauma and Post-Surgical Orthopedics Childhood Cancers (Rehabilitation) Spinal Cord Disorders

New Inpatient Hospital Opens December 2011: 

New Inpatient Hospital Opens December 2011 Total Beds = 86 Infant/Toddler Unit (46 beds) TBI/ABI Unit (10 beds) Pediatric/Adolescent Unit (30 beds) New Patient Care Monitoring Systems Isolation Rooms Patient and Family-Centered Facility

SUMMARY: 

SUMMARY Concussion Blythedale Children's Hosp 87

Concussion = MILD TBI: 

Concussion = MILD TBI Concussion Blythedale Children's Hosp 88

SUMMARY : 

SUMMARY Prevention Pre-season screening for (high risk) athletes Importance of school, family, physicians in recognizing symptoms of concussion Individualized return to play plan Concussion Blythedale Children's Hosp 89

New Blythedale Children’s Hospital Opens December 2011: 

New Blythedale Children’s Hospital Opens December 2011

Blythedale’s New Inpatient Hospital Opens December 2011: 

Blythedale’s New Inpatient Hospital Opens December 2011 Total Beds = 86 Infant/Toddler Unit (46 beds) TBI/ABI Unit (10 beds) Pediatric/Adolescent Unit (30 beds) New Patient Care Monitoring Systems Isolation Rooms Patient and Family-Centered Facility

Blythedale is Unique: 

Blythedale is Unique New York State’s only specialty children’s hospital Expertise and resources to care for medically complex infants, children, and adolescents Day Hospital w Rehabilitation + Special Education

Blythedale Clinical Services Lines: 

Blythedale Clinical Services Lines Ventilator Weaning Traumatic and Acquired Brain Injury Nutritional Support and Feeding Therapy Pre- and Post Organ Transplants Genetic / Neuromuscular Disorders Burn Rehabilitation and Wound Care Complicated Trauma and Post-Surgical Orthopedics Childhood Cancers (Rehabilitation) Spinal Cord Disorders Complicated Pain Syndromes

The new Blythedale Children’s Hospital: 

The new Blythedale Children’s Hospital

Slide 95: 

Blythedale.org THANK YOU

Bibliography: 

Bibliography Aaen, G, et al. Magnetic resonance spectroscopy predicts outcomes for children with non accidental trauma. Pediatrics 2010; 125:295-303. Bowman, S. et al. Trends in hospitalization associated with pediatric tbi. Pediatrics, 2008;122:988-93. Centers for Disease Control and Prevention. Heads Up: Brain injury in your practice: A tool kit for physicians. http://www.cdc.gov.ncipc/tbi/phsicians_tool_kit.htm Centers for Disease Control and Prevention (CDC). Facts about Concussion and Brain injury and where to get help. Http://www.cdc.gov.ncipc/tbi/default.htm Dashti SR et al. Current patterns of inflicted head head injury in children. Pediatr Neurosurg. 1999;31:302-306. Duhaime, AC et al. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics 1992;90:179-185. Dunning, J et al A meta-analysis of variables that predict significant intracranial injury in minor head trauma Arch Dis Child 204;89:653-9 Kirkwood, MW et al. Pediatric sport-related concussion: A review of the clinical management of an oft-neglected population. Pediatrics 2006;117:1359-1371. Kraus, J. Epidemiological features of brain injury in children. In Traumatic Head Injury in Children, 1995 Langlois, JA et al. The incidence of traumatic brain injury among children in the United States: differences by race. J Head Trauma Rehabil. 2005;20:229-238. Langlois, JA et al. Traumatic brain injury in the United States: Emergency department visits, hospitalization, and deaths. 2004. Atlnata, GA, CDC, National Center for Injury Prevention and Control Lincoln AE et al. Trends in concussion incidence in high school sports: a prospective 11 year study. Am J Sports Med 2011;39:958-963. McCrea, M et al Effects of a symptom-free waiting period on clinical outcome and risk of reinjury after sport-related concussion. Neurosurgery 2009;65:876-883. McCrory, P et al. Consensus statement on concussion in sport – the third international conference in sport held in Zurich. Phys Sportsmed 2009;37: 141-59.s Poirer, MP Concussions: assessment, management and recommendations for return to activity. Clin Ped Emerg Med 2007;4:179-85. Practice parameter: The management of concussion in sports. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1997; 48:581-55. Sander, A Extended Glasgow Outcome Scale. The Center for Outcome Measurement in Brain Injury 2002. Sports-related injuries among high school athletes – US, 2005-06 school year. MMWR 2006;55:1037-40. Tang, PH Imaging of accidental paediatric head trauma. Pediatr Radiol; 2009;39:438-46. Ventura, T et al. Mortality after discharge from acute care hospitalization with TBI. Arch Phys Med Rehab 2010;91:20-29 Wetjn, N et al. Second Impact Syndrome: concussion and second injury brain complications. J Am Col Surg 2010;211:553-57. Wilson, JTL et al. Structure interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: Guideliones for their use. J. Neurotrauma 1998; 15:573-585. Yard, EE et al. A comparison of high school sports injury surveillance data reporting by certified athletic trainers and coaches: The National High School Sports-Related Injury Surveillance Study. J Athl Train 2009;44:645-52. 96 Concussion Blythedale Children's Hosp