Concussion Management

Michael Reardon, M.D. April 24,2016 Objectives

• Understand what a concussion is • Know how to recognize it • Understand the differential diagnosis • Know how to manage and treat symptoms • Know when to refer for more comprehensive evaluation What is a Concussion?

• Trauma to the head – Does not have to be direct blow to head • Pathophysiological Changes – Neuro-metabolic cascade • Clinical Syndrome – Signs and symptoms What Causes a Concussion?

• Impact or acceleration/deceleration forces

• Helmets do not prevent concussions What is a Concussion?

• Pathophysiological Changes – Neuro-metabolic cascade Clinical Syndrome

• Observable Signs – Loss of consciousness (only 10-15%) – Amnesia or confusion – “Dazed”, slowed down, sluggish, sleepy – Mood or Behavioral changes – Balance problems – Vomiting Clinical Syndrome • Subjective symptoms – Headache or “pressure” in head – Vision changes: blurry, fuzzy, spots/stars – Nausea – Sensitivity to light and noise – Dizziness – Feeling slowed down, like in a fog – Trouble remembering and concentrating – Irritable, anxious, or depressed mood – Sleepy or trouble sleeping Common Features of Concussion

• Onset relatively immediate, though may go unrecognized • Tends to improve with rest, and worsen with exertion or over-stimulation • With good management, usually resolves over days to weeks Differential Diagnosis

• Moderate to severe TBI • Non-TBI causes of symptoms – Dehydration, heat exhaustion, migraine • Side effects or complications of treatment – Deconditioning, anxiety, somnolence or altered circadian rhythm • Psychological disorders How to differentiate concussion from more severe TBI • GCS >13 • Amnesia/disorientation resolves within 1-2 hours • No focal deficits • Able to walk independently • Normal Head CT or MRI Features suggesting some other problem • Significant delay in onset of symptoms/signs • Displaying profound memory impairment • Continued somatic complaints after several weeks • Very specific or peculiar triggers for symptoms • Significant emotional or behavioral symptoms Management of Concussion

• Immediately remove from game/event • Never return to sport/activity on same day • Medical evaluation prior to return to sports or high-risk activities • Gradual, step-wise return to sports after symptoms and signs have resolved Management of Concussion

• Avoid repeat injury • Education • Treatment of symptoms • Relative rest • Gradual return to activities as tolerated Management of Concussion

• Education – Full recovery can range from days to several weeks; cannot be predicted at onset – Repeat head trauma before full recovery can damage the brain; highest risk in first 1-2 weeks – Light exercise as tolerated will NOT harm the brain, and will likely help – Attempting cognitive/academic activities as tolerated will NOT harm the brain – Treating headaches and other symptoms is helpful for recovery; not just “masking” symptoms Treatment of Symptoms

• Headaches • Nausea • Dizziness • Sleep disorder • Anxiety or depressed/irritable mood • Cognitive impairment Treatment of Headaches

• First line – Naproxen 15mg/kg/day divided BID – Magnesium 250-500mg BID

– May add benedryl + phenergan 0.5-1 mg/kg/dose q 6-8 hr as needed – May add imitrex 25-50mg q 8 hr x 2-3 days Treatment of Headaches

• Second line – Cyproheptadine 4-12mg qhs; may add smaller dose in AM as tolerated or – Amitriptyline 25-50mg qhs

– Consider hospitalization for IV meds if severe and not improving Treatment of other Symptoms

• Nausea – Phenergan, compazine, or reglan better than zofran for migraine

• Dizziness – No medication works for dizziness (including Meclizine) – Time, rest, gradual increase in movement – Vestibular Therapy when not improving Treatment of other Symptoms • Sleep disorder – Sleep hygiene; maintain normal circadian rhythm; exercise – Melatonin 3-6mg; up to 12-15 if helpful; benedryl 25-50 mg – Cyproheptadine, amitriptyline, or gabapentin (esp if headaches) • Anxiety or depressed/irritable mood – Psychotherapy – Consider SSRI and/or psychiatry • Cognitive impairment – Omega 3: fish oil 1000-3000mg/day; or Vayarin 2 capsules/day Management of Concussion • Relative rest, as tolerated – At least one day at home; a few days if needed; plan to return to school with adjustments – Encourage light, relaxing activities as tolerated – Encourage short trials of school work as tolerated – Return to school when tolerating moderate activities without significant worsening of symptoms Management of Concussion • Recommended School Adjustments – Encourage flexibility based on symptoms – Avoid noisy, crowded environments • Bus, cafeteria, gym; change classes before bell rings – Reduce the amount of work; allow more time – Delay testing or adjust tests • Shorter tests; multiple choice or open note – Allow rest breaks and extra time Management of Concussion • Gradual return to exercise – Start very light, low impact exercise, even if still having symptoms; walking or stationary bike – Find pace that does not cause worsening of symptoms; suggest 5-15 minutes – Gradually increase pace and/or duration over several days as tolerated – When symptoms have cleared, can advance to more strenuous, higher impact exercise Management of Concussion • When to clear for full return to sports – All symptoms have cleared, without medication, and with full participation in school and vigorous non-contact exercise – School performance is back to baseline – Neurological exam is normal – If pre-injury baseline tests were performed, post- injury scores are within range of baseline Management of Concussion • When to refer for further evaluation – Complex past history • Multiple concussions; other neuro issues – Unusual symptoms or signs – Severe headaches or other symptoms – Symptoms are not improving in 1-2 weeks with first-line management www.childneurotx.com 512-494-4000 Far West Clinic Physician Back-line: 512-494-4063 Fax: 512-494-4024 Cedar Park Clinic Physician Back-line: 512-494-4081 Fax: 512-494-4045