Sports Medicine Emergencies / Concussion Update 2017 Jeffrey a Zlotnick MD (CAQ) FAAFP Residency Director Sports Medicine Education

7/24/2017

Sports Medicine Emergencies / Concussion Update 2017 Jeffrey A Zlotnick MD (CAQ) FAAFP Residency Director Sports Medicine Education

Penn State Health / St Joseph’s Family Medicine Residency

Asst. Clinical Professor of Family & Primary Care Sports Medicine Rutgers – Robert Wood Johnson Medical School Rutgers – New Jersey Medical School Philadelphia College of Osteopathic Medicine

Clinical Director MedFest (Health Athletes Initiative) Special Olympics NJ Consultant Special Olympics International-US

Major Problems BE PREPARED!!!!!! • A team leader – • Team physician Unconscious Athlete / Neck Injuries – Athletic trainer • Anaphylactic Shock • Appropriate health care personal • Seizures – BCLS certified (minimum) – • Heat Illness How to handle & move injured athletes • Ambulance for transport +/- Paramedics • Sickle cell disease – Hospital notified & ready • Sudden Cardiac Death (HCM) • Communications • Concussions – Cellphone, radio

Equipment: Resuscitation Equipment: Trauma • Airway – Oro or Naso-pharyngeal airway – Advanced airways* • Transport – Football: Clip cutter or Electric screwdriver! – – Newer helmets w/ air bladder Spine board, stretcher • Breathing – Sand bags, foam/velcro, rigid cervical collar – Oxygen, masks & nasal cannulas, • Fractures – Bag-valve masks, – Albuterol inhaler (spacer)* – Splints, immobilizers – Epinephrine (EpiPen)* – Ace bandages, elastic tape • Circulation – Slings – AED * - Optional • Advanced supplies from ambulance / paramedics – ACLS supplies (Defib/monitor, IV fluid, medications)

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Anticipating Casualties Equipment: General • Marathons: 1 – 20% – Half Marathon: 1 – 5% • Triathlon (Iron Man): 15 – 30% – Short: 5 – 20% • Gloves! • Cycling / Skiing: 5% • Stethoscope, Oto-opthoscope, Penlight • Tongue blades, bandages, hemostats • “30/10/1 Rule” (sourceRoss; unknown) Expert Guide to Sports Medicine; ACP 2003 • Alcohol, povidine, hand-gel – 30% of athletes will need some sort of minor medical • attention Thermometer (endurance events) • PO fluids for cramping – Rectal most accurate for on field – 10% will require moderate medical intervention – Ear thermometers becoming more accurate • IV Fluids, Misting or Bath to cool down • Over read low, Under read high – 1% will require intense medical intervention • “Eye kit”(wash, q-tips, shields or patches) • ACLS, Immediate transfer to hospital w/ IV’s

Airway Assessment of an Unconcious athlete • Check for spontaneous breathing • Face down Log roll* • Football: can remove just facemask* • Jaw thrust, chin lift with minimal head-tilt – Always Assume C-Spine Injury!!!!!!!!!!!!! • Clear airway (tongue or turf) • Oxygen • Oral-pharyngeal airway (if unconscious) ABC’s • Bag-valve mask

Log Roll Protect C-Spine • ANY unconscious athlete, assume cervical spine injury & protect • Maintain neutral position • Football helmets: can remove face mask only! – Use helmet to control head – SAFELY remove helmet if prevents airway control or suspect head injury • DO NOT use ammonia capsules on ANY unconscious athlete – Extension reaction

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Stabilizing C-Spine w/ Helmet Helmets • Football: designed to be used to stabilize C- spine along with shoulder pads – New NATA Consensus Statement looking into removal of helmet & other gear on field • Lacrosse: allow 27 deg’s of lateral rotation vs. football helmets. – Difficult to remove face mask – Do not keep C-spine straight with padding • Hockey: offer no C-spine stabilization

Lacrosse Helmet Hockey Helmet

Breathing Respiratory Difficulties: • Artificial respiration (BCLS) – Mouth to mouth (not recommended) – Mask to mouth (various types) • – Bag-valve mask Tension pneumothorax • nd • Endo-tracheal & Naso-tracheal intubation very Large bore needle thru 2 intercostal space mid- difficult on field clavicular line – Oral airway in unconscious athlete • Open pneumothorax “Sucking” chest wound – Naso-pharyngeal airway • Close off wound, Be “inventive” • Most appropriate advanced airway intervention out-of-hospital is unproven • Flail chest – Significant complications and may reduce survival • Hemothorax (Emerg Med J 2010;27:321-323 doi:10.1136/emj.2009.076737) • Cardiac tamponade

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Circulation D = Disability

• Assess level of consciousness – Glascow coma scale • Check carotid pulse • Pupils for size, reactivity • CPR if indicated (B & ACLS protocols) • Motor response • Defibrillation • Verbal and tactile stimuli – 80% of circulatory collapse is Ventricular fibrillation – Portable and Automatic External Defibrillators

E = Exposure

• Check for Bleeding Goal with Unconscious Athlete • Check for Fractures • Check for Contusions Stabilize and • Ecchymosis Transport!!!!

Anaphylaxis Signs & Symptoms

• Apprehensive • Incontinence • Insect bites most common cause • Parathesias • Dilated pupils • Drugs • Generalized urticaria • Fever • Pollens • Cough / wheezing • Shock • Laryngeal edema and • Loss of consciousness • Exercise induced anaphylaxis closure • Seizures – Cholinergic urticaria

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Treatment Assess the Airway • Epinephrine 0.1 - 0.5mg SQ/IM (1:1000 sol) into a NON-occluded limb • – Usual dose is 0.3mg Oxygen via mask or nasal cannula – Peds: 0.01mg/kg • Nebulized beta-2 agonist for wheezing – Can repeat every 5-15 minutes – i.e.; albuterol w/ spacer • Epi-Pens, ANA-Kits (WATCH dose!!) • Alternate: Aminophylline load 6 mg/kg IV • Alt: 0.1-0.25mg (1:10,000 sol) IV q 5-15 then 0.7 mg/kg/hr IV x 12 hrs minutes then 1-4mcg/min IV prn – Peds: 0.01ml/kg/dose IV then 0.1mcg/kg/min IV • Fluid resuscitation prn – Ringers, Normal Saline ***Dosing is subject to change ***Dosing is subject to change

Sports Specific Seizures • Endurance activities (running) • Familiarity with meds & side effects – Unlikely to induce a seizure – Attention span & cognitive impairment • Swimming / Rowing / Sailing – • Nearby lifeguard Decreased potential for seizures w/ – Life jacket exercise • Contact sports (football) – Metabolic acidosis due to lactate buildup & – Usual precautions w/ helmets & pads incomplete respiratory compensation • – Decreased pH >> Stabilizes neuro-membranes Extreme contact (boxing) – Trauma can induce seizures • Good control must be obtained prior to • Some sports too dangerous participation in activities – Skydiving, scuba diving, ??diving

Seizure Acute Treatment Seizure Acute Treatment • No IV access • Monitor ABC’s – Rectal or SL diazepam 2-4mg • Ped 0.05-0.15mg/kg • Remove from any dangerous settings • May repeat in 10-15 min • Monitor activity and type – Fosphenytoin - 15-20 PE (phenytoin equivalent)/kg at 100-150 PE/kg IM – Absence • 1.5 mg of fosphenytoin is equivalent to 1 mg of phenytoin – Partial • With IV – Tonic-Clonic (Gran Mal) – Lorazepam 0.1 mg/kg IV at 2 mg/min • Ped dosing 0.05 – 0.1 mg/kg/ IV x1 • >10 minutes  Status epilepticus • 2nd dose 10-15 minutes – Diazepam - 0.2 mg/kg IV at 2 mg/min up to 20 mg – Fosphenytoin (same dose) ***Dosing is subject to change

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Heat Injury: Hyperthermia Risk Factors • • Fatigue Derangement of mechanism that • Hypovolemia (waiting to feel thirsty) control the body’s core temp – Sodium depletion • Most common in endurance • Previous heat illness (increased risk) • Febrile illness or recent immunization events • Very young or old – Marathons, Triathlons (running stage) • Hypertension • Low aerobic fitness level

Drugs Prevention • Anticholinergic (antihistamines) • Phenothiazines • Adequate acclimatization & conditioning – • Antidepressants (tricyclics, MAOI’s) Some athletes have poor tolerance • Hydration • Diuretics – Controversial: “Waiting for thirst indicates you’re • Alcohol already behind” • Cocaine • Wet bulb / Black globe Temp Index • Supplements (#1 problem) – WBGT = 0.7(WB) + 0.2(BG) + 0.1(DB) – Developed in 1956 by the US Marine Corps at – Creatine, Ephedra Parris Island

Wet Bulb / Black Globe Index

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WBGT Index Heat Loss/Gain

• Generates • Losses – Exercise – Perspiration and – Solar & sky evaporation radiation – Breathing – Ground thermal radiation – Breathing: Insensitive loss of fluid

Info.scientificgear.com. 2012-13

Types of Heat Illness Heat Cramps

• Heat or Post event collapse • Hot, flushed, sweating • Clear mental status • Heat Cramps • Rectal temp 100.4 - 103 (38.0 - 39.4) deg • Prolonged muscle spasm • Heat Exhaustion – 10ly lower limbs • Heat Stroke • +/- Edema • Sodium depletion • Treat: Oral fluids (Na+ replacement) – May need to look at Ca, Mg, & K

Heat Exhaustion Heat Stroke • 2 types: usually mixed • Disoriented, headache, slurred speech • Sodium depletion – milder • May be unconscious • Water depletion – more symptoms • Rectal temp >105.1 (40.6) deg • Conscious, may be more confused • Flushed or pale, +/- Sweating! • • Rectal temp 103 – 104 (39.4 – 40.0) deg Total thermoregulatory failure! – Multiple metabolic & electrolyte abn’s • Sweating +/-, nauseated, tachycardic • Treat: Medical Emergency!! • Hypotension: Worse in water depletion  IV fluids (NS), Wet down & fan, Cool water • Treat: Hypotonic oral fluids, IV fluids, Fan immersion (Ice/Ice water bath ??) on misted blankets (gauze)  Transport to hospital

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Prevention Prevention • Acclimatization of athletes 2 weeks prior • Daily posting of temp & heat stress index – Combination of solar & ambient heat and relative humidity (WBGT Index) • Liberal hydration is KEY! • Systematic schedule of fluid intake • Using weight loss during practice, amount – Before, during, & after events of fluid loss can be estimated and • Weights (determine amount of fluid lost) prevented – Before, during, & after practice – 1 lbs (0.453 Kg) in 175 lbs (79.38 Kg) = 0.57% • Availability of resuscitative and transportation – Approx ½ liter needs to be replaced services

Hydrate or Die!! Sickle Cell Disease

• Liberal hydration • 1st described in 1910 – < 1hr: water alone OK • Most common single genetic disorder found in – > 1hr: think Na+ replacement African Americans • Not usually K+ – Found in 1/375 to 1/500 of persons of African descent • Use of Sport drinks – 10% of African Americans have Sickle Cell Trait – > 1 hr of activity – Also 1/1000 of Hispanic descent – Intense exercise – Also found in many others of Mediterranean, Arabic, – Warm / humid conditions Indian, and South American descent • Remember Sports Drinks contain CHO!! • Various forms of the disease with varying severity

Sickle Cell “Disease” Sickle Cell “Trait” • Various forms: Less severe symptoms • “S” gene from both parents – HgB-SA – Homozygous HgB-SS • 1 sickle gene with 1 normal gene • Most severe form of the disease • Can be asymptomatic until late adolescence or – Limits athletic participation adulthood • Discovered early in infancy due to onset of anemia & – HgB-SC • complication 2 forms of abnormal hemoglobin • Tend to have earlier onset of symptoms – 1st crisis can occur as young as 1 y/o – HgB-SBeta • Survival into the 40’s with current diagnosis and treatment • Sickle cell thallasemia • More severe symptoms

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Vaso-Occlusive Crisis Complications

• • RBC’s assume sickle shape which causes occlusion Splenic Sequestration of blood flow to various organs – Severe enlargement of the spleen • Triggers can include – Organ is usually infarcted in childhood earlier in SS-Disease vs Trait – Exercise – High risk of infections (is athlete immunized?) – Extreme Hot or Cold temperatures • Aplastic Crisis – Dehydration – – Infections Severe anemia – Etc…… – Related to infection with Parvo-B-19 virus • Acute treatment: Rest, Analgesia, Fluid, O2 • Acute Chest Syndrome • Multiple medications being used & tested for – Infarction with secondary infection of the lung prevention of crisis

Complications Sports Participation

• Gall bladder disease • Both the AAP – Committee on Sports Medicine and Fitness – Due to the high breakdown of RBC’s and National Athletic Trainers Assoc recommend FULL sports • Renal complications participation of athletes with Sickle Cell Trait – Hematuria, Proteinuria – Athletes with Sickle Cell Disease are recommended NOT to participate in high exertion and collision / contact sports – Eventual loss of function • ALL require individual assessment!! • Stroke and infarction of other major organs

Sports Participation Acute Treatment • Be aware that athletes with “Trait” may not present with symptoms until as late as college or • FLUIDS!!! even professional level sports! – IV if available (NS, Ringers) • High profile cases – Ereck Plancher, Univ Central Florida ’08 • Oxygen 15 lit/min non-rebreather – Aaron O’Neil, Univ Missouri ‘05 • – Devaughn Darling, Florida State ’01 Cool athlete if core temp rising • Plancher had been diagnosed prior to • Emergency Action Plan / 911 ready participation but had NO symptoms prior to his – death Equipment available (ie; AED) • Various sources list as many as 15 deaths – Advise ER to look for rhabdomyolysis attributed to Sickle Cell Trait complications

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Prevention Hypertrophic Cardiomyopathy ( ex IHSS) • Pre-participation screening tests – In “high risk populations” if not screened before • Most common cause of sudden death in • Close attention to vital signs athletes • Build athletes up slowly • Usually find: – Longer rest periods – Marked LVH (***Need to differentiate from • Hydration Hydration Hydration!!! normal LVH in conditioned athletes) – • Look for signs/symptoms of heat illness Significant L outflow obstruction & Arrhythmia's – – Less symptoms of cramping in “Trait” athletes Both increased by activity – • Hold from participation if athlete is ill PMHx of syncope or FHx of sudden death in a young relative

Symptoms HCM Incidence • Most are ASYMPTOMATIC until Sudden • 0.2% to 0.5% of the general population Cardiac Death (can be the 1st symptom) – All types of HCM • Symptoms with activity: • Appears in all racial groups – Chest pain • Sarcomeres (contractile elements) in the – Shortness of breath heart replicate causing heart muscle cells to – Lightheadedness increase in size – Dizziness – Results in the thickening of the heart muscle – Loss of consciousness • Typically an autosomal dominant trait • Children often do not show signs of HCM – 50% chance of passing trait – After puberty

Cardiovascular Risks Veneto Italy Study • Claim 89% reduction in SCD by screening ALL • SCD (ALL causes) per year in healthy athletes with ECG in the PPE patients • Actual numbers: – – 84 of 12,880 (0.65%) screened had any significant ECG 1 / 133,000 Men (0.00075%) abnormalities – 1 / 769,000 Women (0.00013%) – Study was done between 1979-2001 • – 11 of that 84 (0.09% of the 12,880) had significant AMI w/in 1 hour of exercise 2-10% pathology – 2.1 – 10x higher than in sedentary patients • US athlete population alone is ~15 million • SCD 6-164x greater than sedentary patients Peliccia et al, N Eng J Med 2008 V358(2) pp152-61 • • New findings higher familial incidence of HCM in Recommend higher level of screening in Veneto Italy population high risk patients – Pediatrics in Review November 2006; 27:418-424; doi:10.1542/pir.27-11-418 – European Heart Journal (2011) 32, 983–990 doi:10.1093/eurheartj/ehq428 • Circulation 2007: Exercise and Acute CV Events: Placing Risks Into Perspective

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Problems with Veneto ECG Screening?? • Retrospective study in Israel 1985-2009 • ARVC (Arrythmogenic Right Ventricular • Mandatory ECG started 1997 Cardiomyopathy) conveys the 2nd highest risk of • 24 deaths documented sports related sudden death (not HCM) – 11 before legislation • Most common sport is Soccer vs US Basketball & – 13 after legislation American Football. Soccer may have higher cardiovascular demand • Incidence 2.6 / 100,000 athlete-years » Journal of Sports Medicine Vol 2013 (2013), Article ID 967183 – 2.54 / 100,000 before legislation • Annual death rate before the screening program began – 2.66 / 100,000 after legislation was 1 per 27 000 athletes, "which is high compared with other [US] studies.“ – p = 0.88 (difference not statistically significant) » ECG screening slashes sudden cardiac deaths in young athletes - Medscape - Oct 03, 2006. • No apparent effect on risk for cardiac arrest

Steinvil et al J Am Coll Cardiol 2011 v57 pp1291-6

Harms from ECG Screening HCM Deaths (Athletes) • Up to 5% of healthy people can be suspected of having disease following ECGs, and up to 30% of those screened may be referred for additional cardiovascular testing (= • 1 in 220,000 per year False +) – 66-75 deaths per year – Echocardiography – Stress testing (+/- imaging) • – Cardiac catheterization Between 1994-2006 • Additional tests can lead to unnecessary harms associated – Blunt trauma w/ damage 416 with anxiety and psychological trauma, overdiagnosis and – Commtio cordis 65 overtreatment. And athletes can be subjected to temporary or lifelong restrictions and exclusion from – Heat stroke 46 sport, and impediments to insurability or employment opportunities – BMJ Press Release 4/2016 Circulation. 2009 Mar 3;119(8):1085-92 • False-negative rates average 30% +/- – Allison ; J Pediatr 2011

Treatment HCM Treatment HCM

• Limitation of extremely exertional activities • Alcohol septal ablation • Beta blockers and Calcium channel blocker – Alcohol ablation of the septal branches of LAD (Verapamil) – Less invasive – Avoid diuretics • Implantable cardiac defibrillator • Surgical myomectomy • Pacemaker – Removal portion of interventricular septum – Induces asynchronous contraction of the left – Mortality of 1% ventricle which reduces outflow obstruction

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Other changes • Better cardiac screening for PPE’s Concussion 2017 – Valsalva & Squat test for murmurs Update on Diagnosis and Treatment – AHA guidelines • Close monitoring of athletes during ANY activity • BCLS trained & AED availability at ALL events • Withholding any athlete showing any signs of cardiac disease …. (Similar to concussions) • Recommend physician coverage at broader range of athletic events – Basketball, Soccer, Track & Field…….. • Paradigm change: Injury focus > Medical focus

House committee approves bill on concussion management in youth sports. The state House of Representatives' Education Committee on Monday reported out legislation supporters say is intended to help Pennsylvania schools better manage concussions that happen in interscholastic sports. House Bill NFL head injuries prompt fines, brain concerns 2728 (http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=H The National Football League has fined three players $50,000 to $75,000 TM&sessYr=2009&sessInd=0&billBody=H&billTyp=B&billNbr=2728&pn=4274& for violent helmet-to-helmet hits - which have been known to be Email=True&iRegionID=1&Dome=True) devastating for players. sponsored by Rep. Tim Briggs, D-Montgomery, would require that any athlete The league has been criticized for being too lax with head blows and the exhibiting signs of a concussion or head injury be removed from the athletic league's new medical committee members earlier this year vowed to activity in which they are participating. The student would not be allowed to change that culture. return to participation until the student is evaluated and cleared for return in writing by a licensed or certified health care practitioner whose scope of practice After several players were injured Sunday in what some fans and includes the management and evaluation of concussions. Prior to the observers perceived as a particularly violent weekend of football, the NFL committee's final approval of the bill, the legislation was amended on a close 11- pledged on Tuesday to be more vigilant about ejecting and/or suspending 10 vote with changes offered by Rep. Paul Clymer, R-Bucks, the minority chairman of the committee. Clymer's amendment inserted language to ensure players who have made flagrant hits. no additional civil liability for independent contractors, such as umpires and CNN Health referees, if they fail to recognize the signs of a concussion. http://pagingdrgupta.blogs.cnn.com/2010/10/20/nfl-head-injuries-prompt-fines-brain-concerns/?hpt=Sbin

Sports Illustrated article Cognitive Effect of One Season of Head Impacts highlights brain trauma caused Posted: 07 Jun 2012 06:03 PM PDT Cognitive effect of one season of head impacts in a cohort of by football collisions collegiate contact sport athletes.

Sound Bend Tribune Online McAllister TW, Flashmasn LA, Maerlender A, Greenwald RM, Beckwith JG, Tosteson TD, Crisco JJ, Brolinson PG, Duma SM, Duhaime AC, Grove MR and Turco JH. Neurology. 2012. 78:1777-1784. Published: October 28, 2010 http://www.neurology.org/content/early/2012/05/16/WNL.0b013e3182582fe7.abstract?sid=8ceb45be- aa45-463e-8487-f6dcb215f769 In this week’s November 1st issue of Sports Recently in many media outlets, concerns have been raised over Illustrated David Epstein’s report “The Damage the long-term effects of head impacts on athlete’s cognitive Done” takes a close look at brain trauma suffered function. While many studies have looked at the effects of mild by football players, not from concussive blows traumatic brain injuries, few studies have looked at repetitive head impacts and their long-term effects. Therefore, McAllister and but rather from the hundreds of “minor” hits that colleagues completed a pretest/posttest cohort study to evaluate if are just as traumatic……….. repetitive head impacts sustained over 1 season would affect cognitive performance.

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Concussion (Closed Head Trauma; Diffuse Brain Injury)

N.F.L. Asserts Greater Risks of •THANK Head Injury By ALAN SCHWARZ YOU Published: July 26, 2010 The National Football League is producing a poster BEN!!! that bluntly alerts its players to the long-term effects • (He says VERY tongue in of concussions, using words like “depression” and cheek) “early onset of dementia” that those close to the issue described as both staggering and overdue.

NFL players sue league over concussion health risks Thursday, June 07, 2012

• LOS ANGELES (KABC) -- Over 2,000 NFL players filed a class-action lawsuit in a Philadelphia federal court Thursday against the league. The suit unites more than 80 pending lawsuits, claiming the NFL knew for years that concussions cause long-term brain injury. http://abclocal.go.com/kabc/story?section=news/spor ts/pro/football&id=8693680

Judge blocks NFL concussion settlement, demands changes Concussion

• A U.S. Judge Anita Brody refused to accept a proposed • “Diffuse brain injury” settlement between the National Football League and – thousands of retired players over concussions, saying some TBI: Traumatic Brain Injury changes were needed before she would approve it. • Focal brain injury: More severe • Included in those changes is an assurance that retired players – who died of the brain disease chronic traumatic Epidural, subdural, intracerebral encephalopathy should be covered hematomas • Most common in football, hockey, boxing, martial arts….. Reuters Mon Feb 2, 2015 5:20pm EST • Acceleration / Deceleration injury

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Occurance Other Factors

• 1.6 to 3.8 million sports-related TBIs • “Silent Epidemic” • occur each year Multiple injuries can have long term effects • Over 50% of concussions may go • Concussion accounts for 6-10% of all unreported sport related injuries • Athletes can (& will) hide the symptoms to – Higher risk among high school athletes in remain in the game contact sports • Coaches and parents want the athlete to play – • Langlois, 2006 Will down-play the severity – McCrea, 2004

Key Points Diagnosis of Concussion

• #1 symptom is confusion • Physical examination, central nervous system imaging, and other • Level of consciousness neuropsychological tests cannot diagnose concussion accurately, • – LOC seen only in 10% of concussions Clinicians must rely upon the self-report of symptoms • • Assess memory Athletes will: – 1) Under-report symptoms – More sensitive parameter in conscious patients – 2) Intentionally fail to report symptoms – Look for Retrograde and Anterograde amnesia • Parental, peer, & coach pressure • If unconscious A B C’s – Assume c-spine injury

Consensus Statement: Zurich Neuropsych • #1 Vienna 2001 • #2 Prague 2004 Testing • # 3 - May 2009 • Standardized Assessment of – Clin J Sports Med, Vol 19, Num 3 Concussion • # 4 – Nov 2012 Brain Injury Association of – Br J Sports Med 2013;47:250-258 doi:10.1136/bjsports- America 2013-092313 1608 Spring Hill Road – http://bjsm.bmj.com/content/47/5/250.full Suite 110 • Vienna, VA 22182 Currently under review 703-761-0750 / 800-444-6443 – Lack of diagnostic specificity – Management strategies that are not evidence based • Cost ?? – Rehabilitation goals that are not attainable – Clinical Journal of Sport Medicine: March 2014 - Volume 24 - Issue 2 - p 93–95

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SCAT: Sideline Concussion Assessment Tool SCAT 5 • In use since 2005 • Developed by Prague Group 2005 mainly for sideline • Symptom score sheet post-injury assessment • For athletes 13 & • Mental function assessment in several areas older – • Not a full neuro-psych test Child SCAT for 5-12 • Measures • Does have some baseline to compare with post-injury – Symptoms • SCAT 3 released 2012 – Orientation • SCAT 5 released 2017 – Memory – Balance / Gait – From Zurich consensus paper

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

ImPACT: Neuropsych Testing Univ of Pittsburgh • Computerized system to aid in evaluating concussion management and safe return to play • Battery of scientifically validated neuro-cognitive • Administer before starting any sports testing on large populations – Not just contact – ?Does not require baseline testing for individual athlete – Baseline to compare to • Newer studies question the reliability of the test • Most athletes returned to baseline in 2-4 weeks – Athletes purposely doing poorly on the pretest to make post Can help with determining safe return to play injury test scores seem higher Use in addition to patient report of symptoms – Noting a 37-46% False Positive and False Negative testing rates

• Journal of Athletic Training 2013;48(4):506–511

Traumatic Brain Injury Traumatic Brain Injury • TBI classified by – #1 Symptoms w/ activity and at rest • Both physical and mental function • Need to be aware of Post TBI Syndrome & Second – #2 Amnesia Impact Syndrome – #3 Loss of Consciousness – Pay close attention to subtle neuro signs and • Neuropsych testing complaints of headache, poor concentration, dizzy – Athlete must be symptom free w/ activity and at rest – Pre-participation and back to baseline Neuropsych testing before being – Post-injury allowed to play • NUMBER of events • Minor trauma can lead to rapid cerebral edema – Damage can be cumulative in some athletes – More common in younger / pre-adolescent athletes

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Post Concussive Syndrome Second Impact Syndrome

• Symptoms are: – Headache (Email from Sports Medicine Listserv) Sent: Fri, Oct 29, 2010 11:52 am – Irritability Subject: second impact syndrome – Memory loss Had a young man here in Kansas City area who had a – Fatigability concussion last week that was cleared by his doc. Then last – Dizziness/vertigo night had an interception, tackled, came to the sideline complaining of wheezing, and collapsed, convulsed and was – Impaired concentration lifeflighted to KUmed. He died at 4 AM this morning. most – Sleep disturbance likely second impact syndrome. Already getting phone calls this AM from reporters to comment on story. Very sad.. • May take weeks months to resolve!!

October 29, 2010 Friday Second Impact Syndrome "It was just a routine play. I don't think there was anything special," Orrick told the Miami County Republic after the game. "I • Athlete receives second minor head injury before fully recovering from think he just hit the ground pretty hard with his head. He came on the sideline and told previous concussion one of my assistants, 'my head is really • Can lead to rapid & catastrophic cerebral edema and swelling hurting.' He sat down on the bench. He Nathan Stiles 17 y/o then stood up, but his legs went Spring Hill HS, Kansas City – Mortality is not uncommon! underneath him and collapsed there." • Rare, but more common in younger / pre-adolescent athletes NBC Action News also reports that Stiles was taking part in his first game since returning from a concussion suffered in early October. • Do NOT ignore post-concussive symptoms!! Stiles' father confirmed this to the Kansas City Star, noting that his son suffered a concussion during the homecoming game earlier in the month, but was cleared to play Thursday.

Spivak AOL News 10/30/2010 http://www.fanhouse.com/2010/10/30/nathan-stiles-kansas-high-school-football-player-dies- after-in/

All brains recover at Owen Thomas brain autopsy reveals disease Repeat head trauma may have led to Thomas' different paces suicide last spring by Calder Silcox | Tuesday, September 14, 2010 Daily Pennsylvanian

A brain autopsy of Penn football player Owen Thomas, who committed • Some athletes can recover completely from suicide in the spring, revealed that the standout lineman had developed a disease caused by repeated head trauma. Commonly experienced by football a concussion players, the disease has also been linked to depression. Thomas, then a Wharton junior, hanged himself in his off-campus apartment • Others retain some residual damage in April, shortly after being elected captain of the football team for the 2010 season. The event took family, friends and teammates by surprise. • Repeated concussions, even minor The brain autopsy was performed by researchers at Boston University, The New York Times reported Monday [2]. The autopsy showed early stages of especially starting at young ages, make chronic traumatic encephalopathy, which has been found in over 20 deceased National Football League players. Thomas’ case is the first to be patients susceptible to more damage confirmed in a non-NFL player, and Thomas is the youngest known football player to develop the disease. Cantu: ATSNJ July ‘11

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Researchers find brain trauma in Henry By Peter Keating ESPN The Magazine June 29, 2010 Junior Seau Suicide Shows How Little We Know About Head Trauma The Daily Beast, May 6, 2012 Chris Henry, the Cincinnati Bengals wide receiver who died in a traffic accident last year, had chronic traumatic encephalopathy (CTE) -- a form of degenerative brain damage caused by multiple The suicide of NFL linebacker Junior Seau has hits to the head -- at the time of his death, according to scientists at reignited the debate over head trauma's long- the Brain Injury Research Institute, a research center affiliated with term effects. But as Casey Schwartz reports, West Virginia University. concussions remain a perplexing medical mystery.

Concussion Movie Chronic Traumatic Encephalopathy

• “In Pittsburgh, accomplished • pathologist Dr. Bennet Omalu Found most commonly in athletes with multiple uncovers the truth about brain head “injuries” damage in football players who – Can be an accumulation of multiple small “hits” & not suffer repeated concussions..” all causing symptoms • Actually about CTE • 73% of pro-football players with CTE died in • CTE known since the 1920’s, Dr Omalu noted the relation ship middle age (mean 45 y/o) between football & CTE • 64% of deaths have been from – Suicide – Abnormal erratic behavior – Substance abuse

Pathological Changes Symptoms CTE • Cerebral atrophy • Cognitive changes 69% • Medial temporal lobe atrophy – Memory loss / Dementia • Mammillary body atrophy • Personality / Behavioral changes 65% • Thinning of the hypothalamic floor – Aggressive / Violent behavior • Marked dilation of II and III ventricles – Confusion • Cavum septum pellucidum with fenestrations – Paranoia • Pallor of the substantia nigra • Movement abnormalities 41% • NOT equal to Alzheimer’s, changes deeper down – Parkinson's (Dementia pugilistica) in 5th later of cortex – Gait / Speech problems – CTE is more superficial near blood vessels & no beta amyloid deposition • Sleep disturbance is an early & EXTREMELY important sx

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Treatment of Concussions Treatment CTE • PREVENTION!!!!!!!!!! • New NFL rules regarding helmet hits – Need to be a role model for younger athletes • NONE!!!!!!!! • Air bladders in football helmets. – Treat symptoms – Absorb linear forces so they DO prevent focal • Prevention is currently the only available injuries (eg, skull fractures). treatment option – Do NOT absorb rotational forces!! • – Could cause increase in concussion rate Boston Hospital is working on various because athletes have a false sense of security. pharmacological approaches to prevent – Older helmets with air bladders extended progression of CTE lower on the neck, causing brachial plexus injuries

Helmets & Prevention Helmets & Prevention • Most studies indicate helmet designs do • Impact sensing helmets monitor when an athlete has sustained NOT prevent concussions a potentially serious hit – Effective in reducing the number of skull fractures and brain contusions, • No specific standards yet – Not effective in reducing the shear forces • Various types: involved – Lights on back of helmet http://www.sportsafetyinternational.org/new- – Linked to system on the sideline football-helmet-study/

Treatment.. Other sports Treatment……. Headaches • Acetaminophen • Soccer headers • NSAID’s – Sports organizations are considering rule – Caution: Bleeding changes for younger players. • Narcotics – Hitting a ball with an immature skull puts – Caution: Addiction athlete at risk of concussion. • Antidepressants – Protective head gear will not decrease risk of – Tricyclics concussion. • Low dose useful for pain – Young athletes should avoid headers • Anti-seizure medications

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Waking during the night Clinical Assessment • VERY controversial! • Symptom assessment – Most evidence is currently against – Headache, confusion, blurred vision, nausea – Mostly relates to looking for signs of an • Physical assessment intracranial bleed – *Ocular Vestibular testing • Have observer look for • Pursuits, Saccades, Convergence – *Balance testing – Unusual breathing patterns • Tests to determine mental status. – Atypical movement – 3-5 word recall (usually 3x) – Convulsions – Serial 7’s (count backward from 100 by 7’s) – Bleeding – Recite months in reverse order • Neuro-psych testing • If there is concern…… admit – SCAT3

Childhood CT scans are found to raise Imaging cancer risk

By Steven Reinberg Associated Press Fri, June 8, 2012 • Computed tomography (CT) scan and magnetic resonance imaging (MRI) study results are normal • WEDNESDAY, June 6 (HealthDay News) -- Children in concussions. who undergo CT scans of the head may raise their • Recommended ONLY if focal symptoms present, risk of developing brain cancer or leukemia later looking for: in life, a new study says. – Epidural bleed • Although multiple CT scans could triple the risk, – Skull fracture the absolute risk remains small -- one case in • Be mindful of amount of radiation to which the 10,000 scans of the head, the researchers said. – http://www.philly.com/philly/health/topics/HealthDay665501_2012060 athlete is exposed with CT scans 7_Child_CT_Scans_Might_Up_Risk_of_Brain_Cancer__Leukemia.html?r • MRI - Useful for suspected smaller lesions and ef=more-like-this#ixzz1xCTSUFyO aneurysms.

Other Imaging New Paradigm for Diagnosis • Examination for autonomic dysfunction, including orthostatic hypotension and exercise intolerance with symptom exacerbation (e.g., the Buffalo Concussion Treadmill Test). • PET + CT & new PET + MRI radioactive tracers & • Assessment of cranial nerve abnormalities, especially in olfaction. cost • Examination for injuries of the head, neck, and, especially, cervical spine, which can produce dizziness, headaches, and abnormalities in • Blood Oxygen Level Dependent (BOLD) more balance. Assessments include cervical proprioception and sensitive to small hemorrhages [temporomandibular] joint problems. • Balance/coordination examination. Tests include motor coordination • Susceptibility Weighted Images (SWI) also more and dual tasks (e.g., solving math problems while undergoing the sensitive Timed Up and Go test). • Vestibulo-ocular and ophthalmologic examinations. Vestibulo-ocular • MR Spectroscopy – biochemical info impairments are tested with the Head Thrust Test; dynamic visual • acuity is also examined. Also assessed are smooth pursuits, horizontal DTI – diffusion of isotopes, shows direction of flow and vertical saccades, near point of convergence, horizontal vestibulo- • fMRI – shows increased activation ocular reflex, and visual motion sensitivity.

• Jonathan Silver, MD reviewing Matuszak JM et al. Sports Health 2016 Mar 28.

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Return to Play Return to Play

• • Professional level ONLY Current return-to-play – Athlete sits out of play for 15 minutes. standard of care does not – Retest – Baseline testing required!!!! allow an adolescent athlete – If athlete at baseline and asymptomatic, could possibly return to play to return to play the same • Not recommended!!! day a concussion was • Not allowed at college, high school levels sustained or suspected!

Return to Activity Complete Mental Rest Unnecessary

• Athlete should NOT be allowed full activity • Prospective cohort study of patients presenting to until symptoms have resolved a sports concussion clinic at Boston Children's • Treatment is mainly rest and not only Hospital includes physical activity but MENTAL – Patients sorted into 4 groups: most to least levels of activity as well cognitive activity • – Good evidence that trying to continue full Patients in the highest quartile of cognitive mental functioning, such as school, will prove activity days took significantly longer to recover to be difficult for the patient and may even • Those in the lower three quartiles had similar SLOW recovery! recovery curves – Medical leave….. slow making up missed work

Brown NJ et al. Pediatrics 2013 Jan 6

Return to Activity Balance assessment in the management of sport-related concussion. • Matthew Alan Gfeller Sport-Related Traumatic Brain Injury Research Center, Athlete must close to baseline Neuro-psych Department of Exercise and Sport Science, University of North Carolina at Chapel Hill symptoms / testing w/ SCAT3 Clin Sports Med, 2011 Jan;30(1):89-102 – ImPact – falling out of favor • Although neuropsychological testing has proven to be a valuable tool in concussion management, it is most useful when administered as – Symptom testing: balance, ocular-vestibular part of a comprehensive assessment battery that includes grading of symptoms and clinical balance tests. A thorough sideline and clinical • Serial evaluations examination by the certified athletic trainer and team physician is considered an important first step in the management of concussion. – Athlete performs exertional tests The evaluation should be conducted in a systematic manner, whether on the field or in the clinical setting. The evaluation should include – Rest for 24 hours obtaining a history for specific details about the injury (eg, mechanism, symptomatology, concussion history), followed by – Re-test exertional, balance, ocular-vestibular assessing neurocognitive function and balance, which is the focus of this article. The objective measures from balance testing can provide • Adolescents: must be symptom free before clinicians with an additional piece of the concussion puzzle, remove some of the guesswork in uncovering less obvious symptoms, and returning to full activity assist in determining readiness to return safely to participation.

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Disconjugate Eye Return to Activity • No symptoms reported with/without Movements exertion • Eye tracking test may detect and help • Neuropsych affected by effort & motivation quantify the disruption of ocular motility • Feel threatened associated with concussion • Feel inconvenienced • Fake lower baseline score to try to get RTP sooner – Pursuits, Saccades, Convergence • Is NOT as “cookbook” as with orthopedic • Eye tracking device distinguished patients injuries with concussion from healthy controls • “Can play safely with a below the neck • Helps separate concussions from other injury…. Cannot with a brain injury” conditions » Robert Cantu, MA, MD, FACS, FACSM – Journal Neurotrauma; Samandi et al; Volume: 32 Issue 8: April 7, 2015 » Clinical Professor of Neurosurgery at BUSM

Zurich Graduated RTP Protocol 2012 Complete Rest NOT Indicated • Guidelines are shifting toward exercise earlier in the recovery period • Athletes should become gradually and progressively more active while staying below their symptom-exacerbation thresholds – Activity level should not bring on or worsen symptoms – Br J Sports Med. Published online 04/2017 ALL athletes should start on Step 2 immediately!!

Return to… • School – Symptomatic students may require active supports and accommodation – Gradual decrease as functioning improves • Work – May initially need to reduce both physical and cognitive exertion – Restricting work during initial stages of recovery may Q&A be indicated • Repeated evaluation of both symptoms and cognitive status is recommended

» CDC December 2015

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