With Support From. Evaluations & CE Credits. Featured Speakers. Conflict of Interest & Disclosure Statements

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1 With Support From University at Albany School of Public Health New York State Department of Health New York State Association of County Health Officials (NYSACHO) Evaluations & CE Credits Nursing Contact Hours, CME, CHES and General Education credits are available. Please visit to fill out your evaluation, complete the post-test, & print out your certificate. The New York State Department of Health will provide NYS EMS CME credit hours for EMS providers under core for trauma. Those wishing this credit should request the General Education certificate and submit to the health department for that credit. Conflict of Interest & Disclosure Statements The planners and presenters do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in this activity. No commercial funding has been accepted for this activity. Featured Speakers Identifying and Assessing Mild Traumatic Brain Injury: Guidelines for EMS and Health Care Providers December 17, 2015 Lee Burns, Director, Bureau of Emergency Medical Services and Trauma Systems, New York State Department of Health Hamish Kerr, MD, Director, Albany Medical Center Sports Concussion Clinic and Team Physician, Siena College 1

2 Objectives At webcast conclusion, viewers will be able to Describe the impact of brain injuries in New York State, including populations most affected Name at least three symptoms of mild TBI that can be determined through assessment steps in prehospital settings List the four steps of the pre-hospital assessment to determine the presence of a mild brain injury Evolving Trauma Care in NYS Goal: to enhance standards of care and patient outcomes EMS personnel, physicians and nurses are integral to achieve these results Types of Brain Injury Acquired (ABI): occurs after birth, disrupts the normal function of the brain, and includes anoxia, brain tumors, strokes, and traumatic brain injuries Traumatic (TBI): is caused by external forces, includes concussion A Silent Epidemic Mild traumatic brain injury accounts for at least 75 % of all traumatic brain injuries in the United States. However, it is clear that the consequences of MTBI are often NOT mild. - CDC Report to Congress Known NYS TBI Incidence 400 each day ED Visits 120,409 Hospitalizations 19,368 Deaths 2,279 Greatest Risk of TBI Young children Youth/Young Adults Adults 65 or older 2

3 Leading Causes of TBI in NYS Falls Vehicular accidents Assaults Incidence vs. Prevalence Prevalence: At least 50% higher than reported Excludes persons in urgent centers, physician offices or those undiagnosed Fall Injuries Crash Reports TBIs reported for all age groups Falls impact those less than 10 years of age to those 65 and older Data based on emergency department visits, hospitalization and deaths in NYS 71, ,000 In New York State, 2013 MVT Crash Occupants TBIs from MVT crashes 697,000 17,180 Youth Sports Highest Concussion Rates U.S. Top Sports & Recreation Injuries Boys Football Ice Hockey Lacrosse Soccer Wrestling Girls Soccer Lacrosse Basketball Softball Field Hockey Cycling 85,400 Football 47,000 Baseball/Softball 38,400 Basketball 35,000 Water Sports Recreational Vehicles 27,000 Soccer 24,000 Skateboards/Scooters 23,000 Winter Sports 17,000 Horse Riding 14,500 Gymnastics/Cheer 10,200 Golf 10,035 3

4 TBI Can Be Subtle Spectrum of TBI Mild Moderate Severe Concussion Symptoms of Concussion (MTBI) Mild TBI (MTBI) Cognitive Physical Emotional / Mood Difficulty thinking clearly Headache Irritable Amnesia Fuzzy or blurry vision Sadness Difficulty remembering new Nausea, vomiting Nervousness information Difficulty with concentration Light or noise sensitivity Anxiety Feeling foggy Balance problems Unusually emotional Feeling slowed down Hearing impairment Cognitive and behavioral effects Potentially long lasting May lead to chronic disability Impacts likely if not properly diagnosed and treated Impact of Repeated Head Trauma Over time (i.e., months, years): Can result in cumulative neurological and cognitive deficits Within a short period of time (i.e., hours, days, or weeks): Can be catastrophic or fatal Youth who sustain a concussion are three times more likely to sustain a second concussion Mechanics of Brain Injury The Egg Toss Coup Contrecoup Shearing/Rotation Even a mild TBI can cause permanent damage 4

5 Physiological Impacts of TBI Pre-hospital Assessment - Step 1 A chain of events inside the brain: Biomechanical changes and damage Chemical changes Initial Assessment Assess vital signs and level of consciousness to determine: Glasgow coma scale (GCS) 13 Systolic blood pressure 90 mmhg Respiratory rate 10 or 29 per minute If yes to any, transport to highest trauma care available in a defined system Pre-hospital Assessment - Step 2 If no trauma apparent, determine Loss of consciousness 30 minutes Loss of memory for events immediately before and after injury Alteration of conscious state 24 hours Glasgow coma scale (GCS) score of Pre-hospital Assessment - Step 3 Assess mechanism of injury and energy impact For falls: Adults 20 feet Children 10 feet High energy impact patient needs to be transported to a trauma center Pre-hospital Assessment - Step 3 For motor vehicle crashes: Neck pain Whiplash Headache If yes transport to trauma center Pre-hospital Assessment - Step 4 Special Considerations Children: Preferentially transport to pediatric-capable trauma center Pregnancy: 20 weeks Older adults: Risk of injury/death increases for age 55 SBP 110 might represent shock after age 65 Low impact/ground level falls may cause severe BI 5

6 Pre-hospital Assessment - Step 4 Anticoagulants/bleeding disorders: pose high risk for rapid deterioration If any risks present: Transport to trauma center or hospital capable of thorough, timely evaluation with initial management of serious injuries Pre-hospital Assessment - Step 4 If no moderate/severe trauma, determine if the patient has: Altered consciousness Disoriented to place Pupillary asymmetry Unusual behavior, irritable Seizures Slurred speech Repeated vomiting Unsteady on feet Double vision Worsening headache If yes, transport to highest level trauma care within a defined system Pre-hospital Assessment Pre-hospital Assessment When in doubt, transport to an appropriate trauma center If prior steps do not indicate transport, assess: Physical symptoms Cognitive symptoms Emotional symptoms Ask The Questions If Transport is Refused 1. Have you hit your head or had a blow to your body before? 2. If so, how many times has that happened? If answer is more than one, know there is increased risk of serious harm with the present injury If yes to repeated head trauma, transport to ED Urge person seek follow-up medical care Provide and review Brain Injury Symptom Wallet Card Inform about importance of brain rest after injury Thoroughly document medical care provided Document refusal for transport and/or medical care 6

7 Brain Injury Symptom Wallet Card NYSDOH.ny.gov & search TBI Eye Opening - E Score None 1 To Pressure 2 To Sound 3 Spontaneous 4 Untestable Reason Verbal Response - V None 1 Sounds 2 Words 3 Confused 4 Oriented 5 Untestable Reason Motor Response - M Score None 1 Extension 2 Abnormal Flexion 3 Normal Flexion 4 Localizing 5 Obey Commands 6 Untestable Reason (GCS) Score of: 13 Mild TBI 9-12 Moderate 8 Severe Patient with GCS of 13: Should be transported to the highest level trauma center available in a defined trauma system Should receive expedient neurosurgical assessment and intervention 7

8 Patients with a GCS of 15, in combination with: Moderate-severe extra cranial anatomic injuries Abbreviated Injury Score (AIS) 3 Should be rapidly transferred to the highest level of care within a defined trauma system Should receive multidisciplinary assessment and intervention Standardized approach to GCS assessment and reporting is essential GCS should specify the score for each component (eye, verbal, motor) The sum of the component scores (GCS 3 15) is relevant for classification CDC 2011 Field Triage Guidelines Signs/Symptoms Review CDC Guidelines mirror the GSC - EMS should transport: All patients with a GCS 13 or with GCS 15 AND extracranial injuries (AIS 3) To the highest level trauma center with expertise and personnel To trauma center that can rapidly provide definitive care, usually a Level I or II Trauma Center Urgent Transport Needed Neck Pain Worsening/Severe Headache Slurred Speech Difficulty with Vision Difficulty with balance, walking Seizures Increasingly confused, restless Follow-up Medical Care Sensitive to noise or light Headache Dizziness Blurred vision Nausea Balance problems Feeling mentally foggy Questions? To request Brain Injury Wallet Cards, b0019w@health.ny.gov Program references available on the webpage Evaluations & Continuing Education: Nursing Contact Hours, CME and CHES credits are available. Please visit to fill out your evaluation, complete the posttest & print your certificate. EMS providers should choose the general option to print their certificate. This education program may be applied to Core CME under Trauma for one contact hour. 8

9 Conflict of Interest Disclosure Conflict of Interest Disclosure Statement: The planners and presenters do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in this activity. No commercial funding has been accepted for this activity. Thank you! Evaluations 9