Pediatric Sports Head injuries Richard J. Kanoff, D.O. Pediatric Neurology Essentia Health Children s Services What s all the Fuss? NFL 2010 Zurich 2008 : 3 rd International Conference on Concussion in Sport. Sports Medicine, International hockey federation, Dublin Rugby Board. Kanoff 2005 NHL & AAN 2000 Common Themes and Recommendations: Acute management of symptoms See the patient within the first 72 hrs. Remove from high risk activities Transition back to normal activities: SEE the Patient! 1
What is Still Missing.. Depression: loss of identity, child and parent Post traumatic stress disorder Baseline. Baseline. Baseline. Concussion ANY neurologic dysfunction that occurs as the result of physical contact or acceleration/deceleration of the head. Loss of consciousness Confusion Headache Dizzy: light headed or vertigo. Prominent vertigo, think basal skull fracture, check ears/hearing Attention/concentration/memory Concussion Card Grading System Designed with input from AAN, NHL, others. Established the MINIMUM of what to do Escape hatch: doctor may decide differently. Grade 1, 2, 3. Which is worse: 1 min LOC or 20 minute confusion w/o LOC? 2
Traumatic Brain Injury Concussion with symptoms lasting > 30 days. Some say less than that. Concussion is not always a temporary condition! Abnormal CT scan: contusion. Axonal injury: best seen on MRI; Think this when the patient looks worse than the CT! Longer recovery, then lights on What s All The Fuss? Second impact syndrome: exponential injury, cerebral edema, caused when a second impact occurs while the patient is still recovering from an initial impact. Multiple concussion syndrome: discrete injuries become cumulative over time. The next concussion is likely to be the worst. Data High school > college > pro AAN Soccer data in 2000 Most concussions last 3-7 days. Symptoms over 1 week are predictive of long term effects. Recovery still possible, more cumulative effect. Neurophysiology: trauma induces excitatory neurotransmitter release, depolarization, cell metabolite exhaustion, mitochondrial injury, calcium permeability increases, cell repair, injury, or death. Long term: < 10 % have deficits; Improve to 2 yrs 3
Issues Trust Grades down, cognitive impact, child/parent thinks we are punishing them for the bad grades. Doctor can only exceed concussion card recommendations. So don t go! Faith Come back if you are not better. Playing with pain is part of sports. Is it really? Brett ankles heal, thumbs heal, brains not so much Will the child tell us when things are not going well? Will the parent? Who Has More to Lose? C/D student with concussion. Doesn t apply himself. No college plans. More to lose because of where they start from. 4.0 student. Professional athlete v. student with a profession. But More reserve, faster cognitive recovery. Are B s ok? Management Acute Image? Acutely, research has focused on need for neurosurgical intervention. Canadian CT head Rule (Lancet 2001) (compared in JAMA 2005); No CT recommended if: GCS 15 by 2h: Eyes spont. open, Verbal - converses, Motor follows commands ; 13: follows commands but only opens eyes to voice, confused. No skull fx signs: battles, raccoon, hemotympanum, csf leak Vomiting < 1 or none Retrograde amnesia < 30 minutes Non dangerous mechanism of injury 4
Acute Management SCAT side line tests? Remove the student athlete from that day s play Balance board: correlates, but still separate from cognitive injury Canadian CT Head Rule No patients were missed who required neurosurgery 8% had clinically significant injury 1% required neurosurgery 4% had CT findings treated as not clinically significant. Abnormal CT: small SAH, non displaced fracture 4% error rate in miss-interpreting the guidelines: should have had a CT. What Does This Mean? We want to reduce exposure to radiation. Prognosis impacts treatment Don t fear the CT scanner! Timing is a consideration. Clearly, not everyone needs a CT. If he has a bleed, it s a small one, you can go home now but come back if he worsens. Patient seen 1 hr post injury, GCS = 13. should we wait an hour, to see if he clears, to decide on the CT? 5
Bottom Line No matter how we try to standardize, we need to individualize: the patient and the injury Protect your patient s future Follow-up is the most critical piece. Acute Management - Migraine Rest/sleep melatonin, visteril Pain control non narcotic when no broken bones. Triptans, Nsaids Anti-emetics zofran, phenergan, not compazine Acutely establish the baseline. What is this kid normally like? Grades: concentration, memory Mood Behavior - impulse. Risk taking 6
Follow-up: the critical step: old way was predictive. Now proactive. Weekly to bi weekly till clear. Sicker patients need closer follow-up. Headaches, Intake. Transition activities: symptoms as activity intensifies. Return to last asymptomatic level if symptoms recur. Transition school: testing, time, social function. Deficits at 1 month require rehab model: neuropsychological testing. Why not sooner? Restrictions School rest, then transition if necessary High risk activities stopped until baseline. Then consider modification Advice v. contraindication. Not baseline = contraindication Pre existing headaches, learning issues become key!! Kanoff 2005 - Present Will see any patient within 72 hr of injury Manage acute symptoms and follow through resolution Will make recommendations for restrictions, academics, testing, etc. Will partner with regional docs for local follow-up. Primary care is crucial in the short and long term follow-up of these patients. 7
NFL A survey conducted by the Associated Press found that 30 of 160 NFL players had hidden or downplayed the effects of a concussion at some point during their careers, likely because of both a fear of letting down their team and a culture in which players are expected to play through pain. Roger Goodell - NFL 2007 NFL policy: required LOC to be prevented from return to play 8