Emergency Department Evaluation of Concussion (Traumatic Brain Injury)

1. Emergency DepartmentEvaluation of Concussion(Traumatic Brain Injury) Sylvia E Garcia, MD Assistant Professor Pediatric Emergency Medicine Icahn School of Medicine At Mount Sinai Department of Emergency Medicine

2. Disclosures I have no financial disclosures to report. Department of Emergency Medicine

3. Pediatric Head Trauma Deaths7,000/yr Hospitalizations 95,000/yr 60%↑ in ED visits in last 10 years ED Visits > 500,000/yr Primary Care Office Visits Assume numerous, No data • Hospital care costs alone exceed 1 billion/year • - 29,000 permanent disabilities annually

4. Goals and Objectives • Recognize the importance of obtaining a comprehensive history that identifies previous injury / concurrent medical conditions • Know the importance of assessing vestibular balance • Understand the role of neuroimaging in the evaluation of the concussed patient • Recognize the importance of clear discharge instructions Department of Emergency Medicine

5. Recognition of Concussion • Signs • Dazed or stunned • Confused / forgetful • Answers slowly • Moves clumsily • Loss of consciousness • Behavior / personality changes • Amnesia • Symptoms • Headache • Dizziness • Nausea / vomiting • Double / blurry vision • Sluggish / foggy • Concentration problems • Confusion • Change in sleep pattern Department of Emergency Medicine

6. Comprehensive history • Comprehensive history should include documentation of previous • Closed head injuries / concussions • Depression / anxiety • Sleep disturbances • Learning disorders • Attention deficit disorders • Headaches ( migraines ) Department of Emergency Medicine

7. Physical Exam • ABCs • C-spine immobilization as needed • GCS determination • Neuroimaging as deemed necessary • Detailed neurological evaluation Department of Emergency Medicine

8. Assessment Tools • Acute Concussion Evaluation ( ACE ) • Brain Injury Survey Questionnaire ( BISQ ) • Sport Concussion Assessment Tool ( SCAT ) • SCAT 3 • Child SCAT 3 Department of Emergency Medicine

11. Assessment Tools • The Brain Injury Survey Questionnaire ( BISQ ) is a screening tool that assesses for: • Any unidentified previous TBI • Persistent symptoms associated with a previous TBI • Events and conditions other than TBI that can cause similar symptoms • Parent and / or patient is given Part 1 of the BISQ Cantor J et al. Arch Phys Med Rehabil 2004;85(4 Suppl2):S54-60 Department of Emergency Medicine

13. Assessment Tools • The Sport Concussion Assessment Tool is a standardized tool utilized in the evaluation of concussion in patients ≥ 5 yrs of age Child- SCAT3 ( ages 5 -12yrs ) SCAT3 ( age ≥ 13 yrs ) • Cognitive assessment • Neck examination • Balance and coordination examinations • Delayed recall Department of Emergency Medicine

14. Assessment Tools • Balance exam assesses vestibular system • Double leg stance • Single leg stance • Tandem stance • Tandem gait • Scored by error or deviations from proper stance • Specific, not sensitive, indicator of concussion • Postural deficits last ~72 hrs 3Harmon KG, Drezner JA, Gammons M, et al. Br J Sports Med 2013,47,15-26 Department of Emergency Medicine

15. Assessment Tools • There’s an App for that • Sway Balance SystemTM for iOS devices • Uses the built in motion sensor for cell phone • Patient is given instruction for vestibular exams • Begin test button is tapped when ready and the device is held against the chest Department of Emergency Medicine

16. Assessment Tools Department of Emergency Medicine

17. Neuroimaging • Conventional brain CT or MRI is usually normal in concussive injury • Prevalence of an abnormal CT increases with decreasing GCS Department of Emergency Medicine

18. Neuroimaging Emergent Head CT • Penetrating injury • GCS ≤ 14 • Focal neurologic abnormalities • Signs of depressed or basilar skull fracture • Prolonged loss of consciousness (> 1min) , < • Clinical deterioration or worsening symptoms • Seizure ( other than impact seizure ) or prolonged seizure • Pre-existing condition increasing risk for bleeding • Jeff E. Schunk, Sara A. Schutzman. Pediatric Head Injury. Pediatrics in Review, Volume 33, Number 9 (September 2012), pp. 398-411 Department of Emergency Medicine

19. Neuroimaging • The Pediatric Emergency Care Applied Research Network ( PECARN ) study identified children at very low risk for clinically important TBI after head trauma for whom CT scan is unnecessary Kupperman et al. Lancet 2009;374:1160-70 Department of Emergency Medicine

20. Neuroimaging : PECARN Study • Children up to age 18 yrs old were enrolled • All subjects were seen within 24 hours • GCS recorded was 14 – 15 • Preverbal ( ≤2 yo ) and verbal ( ≥2 yo ) groups were analyzed separately Kupperman et al. Lancet 2009;374:1160-70 Department of Emergency Medicine

21. PECARN Imaging Guidelines > 2yo Kupperman et al. Lancet 2009;374:1160-70 Department of Emergency Medicine

22. Neuroimaging • The prediction rule for children ≥ 2 yrs had a negative predictive value of 99.95% and sensitivity of 96.8% • Normal mental status • No loss of consciousness • No vomiting • Non-severe injury mechanism • No sign of basilar skull fracture • No severe headache • No high-risk mechanism Kupperman et al. Lancet 2009;374:1160-70 Department of Emergency Medicine

23. Management • Medications • Tylenol or Ibuprofen for headaches • Avoid drugs that can alter mental status • Anti-nausea medications used with caution • No medications for sleep, mood or attention disturbances • Meclizine can affect cognitive function Department of Emergency Medicine

24. Discharge Instructions • Instructions should be clear on what to expect after diagnosis of concussion • Monitor for 24 – 48 hours • No need for periodic awakening • Majority of symptoms improve / resolve in 7 days Department of Emergency Medicine

27. Discharge Instructions • Patients should return to the ED • Worsening headaches • Increased drowsiness / not able to be awoken • Repeated emesis • Unusual behavior or seem confused or irritable • Seizures • Weakness or numbness in arms / legs • Unsteadiness • Slurred speech Department of Emergency Medicine

28. Discharge and Follow-up • Rest / sleep • Avoiding activities requiring concentration • Avoid strenuous activities • No alcohol • No sleeping pills • No driving or play until cleared Department of Emergency Medicine

29. Discharge Instructions • Return to learn before return to play • School should be made aware of the need for reduced workload, frequent rest periods, extended time to complete tests or complicated tasks Department of Emergency Medicine

30. Discharge and Follow-up • No one should be cleared to ‘return to play’ from the ED • Excuse should be given for delayed return to school / work Department of Emergency Medicine

31. Summary • Review past history for previous injury and conditions that may exacerbate recovery • Motor domain of neurological function can be reliably assessed by vestibular balance testing • CT scan is rarely necessary • Discharge instructions should clearly outline expectations, and indications for follow-up Department of Emergency Medicine

32. Summary • Patients should be reassessed by a physician in 3 to 5 days • Follow-up with a specialist if no improvement or recovery noted within 5 to 7 days Department of Emergency Medicine

33. Play Safe 1-800-283-8481 Department of Emergency Medicine