This guide for the primary care provider covers concussion assessment tools; explains when imaging is essential and which technologies offer the most value; and reports the latest on treatments to speed recovery, including amended perspectives on strict rest and certain medications. Learn about new testing options, such as serum biomarkers, and promising therapies, ranging from a brain cooling device to natural supplements.
So Chris Speaker here, uh many of children's hospital for 22 years now. Um I joined the neuro trauma uh subcommittee of of our trauma group about eight years ago, we kind of faltered a little bit, and then about three years ago we were lucky enough to have um Lauryn Williams, who is a coordinator event, get it back up again and through her and through chris Newton, and a whole bevy of other professionals. Maybe more savvy than I am in this. We've got some really good uh programs, both an ambulatory and inpatient for neuro trauma, including concussion. Um They Lauren asked me if I did anything else for nothing else to get the word out that we do have access via phones, uh some some phone numbers for access for more difficult patients, as well as our website, which you can go toward general website and then type in neural trauma. And there are teaching materials, discharge instructions, and again, the access numbers for further care. Um And Lauren, well, you can't speak, but if I miss anything, um she'll chime in but uh via chat, but again, and we're building a very robust concussion support for our colleagues in the community to support you and if needed to support you in hospital for the more difficult concussion patients. So I have no conflicts is close. Um, I want to go over some five different subjects during the talk, including just an overview generally of concussion in childhood, the evaluation diagnosis. I think we all kind of no, we see it but well, maybe learn how to speak the same language. We can communicate better. Um We'll talk about uh imaging management and then at the end a couple of slides on new things that are coming. Um There are more and more more and more effort being thrown at concussion Over the past 10 years, mostly given The upheaval in the National Football League in about 2011, where they are dealing with repetitive concussions and problems from there. But if nothing else, if you don't like the NFL, they are offering us a lot of, a lot of media on concussion. So even even way back then, during the times of your Hippocrates, like now we're feeling like no injury is too trivial to ignore. And again, this is coming back in the forefront given given the attention that the NFL has given to concussion. Um, now the army is getting involved and now we are too, so much of concussion care research falls pretty short on good evidence. And so we were relying on consensus expert opinions and these two groups, Percussion sport Group, that's been around since the early 2000, as well as CDCs concussion group has been offering the best information that we have on diagnosing and caring for concussion. I will say. Like I just said, there is more evidence based information coming and mostly in terms of therapy, which I think is what's needed diagnosis is. Again, I think we know this, but we need to just be able to speak the same language, but the therapy is something that's really in need. Okay, so basically we define concussion as a brief impairment of neurologic function, not structural lesions and in concussion science function refers to four general symptoms silos and those are physical emotional sleep and cognition, And those are the four silos that the diagnostics focus on um customers caused by any kind of rotational angular force transmitted eventually to the brain. Um, And typically revolve results spontaneously in 7-10 days. There's about 80, who do so about 15% have prolonged symptoms. I think you in the community follow these folks obviously more than we do and in the chat function certainly give us your feedback on what you do and what you need more from our neuro trauma group in dealing with them how the fears quickly. This is quite interesting, but the path is a concussion leads to an eventual metabolic impairment in a lower metabolic rate That corresponds to the symptoms will talk about after the injury. There's some accidental stretching and that leads to a series of events that begins with the release of excitatory transmitters like glutamate, um which itself causes the potassium to leave the cells in calcium to enter the cells, which in turn turns on um sodium pumps consuming energy that eventually causes a general decrease in metabolic state or dysfunction of the mitochondria and and lower blood flow. And again, this all kind of leads to the symptoms, the various symptoms that we see with the patients that, that we see here in the head. And you'll see in your clinics. Um, as you know, there's, there's many concussions a year, um, likely unreported, but more more reports them in the past 10 years, given the media testing that they've gotten Likelihood in contact sports about 20% per season. And you see below there, the rates of concussion in the various activities and settings like sports highest in schools, playgrounds on the wreck fields. And then India's just briefly looking at the gender comparison throughout the various ideologies of injury states. And um, you know, females that are like gray bars edge out males in most categories except in primary school and males just edge out females in all sports combined. But it is pretty interesting that females do have an edge in a lot of these categories. So again, we'll jump into concussion evaluation and diagnosis and again, like I said, this is all something that we all kind of know what we see it. It's you get the history and they look kind of glassy eyed and we say yeah they're concussed, we'll discuss at least two of the more common ways or tools that we use to better objectify our institutions, way of looking at things so we can better uh speak to each other in the uniform language. Um All tools attempt to um diagnosed concussion looking at these like I said, these four domains or categories and those are these, so physical and cognitive which include the below um symptoms that you see there are seen on the day of injury. These are the those two styles are seen on the day of injury, emotional and sleep are the ones that we don't necessarily see in the er but you out peculiar we'll see in the days following the initial injury. And so uh um in any one of these domains is seen and we concussion is suspected. So really two main tools that are formally used if we're going to formally use anything for acute evaluation of concussion. The Scat five is the sports concussion assessment tool includes the standard assessment of concussion, the sack which we all were brought up on if you're as old as I am, the glass in a coma score, balance testing and symptom, a symptom inventory And it takes about 20 minutes to do and so it's not lost. My wife is in primary care and it's not lost on me that you don't have clearance probably do all this. Um We we kind of do and and we are trying to do more of this more with the acute customer evaluation, that a score, which is the the CDC's index And this is similar to the scat five, but part of the CDCs heads up program that you're probably familiar with. Um Finally the neurocognitive testing is something that's more detailed um and gives you information on psycho, motor function, processing speeds, um visual attention, vigilance and verbal and visual learning and memory. And again, this is much more detailed, something that we can't expect to be done in the er or in the community, but it's something that's done for the more acute patients, I'm sorry, the more severe patients who did not getting better um to get a notice psychologist to do this is probably the best way to do it, but they're hard to come by. So there are two main online tools you can use, the the college sports and the impact, which is out of Pittsburgh and we'll talk about those in a second, so brave again. Briefly, that's got five is used for both immediate on field evaluation as well as in office evaluation of ISIS in the, the evaluation, knowing that these are likely aren't being done fully in offices if they are fantastic. Um And the scott find is great for folks 12 years and older and the child's cap five is four folks between five and 12 years of age. Um It's not great for tracking out past two or three days, but the symptom list, Um that is part of this. Got five is often used in um in evaluation in in community clinics. I've spoken to a couple of my friends in the community, they say, yeah, they use something like the symptom inventory to give the parents so they can track better when they are advising parents to return to learn and we're trying to play. Um So similar to the um the acute evaluation, how the CDC heads up program Serve the same purpose. Is that Scott five and this is the one that we children's Oakland have integrated into our shorting unfortunately two years ago or a year and a half when we integrated with Mission Bay and the apex we're gonna get lost. We're putting it back in. But the point is eventually if you see patients um coming out of here you'll be able to access a more details, question evaluation that followed the tracks this ace exam um And I mean something that really should be doing because we we have more probably um sort of that we have more um resources then you like to do during the during an acute event. And so what I've been toying with while we've been putting together our discharge education and and follow up criteria or putting in or sending them home with something like this, the greatest symptom checklist But again are part of the eastern part of the Scott five and as I said are likely part of a lot of what you all do for your patients to follow them. Um And again in the chat function, please let us know what you're doing. So we can better no what are community doctors are doing and how we can better support that and and be and be more aligned with what you're doing. Mm So as mentioned, the neurocognitive testing is not needed for everybody but is really the cornerstone of evaluation, It was deemed necessary. When is it deemed necessary? So Cindy chang is or is our concussion guru, part of the neuro trauma committee? And she said really you use it when there's a need to document objective findings for schools so they can make accommodations for the students who are having prolonged symptoms as well as students or student athletes who are having concussion symptoms and involved in sports and maybe have had a previous concussion and really want to better document the more detailed things like visual and verbal memory. I'm sorry for memory, visual motor speed, reaction, time, impulse control that are hard to do on those other two tools, like I said without a neuropsychologist, these are easy to access because they're on the computer and they're useful for you all because there um, you can remotely monitor them and monitor progress along with teachers and along with the coaches. I mean, here we go. So a recent study out of Pittsburgh, which is a pretty much at the center of concussion research, um, came out with something that we probably is again, a lot of obvious statistics here, but that the earlier we identify with these tools, the better the students and the patients are going to do, um retrospective, as a lot of these are in student athletes who receive care within the first week versus those who received care after eight days. And they found that if you can identify them earlier, they did better. Again, obvious. Um, but it just kind of bore out what we kind of know, so getting them in to see us or you sooner using the tools that we just talked about and then tracking them with the symptoms. Symptom inventory are great ways to at least track the symptoms, um, and uh, and give them better return to return to play and return to to learn advice. So, you know, we think someone has a concussion here in the cd and and why not image them to make sure they don't have a more severe injury because as you know, folks come in here can cost they, they share symptoms with those who have more severe injuries. Um, So anybody with precision injury symptoms that are primarily vomiting or nausea or headaches and they need symptom relief, we will first get an image. So that's kind of um, you know, standard care for for us and in our protocol. So if you're having symptoms, I think it's probably concussion, but your discharge instructions say we'll come back. If you have more nausea or more headache and they already have in front of you, you better just kept the image right then and then you can go, you can feel safe about getting them out of there with some Zafran or some some have seen him in the final round problem. Um Yeah, a more scientific way to look at this is through pecan and pecan, as you know, is the research consortium, the performance very large studies to answer um clinical questions in pediatric emergency medicine. And they had imaging study looked over 40,000 Children with mild traumatic brain injury and found the likelihood of a more severe injury was very low and so did not do imaging if they did not have those symptoms here. Um, So if they Glass of coma, score was normal, didn't have signs of basal skull fracture, they weren't vomiting, they didn't have a prolonged loss of consciousness, no severe headache and most of your mechanism, they were pretty good to go without imaging useful tool, pretty widely accessible, be it through handouts or even um as more of my, um, my colleague residents and students using on online energy calculator, you click in if you click through the symptoms and it gives you kind of a score on, on the likelihood of more severe injury and whether whether or not they need a need imaging. So certainly that's, that's useful. So, you know, the risk of CTS, Why not scan all these patients to make sure I miss anything bad? Well, the short answer is time expense and risk of cancer is the big one. Um, Children's brain cells are more susceptible to having a longer, um, uh, federal to a, to an injury. They have a longer life with which to expose this injury or develop cancer. These learnings kind of came from largely from tracking survivors in Hiroshima Japan after the nuclear bomb in December of 1990, 1995, Um Most hospitals, especially in Children's hospitals, our imaging with as little radiation as possible. Um and so the relative risk is still pretty low. So it's about 1.1 which is just above baseline for those who don't have C. T. Scans. It increases with the number of headsets that we do obviously. Um in one colour data study showed that there's one excess brain tumor that occurs after every 4000 cts. And so, You know, in a 30 year career that's not insignificant. It's um so we definitely want to image gently. And that website down below is one that Doron Cohen, who's the chief of radiology here, asked me to get out to you all. It's good reference for you all as well as your parents if they have questions about um the risk of radiation, So why not consider M. R. For worried at all about anything worse? Well we do so in rapid sequence and more has been used is being used more often now in Children with suspected traumatic brain injury. As it has a higher detection of hemorrhaging of hemorrhage. It misses some skull fractures. The big issue is that the availability of the machine and the text. And so we really um would like to do more of this and Children's Oakland. We do as much as we can with as little as we have but we are moving towards this more um as as we as we want to better placate ourselves and parents against anything worse than a concussion so they may still be room to further decrease the need to image with biomarker tests. And these are pretty new. They're not even in my my new my new science section at the end because they are actually being used now. Not here and not so in the U. S. But Abbott and banning just came out with some new serum tasks that measure glial february acidic protein. Um In ubiquity and car boxy terminal hydro facilities are mouthfuls. They're both um neuro trauma specific. Very good negative predictive values around 99.6 for any kind of dramatic brain injury. And so if we apply this on top of popcorn we may be able to further decrease Cts uh in the future. And this is something I'm talking personally to Abbott about doing a study either either here or through orthopedic corn, a bigger lift but I think it would be certainly worthwhile and it's a point of care test Comes back in 10 minutes. Um It's as good as they say it is then this this might further help us out in decision making on on imaging. So beyond biomarker testing, click your here. There are other screens um that are concussion signals picked up by devices that won't go into detail about, but there's E. G. Um signals I can people on tree, all of which are being studied. Um not going to diagnose concussions but to put to track them objectively. I mean, the big problem is that concussion is a clinical diagnosis and so these can't really clinically diagnosed concussion, but they may offer us and you all in the primary care community. Bit objective way to track your patients down the road and add one more, one more tool in your in your kit to make sure they get back safely. Um In my opinion, I think the people on the tree is going to be the earlier winner. There are some companies out there that are using people on the street in Euro issues and are transitioning over to to er concussion care. But maybe in the year, I want to give us talk again. We'll we'll revisit these. But anyway, look for these for for for tracking diagnosis. Alright, so management's again, this is this is something that I think that you all do as well as you can and as well as we can with the information that we have the obvious items to address as a primary evaluator in concussion or listed here. So you want to rule out other injuries, especially the C spine, They got hit their head to make sure their spines okay? And don't clear their C spine. If they're altered. Now, when they get to you all, they shouldn't be altered. But if there's any question then you want to make sure they get appropriate clearance of the cervical spine. Um, like we just talked about with imaging and with, with testing, you want to rule out any other worse intracranial injuries. And again, the p corn is a good, is a good tool to use and maybe some other things coming down the pike and then finally managed to acute symptoms again, which are usually nausea and pain. Later on, it's going to be things like behavior issues and depression that for which you all will likely be accessing some specialists. And again, please chat in what you all who you all access and what you use or what you would want to use for the more severe, um, severe symptoms. The next few slides touch on this newest notion of not cocooning their patients for seven days. As many of us were weaned on in concussion care but rather getting them back to some sort of limited activity. The data on the effect of rest and recovery is really sparse and basically until a couple of years ago was based on expert consensus, still is, but it's getting it's getting to be more prospective evidence on the alternatives. The first two days of rest seems to be beneficial for your patients, but too much rest as we'll see, seems to be detrimental. Um in activity may exacerbate symptoms and depression and so sub symptoms, so called substance exercise, getting more attention, and where did that come from? So I won't go into detail on this because this is a rat study, but it's compelling towards linking it over to human um uh in aspects um so that the rats in the study underwent um controlled cortical impact injury. So a fancy word for their probably bump on the head and some controlled fashion to give them concussion. They are randomized between strict rests, are placing a small box or exercise on a wheel and those rats who exercised were shown to have better object object recognition in histological neural protection. So these are both validated rat concussion model outcomes. I'm so again, it's tough to make an immediate leap to humans with this data, but it's compelling towards other studies like this. One came out five years ago, a university of Wisconsin where they want to determine if recommending strict rest delays recovery after a concussion. Look at 99 cost Children who are randomized between strict rest. So for five days or usual care where they were given strict rest for one or two days and then followed by the stepwise return to activity or step return to sport. And as a result, they show that the strict rest group had more symptoms in a slow resolution. Um So again, early early data but compelling to get these kids out of their dark room and doing some walk around the neighborhood um in in general activity. This last study came out four years ago, five years ago now. It also looked at uh subsection exercise, whether it's beneficial or not, And I don't read through it. But 300 patients retrospective with concussion, it showed that higher levels of physical activity was associated with a shorter duration of symptoms. Um so again, we're, the message here is we're not at all doing anymore, The 5-7 days in a dark room, and we are considering a return to activity sooner. Um uh if they don't return to their symptoms with the stepwise activity, so more activity than zero activity does seem beneficial and we'll help with return with the progression so that you will have have your charts on the stepwise progression That involve 5-6 levels of activity of increasing activity. And if they reach A level, um and they don't have any more symptoms that one day they can go the next level until they are back to full learning in or full sports activity. If the symptoms do re occur, they need to drop back the last day symptomatic level and the CDC and the sport concussion group has these type of tables. Um This is an example of a suggested Return to play protocol and this gets us back to the importance of having a good tracking system for parents and for for for student athletes and student uh students rather um in getting back to um in traversing through these graduated return turned protocols. So the main issues for patients with concussion like I said before or um medicating their headaches and medicating nausea and that's basically we're focusing on the next couple of slides here. Um There are certainly sleeping emotional issues that will come days and weeks. Beyond that, they don't spontaneously resolve their their symptoms. But then again, that again is something more for specialist and I'm sure you will have ways to plug in and if you don't, then we invite you to get a hold of our um newer trauma group. So what about ibuprofen for headaches after concussion? Were the short answer right now is let's hold off for two days. The premise is that it may exacerbate bleeding from micro damage, blood vessels not proven. Um, The again, start with the concussion model. Back in 2000 and six rats were given concussions and then half were given ibuprofen, half were not given ibuprofen and four months post injury the treatment group and performed worse on again, a validated rodents learning model. Um so hard to make a jump to humans, but it was compelling enough to say, well let's let's hold off. So more interesting and it just came out four years ago. Is the study out of also Wisconsin where 20 patients per for these four groups. So four arm open label study, one group getting ibuprofen want to see them enough in one both and one nothing after their concussions. And it showed that The treatment group with both Republican and I see the minutes and four headaches got back 80%, got back in a week to school. I broke in alone 61% um acetaminophen alone 33% and nothing just regular care. 21%. So very compelling. They say, well why don't we just give them whatever they want, their headaches and you know, I think it's going to go there in our protocol now and under the guidance of some of our concussion gurus, we're kind of saying, let's hold off right now. This is, this is a great study to look at and to expand upon. Um, and frankly, if patients got ibuprofen after concussion, it probably wouldn't be the end of the world, but we're tracking it closely and our current guidelines are let's hold off for two days and then you can give me whatever you want. But the first two days it's a city, many finishes. What are our guidelines show? And what about Zafran uh nancy trauma? Does it cost misdiagnosis? Um, the bottom line is, I'll jump to the bottom and I'll go back and study is that it's still recommended that if one needs an anti a medic, you need to get imaging because we don't want to miss, we don't want to cover up vomiting. It's from a worse injury than just a concussion. Um This is a large study done by one of my colleagues over Mission Bay. A couple years ago last year came out, 35 Emergency departments retrospective Um towards and 20,000 patients and 3% got Zafran going home. The other 97% did not get Zafran And there is no difference in MS fractures or intracranial injury between the two groups. Now, only 3% who got Zafran. So you can't make a big jump to this. But again, this goes back to, I mean my gut feeling and then those are owned by everyone else in my committee are that if we're sending kids home with pain control or nausea control, that means they have a symptom for which we tell them to come back and so we don't want to discharge them. And how the, how the parents wonder if they should be coming back and their Children's story, any headaches or um or nausea. And so right now we're saying if they needs a friend and we definitely give it out like water if they're having nausea, Well 1st image these patients. So coming in here, so the new therapies for concussion and I'm really gonna focus on one therapy that is near and dear to my heart. So we do a small study here on it, but I think it might be getting out into the community is brain cooling, that's here we go. So basically the premise here is you want to turn off the cells damaging biochemical pathways, reduce inflammation, reduce pressure and we know from adult studies and more severe head injury studies of hypothermia worsens outcomes and increases inflammatory activity. We also know from adult studies that systemic cooling can cause problems such as pneumonia, sepsis cardiomyopathy. So why not regional cooling? So there's some companies that come out with ice helmet, basically, um, That has been shown to locally decrease the brain temperature by about 2°C and not until 46 hours later. Does it cause systemic cooling? So it's perfect for cooling the brain if that's what you think needs to be done. And it does have some pretty good outcomes in some small studies. Um, you know, why couldn't you just use an ice pack and some and some cooling packs of the neck maybe? And frankly not everyone has these cooling helmets. So that's certainly an option. But two studies, I'll talk about one here and this is a, a small study came out this year, I believe. This is also out of Pittsburgh Um randomized 27 student athletes with concussion and randomize hymen blinded obviously the application of a regional coin device for 30 minutes. They measured The accepted tools of scat fi before and after the treatment 10 days and four weeks after the initial therapy. And they showed with pretty good confidence though small number greater symptom reduction after treatment and faster symptom recovery after treatment and no adverse effects. So again, in 27 patients. Now, we actually did this study with smaller patients in this same um device here three years ago on 30 patients. It was mostly a a tolerable the study for this company And put these kids through 30 minutes of the same kind of regimen that this study did And found that 20 of 30 tolerated it, that's fine, is keeping it on at least 20 minutes. But secondarily, we found that the majority of them indicated they felt better afterwards, a very loose outcome and and published only in a poster, but again compelling and simple and elegance. And certainly we'll be pursuing bigger studies like this in the future. So along with your symptomatic care with with headache management and nausea management and eventual hopefully not too often. Second behavior management. Head cooling might might have something going on last couple of therapies here. Um What about steroids? A list here because steroids have been shown actually in bigger studies to increased complications post post head injuries. So steroids, we don't think so, but these four items are being looked at with increased frequency fish oil. The premise is that Omega three fatty acids is key. And seeing some membranes and mail for some of anti inflammation that is contributory to concussion. Progesterone is looked at by the military has also anti inflammatory antioxidant properties after brain and salt. Um Some traditional chinese herbs are being looked at for both post head injury and post my cardio unfortunate which doesn't affect this talk but getting some some good studies early on here and then a hyperbaric oxygen. Again, not that really. Um not that available and early early on. But again I hope to give us this discussion talking a year or two and have more prospective information on on other things we can actually do and not just not just stand there and watch them get better but actually be proactive. But Let's look at brain cooling now all the sidelines now for these four for interventions. Um Okay so again you know we advise to see um uh patients following coming to the er but if you need back up again I'm I'm I'm implored to get out that we we are available um now much more than we have been in the past years. So it's sort of neuro trauma on the Beach Show website or um sweetheart get your handouts there and or get the phone number to call the access center. You referred to the referral center closest to you and your patients. Um but please please use this um if if needed and please let us know if there's something more we can be doing for your patients that we're seeing here here first. Mm Okay, so like most of our your patients are patients get better in in 7-10 days and those are prolonged symptoms. You may already have a protocol in place for your clinic and if not or if become complicated, please please use us. Um We are going to be using the Ace um Univision tool more practically in our, in our initial evaluation, Find what you want to use, but more importantly, you know, find a symptom inventory that you want to use for your patients and families to track along with you. Um, rest in the first few days is a key now and don't keep them cocoon for for summer to 10 days. Um, consider cooling regimens. Again, it's pretty loose right now, but, but it's, I think it's a low, low risk and possibly high benefit and again, stay tuned for new therapies and diagnostics. And this is a rapidly changing field again, thinking well how you feel the NFL, but thanks the NFL and thanks to the military and now thanks a lot of us who are tracking it.