day before Thanksgiving day after snow storm early morning when you’d rather be sleeping Wednesday 11/24/10 case

1. day before Thanksgivingday after snow stormearly morning when you’d rather be sleepingWednesday 11/24/10 case Thanks for coming!

2. Cc: sports physical 16 yo male Pre-season football practice has started, practice starts next week Screening questionnaire: + Exertional asthma - seems to be worse in the spring, has not used his albuterol in a long time + Family history of hypertension in father who smokes and is overweight No serious injuries, no hospitalizations + Allergy to penicillin Social: He has 2 brothers 14 and 11 who are healthy. He is a good student. Wants to play varsity football this year. He also plays soccer and baseball. No alcohol, smoking or other drugs

3. Exam: Vitals: BP 105/65 HR 65 H 5’ 11’’ W 205lbs BMI 28 Normal exam with the following exceptions: - Peak flow of 350 (75% of expected) - A bruise on his forehead near his hairline. - A mild valgus stature and pronation

4. What’s next? Reactive airway disease Proper footwear and possibly inserts Graded activity and stretching Healthy diet Have a great season!

5. The “fall” 4 days ago He was playing with his brother and he fell on a concrete planter and hit the back of head. He assures me that he is fine. I mistakenly ask him how old his brother is. Bashfully he says 14 and then changes the subject. No loss of consciousness. “I had a headache and it is still kinda there.”

6. SCAT2 headache 3 dizziness 2 feeling slowed down 2 trouble concentrating 3 fatigue 4 irritability 4 He has not done any activity since then and feels that he might have more of a headache if he goes to practice

7. symptom evaluation

8. Evaluation of signs at the time of the accident No loss of consciousness / unresponsiveness No reported problems with balance

9. at the time of the accident

10. Cognitive evaluation Cognitive assessment Orientation  normal Immediate memory 5 words, three different sets  slightly impaired, missed 1 word Concentration (Listing numbers backwards (3,4,5,6 digits and months in reverse order)  mistake with 2 months

11. Physical evaluation Double leg stance (eyes closed feet together, hands on hips, 20 seconds)  normal* Single leg stance (non dominant foot, eyes closed, hands on hips, 20 seconds)  positive* Tandem stance (heal to toe with dominant foot in front, eyes closed, hands on hips)  positive* (*hands lifted off iliac crest, opening eyes, step, stumble or fall, moving hip into > 30deg abduction, lifting forefoot or heel, remaining out of position for > 5 seconds.)

12. Finger to nose  normal Remember the list of words?  missed 2

13. What I am hoping to help you remember –or know what you need to look up: - Concussion or not? - Further evaluation? - Significance for provider? - Significance for player? - What is post concussion syndrome? - When should he return to play? - What were my recommendations from here?

14. Concussion or not?  yes Grade?

15. Other evaluative tools? CT scan: • LOC • Seizure • Focal neuro findings • Prolonged or severe post concussive symptoms Neuropsychiatric testing • Useful in detecting or following subtle cognitive deficits. • Precise guidance for clinical use remains controversial. • 2-3 hours long • Reviewed by the neuropsychologist • Computerized assessments: ImPACT* headminders and CogSport/Sentinel.

16. Significance for provider? “Just a bump or” … • Microscopic axonal shear-strain, damage in the ponds and midbrain. • Metabolic changes that occur in the animal model: • alterations in glutamate, potassium and calcium  relative decrease in cerebral blood flow in the setting of an increased requirement for glucose (increased glycolysis). • mismatch in the supply and demand of metabolism may result in cell dysfunction and increase the vulnerability of the cell of a second insult. • * brain injury evolves, not static • * neuronal tissue becomes more vulnerable. • * brain needs time to recover http://www.msnbc.msn.com/id/3032619/ns/nightly_news#33610637

17. Significance for this patient?

18. Post concussion syndrome • lasts hours to weeks, up to 2 months. • Headache +/- exertional, memory & cognition impairment, personality changes, irritability, fatigue, dizziness. • utilize progressive aerobic and resistance exercise challenge tests prior to full return to play • the younger the athlete the more conservative you should be • no simple test, use signs and symptoms • be alert to subtle deficits

19. Return to play

20. Return to play -

21. Where to go from here?advise AND after visit summary instructions • Do not go to practice – note written • Warning sings: Change in behavior, vomiting, dizziness, worsening headache, double vision, excessive drowsiness. • Avoid strenuous activity • No sleeping pills or alcohol • Do not use NSAIDs or aspirin for headaches • No not drive for the next week • Come back in a week

22. Where to go from here?advise AND after visit summary instructions He came back in a week. Symptoms better. • Start light aerobic exercise x 24 hours • Non contact drills x 1 week • Full contact training x 1 week • Return to competition *If symptoms return, do not advance to next stage * If he hits his head again, tell coach, stop play return for a visit.

23. Case #2 9 y.o. boy transported from Jimani to a church in the Dominican Republic. He was being taken care of by nuns. He came with a piece of scratch paper: 15-1-10 Horall, J 28—9—2000. Arrived 1—15—10. Carried by mother and brother. Head injury, posterior, sutured. Lethargic. 1—18—10. wound infection. Antibiotics.

24. More history (1/27/10, 15 days after the earthquake) Found inside the fallen building, not conscious unknown duration. People dragged him out of the building, he was breathing, not communicating Mother and brother brought him by bus to Jimani. He became intermittently responsive He is not “himself” now and does not remember the accident or the earthquake

25. no SCATavailable

26. Neuro eval Exam: Cranial nerves: I – was not eating ? II – monocular blindness III – right pupil was less reactive III, IV and/or V: loss of depth perception and reading difficulty V – decreased sensation of the forehead . Motor: could not walk (femur fracture) Finger to nose: unsteady Reflexes: normal Clonus: none Sensation: light touch and two point discrimination normal GCS: 13 (confused, not consistently obeying commands)

27. Grading criteria- * Cantu

28. Grade 3 concussion Neuro imaging: would be considered reasonable, not available My advise: avoid strenuous activity for >1 month, until all symptoms resolved for a week.

29. Case #3 45 yo man who is a recreational soccer player, father of 3, and skier. Seen at Mt Baker ski patrol. • Skiing alone without helmet, his fall landed him on the hard packed snow. He was found still on his back by the patrol. • He thinks he had the “wind knocked out of him” because he could not move or breathe. His back hurt • He is not sure if he lost consciousness • Does not remember how he fell, does not remember much about the toboggan ride. But he remembers arriving here.

30. Neuro eval Exam: Cranial nerves: intact On a back board, which was cleared, normal reflexes, normal strength Cerebellum exam: wnl Clonus: none Subjective light touch and two point discrimination: normal GCS: 13 (off for confused, not consistently obeying commands)

31. Cognitive assessment Cognitive assessment Orientation  normal Immediate memory 5 words, three different sets  slightly impaired, missed 1 Concentration: Listing numbers backwards (3,4,5,6 digits)  normal Months in reverse order  mistake with 1 month

32. *PTA: post traumatic amnesia

33. Next step • Transport by private car, (likely to be faster than the helicopter or ambulance) to the hospital • Warning sings: Change in behavior, vomiting, dizziness, worsening headache, double vision, excessive drowsiness. • Avoid strenuous activity • No sleeping pills or alcohol • Do not use NSAIDs or aspirin for headaches • No not drive for the next week • No skiing until asymptomatic x 1 week.

34. Review What are you going to type into Google when you see a person with a concussion to help you evaluate and manage?  SCAT2 What five components might you assess if you are without a SCAT2 form? • Symptoms • LOC, pre and post-traumatic amnesia • Neuro exam including GCS • Cognitive assessment • Balance and coordination

35. Review Grade 1 No LOC, PTA < 30 min Grade 2 LOC < 5 min, PTA > 30min Grade 3 LOC > 5 min, PTA > 24 hours Grade 1 (1st injury) 1 week Grade 2 > 1 week when asymptomatic x 1 week Grade 3 Wait at least 1 month, return if asymptomatic x 1 week.