concussion management: sideline assessment and injury recovery by jeffrey s. kutcher
TRANSCRIPT
UMIC Sport Concussion Injury Summit
Concussion Management: Sideline Assessment and Injury Recovery
September 24, 2015Jeffrey S. Kutcher, MD
Associate Professor, University of MichiganDirector, Michigan NeuroSport
• Team Physician, University of Michigan• Team Neurologist, US Ski & Snowboard
Team• Director, NBA Concussion Program• Consultant, NHLPA• Consultant, NFLPA• Consultant: ElMindA, Ltd.
Disclosures
1. Things to keep in mind about concussion
2. Know your sport and environment
3. Know your players
4. Concussion Diagnosis
5. Injury management and return to play
Topics
“Concussion” Clinical Timeline
Concussion: transient alteration of brain function as the direct result of a biomechanical force. Days to weeks.
Post-concussion syndrome: complex pathophysiology, both biological and psychological, that occurs after the concussion is over. Months to years.
Chronic effects: unknown pathophysiology, unclear epidemiology. Chronic Traumatic Encephalopathy (CTE), depression, cognitive decrement. Lifetime
Not every injury to the brain causes a clinical syndrome
Not every brain symptom or clinical sign following exposure to mechanical force is due to concussion
During the clinical syndrome of concussion, symptoms may be from something other than than the injury itself
Three concussion axioms
1
1: Injury Threshold
22: Symptom Threshold
FORCE
Injury vs. effect
The initial approach
No Injury Concussion Emergency
Emergency action required
Safety first…
• ABCs• C-spine• Seizure• Level of consciousness• Focality
Common Symptoms
Kutcher and Giza. Continuum, December, 2014
SCAT 3
SCAT 3
Concussion examination
Mental Status – talk to the patientlevel of consciousnessorientationconcentrationmemory
Cranial Nerveseyes: pupils, duction, smooth pursuit, saccades, nystagmus
Concussion examination
Motor and motor controlstrengthcoordinationreaction time
Balance, coordination, vestibular controlRombergFakudacomplex balance maneuvers
Diagnostic (Un)certainty
Kutcher and Giza. Continuum, December, 2014
TIME
INJU
RY
Resolution
Clinical dynamics
FORCE
TIME
INJU
RY
RTP Protocol: R.R.E.S.D
FORCE
Rest (physical)Rest (mental)EatSleepDrink
Common Symptoms
Kutcher and Giza. Continuum, December, 2014
TIME
INJU
RY
RTP Protocol: B.R.A.I.N
FORCE
BikeRunAgility“In red”No restriction
• Get a sense of the timing• Look for inactivity related symptoms• Past medical history• Psychological factors & personality
TIME
INJU
RY
Concussion vs. PCS
Post-Concussion Syndrome
Peel back the layers…• Unplugged Syndrome• Primary headache• Mood• Sleep• Neck• ADHD
Lodestone vs.. Keystone symptoms
Post-Concussion Syndrome
Clinical Approach to Medications
24 hours
“Typical” Conc.
Persistent Conc.
PCS
HA Sleep Mood Attent.
Summary: Key Points
1. Getting the diagnosis right is important
2. Getting the management right is more so
3. These are complex medical decisions
4. Tools only gather information
5. Manage for patient’s overall brain health
Thank you!