on-field management assessment and differential … · •inc graded symptom score ... test is a...

2/20/2018

© All rights reserved. Sports Medicine Concepts, Inc. Concussion Management Specialist Program 1

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Sports Medicine Concepts

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Concussion Management Specialist

On‐Field Management and Differential Diagnosis

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Session Recordings

Pre‐Recorded Sessions

Seminal Readings

Open Quizzes

Case Study / Essay

RFQ

The CMS Resources Page

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Represent A Standard of Care

Position statements

Peer‐Review

2Min Drill®

www.TeamEMSoft.com®

Must NOT BeWithout EAP

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Perhaps the most critical element of an EAP

The Medical Timeout

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Obvious vs. Subtle

• Follow the ball

• Scan the sideline, back field, and court

• Watch players coming off the field

• Consider an Injury Spotter

Eyes on The Field at All Times

I really like this!

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Gain and Maintain Control of Scene

Initial CABin Check

• LOC / Responsive

• Determine extent of injury and likelihoodof transport

• Safe handling

• Level of service required

Phase I: On‐Field Management

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Spreading depression

Head Trauma and The Unconscious Athlete

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Brief vs. Prolonged

Cantu Evidence‐Based Grading System• Grade 1 (mild)• No LOC• PTA <30 min

• PCSS <24 h

• Grade 2 (moderate)• LOC <1 min or • PTA > 30 min <24 h

• or PCSS >24 h <7 d

• Grade 3 (severe)• LOC >1 min• or PTA >24 h

• or PCSS >7 d

LOC and Transport

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Seizure secondary to head trauma

• Protect from further injury duringseizure

• Prepare for airway management once seizure subsides

• MJT

• OPA/NPA

• 2‐Person BVM

• Manual suction

• Secure ALS Service

• RSI

Seizure and Airway Management

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Diffuse axonal injury disrupts brain‐stem centers resulting in vicious cycle:

• Totally unresponsive

• GCS = 3

• Cardiac

• Strong, rapid carotid pulse, tachycardic (> 100bpm)

• Airway

• Jawmay be clenched

• Breathing

• Tachypnea or Hyperventilation

After 30 seconds breathing stops, pulse weakens/slows

As CO2 rises, reflex initiates breathing

• Tachypnea/hyperventilation and tachycardia

Acute Central‐Neuro Hyperventilation

Working Definition

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• Activate EMS

• Prepare for HQ‐CPR

• Monitor vital signs

• Be very diligent with carotid pulse checks prior to arrival of EMS;

• Only applyAED if there is NO pulse

• Prepare for safe handling during transfer and prep for transport

ACNH Management

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• May wake‐up and be stable prior to orduring transport;

• May be stable, but remain unresponsive for period of time

• Long‐term consequences?

ACNH Prognosis

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Progressive Transition

• SMC’s Progressive Algorithm• Reposition• CABiN• Apprehension• Reassess in seated

position• Reassess in standing• Support

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Vital Sign Triad

Sure CABiN, but what else can we get from vital signs?

• Pulse rate

• Systolic blood pressure

• Body temperature

Initial Vital Signs

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Radial Pulse Check

• Screen for accelerated heart rate

• Screen for regular pulse pattern

• Rates > 140 may indicate abnormal heart rhythm

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Electronic oral or tympanic

• Initial temperature readings > 100 occur during heat stress

If elevated heart rate or low systolic blood pressure

Temperature

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Vital Sign Trending

Rule of 100

• Pulse >100

• Temperature > 100

• Systolic BP <100

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Serial measurements at 10 minute intervals for 30 minutes

• Differentiate between serious and minor injury

Trending

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Pulse Rate Blood Pressure

Initial readings of 140‐170mmHg

Normalize to 120/70

Persistent systolic pressure elevations• significant head trauma

Conditioned athletes normalize within 20‐30 minutes

• Pulse rate >100• Anxiety

• Temperature

Trending

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Post Concussion Blood Pressure

Widened pulse pressure with bradycardia

• increased intracranial pressure

• 120‐70 = pp 50

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Serial Temperature Readings

Performed to confirm initial readings

Useful in assessing heat illnesses

Internal injury

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Pulse Oximetry

SpO2

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Applied again following vital sign trending

• 30 min normalization for majority of injured athletes

• Persistent triad abnormalities referred to ED

• Normal vitals following trending sent for physician consultation

SMC’s Enhanced Vital Signs Trending Report

Rule of 100

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Lucid Interval

• Intermittent improvement / deterioration of level of consciousness and other s/s

• More typical of hematoma than concussion

Interpretation of Signs / Symptoms

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Body’s compensatory reflexes will accommodate small rises in ICP

• Initial inc may not be readily observable

• When ICP reaches MAP there is a decrease in CBF

• Inc systolic blood pressure to compensate for dec CBF

• Vicious cycle with devastating consequences

Intracranial Pressure

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• Bradycardia

• Hypo‐hypertension

• Respiratory depression

• Systemic vasoconstriction

• Lucid interval

• Hyperventilation

• Sluggish or dilated pupils

• Widened pulse pressure

Hematoma

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Relatively minor blow

• loss of auto‐regulatory centers of the brain

• cerebral hyperemia and edema that is virtually impossible to control

• Elevated ICP w/herniation

• Adverse affects on CNN within minutes

• Death in 50% of cases

Second Impact Syndrome

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Acute S/S Resemble SRC Children and Risk

Children appear to more vulnerable to cerebral swelling and subdural hematoma

• Increased sensitivity and more conservative approach

• Loss of coordination

• Rapid LOC

• Coma

• Dilating pupils that are motionless

• Respiratory distress

a minor concussion, but readily deteriorate due to pressure on CNN

Acute Signs & Symptoms of SIS

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Level 1 Trauma Center

• Cannot rule out CSI

• Hematoma S/S

• Increased intra‐cranial pressure

Indications for Transport

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• Monitor vitals and LOC every 5 min

• Lucid interval

• Deteriorating S/S

• Inc number of

• Inc graded symptom score

When to Refer

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Protect immediate health / Prevent protracted recovery / PCS

What you do from minute 1 could make the difference between simple recovery and protracted recovery or post‐concussion syndrome

• CRT

Phase 2: Sideline Assessment

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“Special Juice”

• 1 qt

Omega‐3

Witch Doctor?

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If you’re Not Measuring, Your Guessing

Protracted Recovery and PCS

Journal of Athletic Training 2017;52(3):160–166

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Follow‐Up Acute Assessment

Cranial Nerves

• 90% of a thorough head injury assessment

• CNN Assessment Guide

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When and Where?

Directly after injury? / On Sideline?

Upon determination of concussion to document signs and symptoms?

• Graded symptom checklist at injury

• SCAT5 20+ min post‐injury

• Locker room

• Training room

SCAT 5 and Child SCAT 5

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Acute signs and symptoms may not be accurate indicator of VS injury

• Within first week

• 40% report balance problems

• 30% report vision problems

• Generally recover in 3‐5 days, maybe up to 10 days.

Vestibular Signs and Symptoms

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• Smooth Pursuits

• Horizontal Saccades

• Vertical Saccades

• Near Point Convergence

• Horizontal VOR

• Vertical VOR

• Visual Motion Sensory Test

VOMS Tests

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0‐10

• Headache

• Dizziness

• Nausea

• Fogginess

VOMS Recordings

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The King‐Devick (KD) test is a screening tool designed to assess cognitive visual impairments, namely saccadic rhythm, postconcussion.

King‐Devick

Journal of Athletic Training 2017;52(5):439–445

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Concussion Assessment System i‐Pad Based

• Cleveland Clinic

• Combines benefits of ImPact, SCAT3, BESS, and RTP

• Completed in about 20 Min

• Cloud based application

C3 Logix

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Provides for

• Graded symptom checklist

• Reaction time

• Memory & Speed processing

• Motor function

• Vision

• Balance

• Vestibular function

Concussion Assessment System

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Risk Predicting

Significant predictors• amnesia, balance abnormalities, tinnitus & visual impairments at 20 min.

87% probability• headache & amnesia at 5 min

73% probability• headache, dizziness & balance abnormalities at 20 min

Epidural and Subdural hematomas and SIS are life‐threatening, but PCS is a more likely consequence of sports‐related concussion

Post‐Concussion Syndrome

Cameron KL, et al. (2000). Predicting the development of post concussion syndrome from initial signs and symptoms following mild traumatic brain injury. JAT‐S, 35(2), S‐54.

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Written concussion signs and symptoms even if there is a remote possibility that the athlete suffered a concussion

Head Injury Warning Sheet

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72hrs post‐injury critical

Pass from school, homework

Full physical and cognitive rest

Yellow Card

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• Signs and symptoms checklist

• Explicit diagnosis of concussion

• Physician follow‐up

• Policy overrides ER/Physician

Physician Evaluation Form

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Sports‐related head injury has a relatively high incidence rate in youth

• 15% of all ER head injuries

• 3% of all sports related injuries

• 24% of all serious head injuries

Age related difference exist between HS and college athletes

• Increased symptom severity

• Prolonged recovery

Special Consideration for Young Athletes

Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M, Putukian M, Valovich McLeod TC. National Athletic Trainers’ Association position statement: management of sports‐related concussion. J Athl Train. 2004;39(3):280‐297.

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Proper Fit

Equipment Issues

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Session Review

• Recording posted shortly

• Power Point link

Readings

• Hematoma vs. Concussion

• Leddy‐Neuro Rehab

• Adolescent and Pediatric Rehab Strategies

For Tomorrow

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Assessment Concussion vs. Hematoma

Rising ICP

• Widened pulse pressure

• Bradycardia

Interpretation of signs and symptoms

Vital signs trending

• Rule of 100

• Pulse pressure

• Pulse rate

Predicting PCS / Protracted Recovery

Conclusion

on-field management assessment and differential … · •inc graded symptom score ... test is a...

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