Improving communication, setting expectations highlight opportunities for improved concussion management in the ED

Concussion management and diagnosis is an evolving area both in medicine and in the public arena with increased attention being paid to neurocognitive protection and downstream impact following a head injury.

The National Law Review published a synopsis of a Journal of Head Trauma Rehab on March 1, 2017 that outlines opportunities for improved communication between emergency medicine providers and patients suffering acute head injury, such as traumatic brain injuries (TBI) which can include concussion. There is also an opportunity within medicine, and between disciplines, to tighten up our definitions as we learn more about concussions and how that diagnosis fits within the larger category of TBI.

This represents a good opportunity to outline how the patient with a head injury is approached differently in the ED than on the playing field and at different stages of disease progression (i.e. right after injury by EMS or training staff compared to in the hospital versus in rehabilitation and later with neurology and neuropsychology when needed). Since each of these providers has a different role and responsibility to the patient, jargon and emphasis on specific diagnoses and care can vary – and with that variation comes a set up for unclear expectations and possible miscommunication between patients and physicians.

Let’s cover some important terminology before we jump into a review on the subject.

IMPORTANT TERMS:

Concussion: A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth https://www.cdc.gov/headsup/basics/concussion_whatis.html

Traumatic Brain Injury (TBI): head trauma resulting that disrupts normal function of the brain resulting in loss of consciousness or loss of memory, or alteration in mental state or focal neurological deficits. Also, other criteria that define mild TBI include GCS score > 12, no abnormalities on CT, no operative lesions and a hospital length of stay < 48 hours. https://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf

Second Impact Syndrome (SIS): Occurs when the brain swells rapidly after a patient suffers a second concussion before symptoms of an earlier concussion have subsided. Can be fatal.

Post-Concussion Syndrome (PCS): physical or cognitive symptoms that can last for days, or months following a concussion. Physical symptoms usually resolve prior to cognitive symptoms, emphasizing need for cognitive testing to diagnose ongoing occult PCS and to avoid sequelae and risk of SIS.

Neurocognitive Testing (SCAT2 OR SCAT3, SAC, ImPACT): Standardized tools to evaluate athletes for concussion, ImPACT involves computer testing while SCAT2 and SAC can be quickly administered with paper/pencil and on the sideline.

SCAT2 and 3 are the most widely used evaluation tools

http://bjsm.bmj.com/content/bjsports/47/5/259.full.pdf

http://www.sportconcussions.com/html/SCAT2.pdf

http://knowconcussion.org/wp-content/uploads/2011/06/SAC.pdf

https://www.impacttest.com

Maddocks Questions

Specific memory and recall questions used in sideline assessment of athletes to diagnose concussion.

https://www.gpnotebook.co.uk/simplepage.cfm?ID=x20150311134026700288

CDC Heads Up Program https://www.cdc.gov/headsup/

Zurich Consensus Concussion expert gathering statements regarding diagnosis, management and prognosis of concussion. The highest level recommendations are to remove concussed patients from play and to follow an objective evaluation tool when making eventual return to play decisions. http://physicians.cattonline.com/resources/files/consensus-statement-on-concussion-in-sport-2012.pdf

 

GCS Card designed by sketchymedicine.com

 

Return To Play Progression: minimum of 24 hours for each phase, no less than 5 days for full progression. If athlete develops symptoms at one stage of progression, they should rest 24 hours and then begin again at previous stage.

Rehabilitation Stage Functional Exercise
No activity Complete physical and cognitive rest
Light aerobic activity Walking, swimming, stationary cycling at 70% max heart rate, no resistance exercises
Sport Specific Activity Specific Sport Related Drills but no head impact
Noncontact Training Drills More complex drills, may initiate light resistance training
Full Contact Practice After medical clearance, participate in full training
Return to Play Normal game play

Patient 1: NCAA Football Player

Bright lights, big stakes, early September heat and humidity. NCAA Division 1 football. A wide receiver comes over the middle and takes a hard hit from the opposing free safety. Nothing dirty, not even helmet to helmet. But down he goes. The play ends, players scuttle around and noticing the receiver is still lying on the ground. Here come the training staff, quintessential khakis and polos, to find the player on the ground in semi-responsive state. He is able to open his eyes when his named is called and moan to pain and seems to be moving all of his extremities. Training staff and paramedics are called to the field and the receiver is helped to the sidelines.

Patient 2: Adult Road Bicyclist

The next morning a group of bicyclists meet up at 6am trying to beat the hot summer sun for a 50 mile group ride down a set of paved trails. In full spandex bike garb, helmeted with clip shoes on the pedals, the group takes off at a fast 20mph pace when one of the riders, a 45 year old male engineer, is unable to avoid the back tire of a friend close in front causing an abrupt ejection from his clips and an unplanned flight of about 10 feet, landing hard on the asphalt. The group calls EMS and the patient is placed on a backboard and in a cervical spine collar and transported to a local emergency department (ED). En route, the engineer repeatedly asks the EMS crew where he was at and has no memory of a bike ride that morning.


Now, what do you do when your 7 year old asks to play tackle football? Well, if you’re like me, you deflect and refocus until you hope he forgets – or at least doesn’t remember for as long as possible to give his growing, plastic, brain the best chance of cognitive development without blunt force trauma as possible. Apparently brain growth takes place until the age of 24, however, ages 0-10 years old are critical time periods for axonal connections – the wires that transmit signals from one neuron to another, eventually forming a complex web and matrix of interrelated memories and references. For some reason, the offer to sign up for flag football does not have the same appeal as as jarring other 7 year olds to a 7 year old boy.

Forget the obvious hypocrisy that his dad works as an ER doc on the sidelines of NFL games any given Sunday and played football myself until the laws of nature (um, puberty and athleticism) caught up in high school and AP chemistry started to look more appealing than another face full of dirt. No one is oblivious to the notion that football is a contact sport. Looking back on my amateur playing days, or my childhood in general, it does seem as though our society was (maybe intentionally?) oblivious to the incidence of concussions, the prevalence of post-concussive symptoms and the possibility that concussions, especially repeat concussions and concussions that occur earlier in life during brain development, could have lasting detrimental impacts on cognition and mental health.

However, over the last twenty years, there has been increasing awareness that sports related concussions can occur and may be associated with co-morbid conditions such as second impact syndrome and chronic traumatic encephalopathy (CTE)

 

Normal Brain compared to brain of patient with evidence of CTE. CTE has now also been found in patients with no known head trauma at autopsy. Boston University Center for the Study of Traumatic Encephalopathy – http://www-tc.pbs.org/wgbh/pages/frontline/art/progs/concussions-cte/h.png

associated with a cognitive derangement that occurs as plaques build up in the brains of those that sustain repeat head trauma. Football is not the only origin of sports related concussions and activities such as horseback riding, bicycling, and motorcycle racing may be even higher risk according to the CDC. In addition, sports such as ice hockey, soccer, martial arts and boxing are also associated with concussions. While most concussions do occur from blunt head trauma, concussive forces can arrive via a hit to other interconnected body areas. Minimizing impact in general is important for concussion prevention (one of the reasons for mouth guards).

The diagnosis of sports concussions are not the only common source of brain injury that have increased as the country’s military remains in an almost perpetual state of combat. The post-concussive sequlae documented in returning soldiers has led to increased emphasis on diagnostic and management strategies by the Department of Defense (DoD). As a matter of fact, DoD has spent millions on R&D for devices such as the “Ahead 300” by BrainSpace (FIGURE 1) which utilizes a smart phone, connector, and head electrode band to examine electrical waves in the brain (EEG) to determine the presence of a concussion. In addition, a number of biomarker candidates, such as S100B, have been correlated to concussion but not validated for clinical use.

These devices and lab tests are sensitive for concussion but their usefulness on sidelines and in emergency departments has been limited given the inability of specific diagnostic concussion devices and blood tests to rule out other injuries that might exist along with the concussion, such as an intracerebral bleed, any more so than a physician that conducts a physical exam and history using a number of available scoring systems, such as the SCAT3.

These devices and lab tests are sensitive for concussion but their usefulness on sidelines and in emergency departments has been limited given the inability of specific diagnostic concussion devices and blood tests to rule out other injuries that might exist along with the concussion, such as an intracerebral bleed, any more so than a physician that conducts a physical exam and history using a number of available scoring systems, such as the SCAT3.

Biotech developments in concussion diagnosis do not progress quickly – you see, as a physician, the diagnosis of a concussion is not difficult – did the patient have a head trauma or other significant blunt trauma in which associated forces could cause brain injury? Does the patient have short term retrograde amnesia surrounding the event or a headache or nausea or neck pain? Oddly while the diagnosis is not difficult, the diagnosis is simultaneously quite challenging. Huh? Let me explain.

The diagnosis of only concussion remains the real challenge and barrier to developing new imaging and blood tests designed to test for concussion. And, just to be clear, no specific test has been validated to even diagnose concussion, much less rule out those other serious problems like a head bleed. Not even MRI works well for this with our readily available technology (there may be a role for specific type perfusion MRI study in the future). Certainly not CT scan, xray, or blood work. So, for now, the history and physical exam remain the key components in determining head injury is a concussion. In many ways, a concussion is a diagnosis of exclusion – meaning, there isn’t a more serious injury such as a bleed inside or around the brain and there is no lesion or other structural abnormality following an injury. If lab or imaging diagnostic tools are ever created for this diagnosis, there will need to be added value over a physician that leads to different clinical decision making. What would I do with the test results that I would not already do for the patient now?

In addition, a number of synonymous terms with multiple meanings are found scattered throughout the medical literature which essentially mean concussion. Mild TBI and concussion have the same meaning to some, or at least concussion is a subset of mild TBI. However, mild TBI itself is a term with a fairly wide distribution of clinical entities. The definition of a mild TBI is an acute brain injury with loss of consciousness (LOC) less than 30 minutes and a GCS of 13-15. Ok, let’s unpack that for a moment.

We can start with the inclusion of up to 30 minutes LOC in the definition. If I had a patient with a true 30 minutes of LOC, we would certainly be working up and assuming much more than a concussion – that is a long time for a person to be comatose and rarely seen in benign events with quick recovery. In addition, a patient with a GCS of 13 will clinically present much differently than a patient with GCS of 14 or 15. The huge range within the definition of mild TBI likely means that the definition includes concussion but also more serious brain injuries as well. Unfortunately, the distribution of mild TBI is not well examined beyond examining the risk of head bleed on CT imaging.

Let’s return to our two patients – the college football player and male bicyclist. The NCAA football player and the amateur bicyclist may have different courses in the ED. Why? Well, for starters, baseline neurocognitive testing. Not too mention, concerns regarding game day play and return to play.

The 20 year old star receiver wanders over to the sideline and is asked the Maddocks questions and the SCAT3 is administered by the team physician. A member of the training staff runs to find baseline scores from the beginning of the season for that player’s SCAT3 test. During evaluation, the player vomits and his headache continues to worsen. The SCAT3 score is lower and the player is unable to answer all of the Maddocks questions. At the end of the game, the worsening headache and continued nausea concern the staff enough to ask for transport to the local ED. In the ED, the patient is evaluated and a non-contrast brain CT is ordered to evaluate for a bleed inside the head given the progressive symptoms. Pain medications and anti-nausea medications are provided. By the time the CT scan is completed and reviewed by the ER doc and radiologist (no bleed, normal CT), the player is now feeling better and able to answer basic questions regarding who he is and where is at currently but remains unable to recall all the play leading up to the hard hit and asks numerous times who his team was playing. The patient is diagnosed with concussion and returned to the team for further care under the supervision of the medical staff.

This player was assessed on the sidelines and had positive neurocognitive test findings for concussion. Specifically he was unable to answer validated questions for brain injury. It is not enough to simply ask orientation questions but instead, specific memory recall surrounding the event must be utilized (who is winning, who are you playing, who were you playing last week). In addition, no matter what neurocognitivel test is used (other tests include SAC, ImPACT, SCAT3), the results have increased validity if baseline testing is also available for comparison. The highest evidence findings once the diagnosis of concussion is made mandate that the player is removed from play and then enters an objective return to play protocol that allows progression in activity every 24 hours unless a stage is failed, in which the patient goes back to the prior stage for another 24 hours before re-evaluation. Ideally, with no setbacks, a player with one concussion could return to play after five days.

Specific return to play precautions are an extremely important aspect of concussion care and post-concussive management. A
subsequent concussion while a patient remains symptomatic could result in second impact syndrome – which, while rare, can result in death secondary to brain edema. Neurocognitive testing is critical in making return to play decisions as the clinical symptoms (headache, nausea, vomiting) may resolve well before cognitive symptoms that are only revealed by comparing baseline test results to current testing via serial evaluations.

Some players may experience longer post-concussive symptoms and, while there are some specific symptoms correlated to those longer periods of time (such as multiple concussions, worsening headache and amnesia), no set of symptoms has resulted in a validated risk stratification tool to predict which players will experience a prolonged recovery phase.

In addition, both the football player and the bicyclist need to undergo complete rest while experiencing post concussive symptoms. By rest, this means essentially all cognitive tasks – including work, school work, emails, and texts. This will not be easy for a professional engineer at the peak of his career with a project deadline in one week.

Let’s return to the weekend warrior engineer bicyclist who comes into the ER on a backboard with cs-pine collar in place via EMS. The bicyclist does not have a headache and appears well, aside from abrasions and bruises on the face and swelling of the right hand and shoulder. You decide to obtain a CT of the patient to look for a bleed given the significant mechanism (ejection at high speed with blunt trauma impact) and also obtain plain xrays of the swollen wrist and chest, suspecting fractures of the radius and clavicle. Even after finding those fractures and splinting the wrist, the bicyclist remains amnestic to events and continues to have some repetitive questioning – why is my wrist broken? How did I get here today? Fortunately the CT is negative and there is no head bleed. Once the patient’s family arrives and agrees to watch the patient closely the rest of the day (also a key recommendation for patient’s with concussion), you prepare to discharge the patient home with primary care follow up.

You diagnose the bicyclist with a mild TBI, Colles’ fracture (common type of wrist fracture) and clavicle fracture. The patient is given instructions to follow up with his (and they are much more commonly males than females when it comes to concussion) doctor and told he may need to see a neurologist if symptoms persist. Specific instructions to take time off work until symptoms resolve are written down, given to the patient verbally and to the wife. In addition, the patient is advised to not participate in any work related projects or tasks and to avoid texting, typing and engaging in cognitively demanding tasks. Complete rest is emphasized.

Eventually, the young football player is able to return to game play 4 weeks later after a bye-week and a few set backs in the return to play timeline. In addition, he reveals to training staff two to three similar episodes over his playing career dating back to high school, likely adding to his slower progression through return to play milestones.

The bicyclist is found working on a the bridge project by his wife at 2am the next day after he goes to the kitchen to find Tylenol for a headache. The wife appropriately scolds the engineer for not complying with the rest instructions and, the next day, request a short period of work leave until symptom resolution. One week later, the engineer has no further clinical symptoms and returns to work. The usefulness of neurocognitive testing with tools such as SCAT3 are not as useful if no baseline score is available and thus those specific scores are not obtained during the ED visit.

At discharge, the engineer and his wife ask about treatment for concussion. We have been involved in a number of studies at our institute focused on developing treatments to decrease time for symptom resolution and overall impact of concussive symptoms. Progesterone is the most promising therapeutic agent by potentially protecting neurons from cell death. A series of clinical trials, termed ProTECT, continues the efficacy of this steroid hormone (http://www.medscape.com/viewarticle/715373).

While I am writing this, I am watching my kid’s basketball practice (a sport not immune to concussion), happy that with baseball and basketball ongoing at the same time, he seems to distracted to ask me about football. But, the next email in my inbox is a message to begin scheduling our sideline coverage next season and I realize that not only do I not want football to disappear, I can also count on the fact that the request to play contact ball will also not disappear from my active little 7 year old. Fortunately, there is some hope –  the Heads Up program attempts to teach safer tackling techniques but if those skills do not translate to high level play in high school and college, the likelihood of adoption by kids, coaches, parents and sports leagues will likely be low. I don’t have all the answers but I am glad we are in a very different place then we were when I would find myself face down in the dirt after running a tough drill called “Oklahoma” (two tires and a big guy hitting me hard enough to fly every time) 25 years ago. Even over the last decade, professional sports denial has decreased and more research is moving towards prevention. Overall, the R&D space should likely skew towards development of preventive technology (https://ninesights.ninesigma.com/web/head-health/challenge-3-winners) such as improved helmets and equipment, instead of diagnosis given the limited clinical utility and unlikely value add over existing diagnostic ability. Perhaps with increased preventative strategy and technologies, we can prevent the serious related disease states that are correlated with repeat head trauma and have even been associated with suicides (Junior Seau) and dementia (Mohammed Ali).

Jason W. Wilson, MD, MA, FAAEM, FACEP is an emergency medicine physician. Emergent Medical Consultants of Tampa (EMCOT) arranges personalized concierge care and event coverage for athletes and performers. Dr. Wilson serves as a team physician for an NHL team and medical liaison for the NFL. He has also worked with PGA and NCAA to provide medical oversight. In addition, Dr. Wilson is the associate medical director of the emergency department and the medical director of the office of clinical research at Tampa General Hosptial for TEAMHealth. He is a clinical assistant professor in the Department of Internal Medicine at the Morsani College of Medicine, University of South Florida. Jason Wilson reviews cases for compliance and standard of care within his specialty areas. http://emconsultantsoftampa.com/

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