Welcome to a discussion about concussion, I’m Geoffrey Laurer with the Brain Injury Alliance of Iowa, and I’m here today with dr David Baumgartner, Dr. Baumgartner is a specialist in emergency medicine and affiliated with UnityPoint – St. Luke’s Hospital in Cedar Rapids, Iowa. Thank you for being with us today. My pleasure Yeah, we’re here to tell you to talk a little bit about concussion from an emergency department Urgent Care standpoint. So when should a person either take themselves or their child? What should be the the flag that a bump on the head maybe a little bit more than a bump on the head and would be a sign or symptom to go to emergency care or urgent care? There are some things that we first of all consider like red flags per se and so if the mechanism was obviously severe that would be either one of the first and primary reasons. The other thing is if there’s a anything that would potentially alter your mental status whether it’s maybe confusion a pretty significant headache, neck pain associated with it and then bottom line if there’s any question, you know. We’re happy to see anybody for any type of injury to their head. Understood. So severe mechanism. Let’s give a couple of examples of what that might be? What would be in your opinion a couple of examples for kids of a severe mechanism? Well, some of the times we think about in automobile accidents… It’s not death sight just being in an automobile accident, but if the child was thrown from the vehicle the vehicle The automobile accident was so bad that somebody died in the accident. Severe car crash. What about monkey bars on the playground? You know from from a normal height fall down bump on a head. Is that in and of itself a flag to go to the ER? It can be, yes, has anything over about three feet. We tend to think of a severe enough mechanism that they should be evaluated by a medical professional. Good to know. Good rule. Thank you. With kids there are a range of ages are there any differences in flags for younger kids versus older kids versus adults? Are there any behavorial signs or symptoms that are unusual flags in any of those ages that you see? Actually generally speaking probably not. Obviously if a child is less than 2 years old or so that the ability to communicate certain things like I feel dizzy or lightheaded or confused is going to be a little bit more difficult than you know a 35 year old. So we’re trying to take that into account. And so some of the things we look at in a younger child would be more of a physical exam or other hard findings where as we get a little bit older some of the more subjective symptoms come into play. So if I were to bring myself or my child into your emergency department What might I expect you to do would there always be for example an x-ray or a CT scan? That’s an excellent question. So the first thing we do in the particular emergency department is make sure there aren’t any life-threatening injuries. That could be just as a quick as a glance within the first few seconds and once we’ve established that we move on to kind of a physical exam to make sure there aren’t any signs of a skull fracture, significant alteration in the mental status and then we proceed down certain algorithms that would let us lead us to the conclusion that we would be looking for what we call a clinically important traumatic brain injury. And that’s an injury in the brain where there might be some significant swelling or bleeding to the point where we would have surgery to relieve those symptoms. And to answer your question about any type of imaging Any imaging with the exception of MRI causes a significant amount of radiation so we try to minimize that and we’ve done some great studies through the years to help us find some signs and symptoms as well as physical exam findings that would lead us to discover those important brain injuries without those signs or symptoms the the risk of having a very significant brain injury where we would potentially do a surgical interventions on the order of less than 1%. Oh, so that that would do a lot to make me feel Llke the odds are in my favor when I came in. Very much so. So, so I wouldn’t have to feel as a parent that if I left without an x-ray or a CT scan that I was getting Substandard care anymore. Absolutely, not a matter of fact, he’d probably be getting pretty darn good care. So what other kinds of recommendations or treatments might you send somebody home with if… they had if you will, a less than a 1% outcome if you know, hopefully a recoverable outcome. What do you send people home with suggestions for treatment or for care in the first few days? That’s a great question. And that’s where we spend probably a majority of our time just because the risk of those significant injuries are so rare. First and foremost one of the things that we’re stressing right off the bat is to get as much mental and physical rest within that first 24 to 48 hour period. And then we have to ensure that they follow up with another provider Preferably within 48 to 72 hours for a recheck of those symptoms. What kind of provider would a person want to go to in that first a couple of days if that individual has a primary care? Provider we recommended that also.. but because of timing for instance a lot of these injuries happen Thursday or Friday evening. Won’t necessarily all in that. So we recommend either an urgent care that’s comfortable with reevaluating the patient or they’re always welcome to come back to the emergency department for the reevaluation. Got it. Okay How about in the school systems? There are athletic trainers and school nurses if they were involved in in the knowledge and information about that concussive event would they be somebody for families to seek out to let know that this has happened? I would think so eventually down the road because they’re going to be the one so that helped with the child’s ability to return to learn to return to play and they’re gonna play an integral part and the child’s overall recovery. Yes. Got it. Do you send folks home with any specifics about how? How hong to keep you said 24 to 48 hours of of rest but it used to be that there was a belief that we should wake kids up every hour over the course of a night Is that still standard of care practice? That’s actually the most common question? I get from parents and other individuals and the answer is back in the day before probably we had the imaging or these decision rules that’s what we were looking for. Somebody had a significant change and their mental status that we would be worried about a significant injury with all the questions in the physical exam that we do now what we want them to do is get as much mental and physical rest. And so the answer to that question is no. If we did that that nobody would get any sleep the parents included. Indeed. What about screens? There’s a there’s a lot of concern about too many too much time on screens screens, phones or TVs or pads or laptops? Interfering with sleep. Do you have any suggestions or is there any change in recommendation about screen time relative to rest? Yeah, that’s a that’s a great question. What I equate concussions to is somewhat like a sprained ankle and a loose term meaning that if we’ve ever sprained our ankle or another joint for the first couple of days we don’t do anything with that and we try to nurse it and rest it as much as possible and then after that time period slowly increase your activity depending on your symptoms of the pain. The brain is similar in that respect to that. It needs rest and anything we do to stimulate the brain whether it’s visually oddly or through physical activity that needs to be minimized in that initial period then with a gradual return to normal activity based on your symptoms got it. So this last weekend here in parts of Eastern Iowa, it was homecoming and there there’s a question that might come up depending on an event that’s coming coincidental with a concussion if I brought my teenager in to the ER on a Thursday night and Friday night was homecoming would there be how would you help me navigate whether they should go or not go? One would the big in primary reasons would be how severe was the head injury? I mean was it they bent over to pick up a book and hit their head on the wall and everything seems to be fine? Whether that’s on the very mild end to pProbably the one of the most common scenarios we would see someone within the football game took a pretty big hit and was possibly unconscious for a little bit. If it’s on the the latter side where there was a significant injury I definitely tell parents and students that the better part of valor is to probably rest up and not take any chances of prolonging the recovery or making things worse makes sense. Do you ever see a delay? because of either the onset of symptoms being delayed between the time of a an event that might have been concussive and the time that people might start to become aware that they’re symptomatic and and their arrival in theED or Urgent Care? Yes, of course, and I’ve seen people in from just a couple of days to you know to immediately after the incident so what I mean is can symptoms emerge – later like days or hours or days later from the time an event? Obviously if a kid or maybe not obviously many times if there’s a football game or a athletic event and there’s a very visible event with signs symptoms or behaviors. We know something’s probably happened but if I was at Menards and stood up and bumped my head on a 2×4 and then 24 to 48 hours is there ever time that I might have a delayed onset in feeling weird or or concerned. Yeah, I think there is a chance that especially if there are some what we call prolonged symptoms so the headache just seems like it’s not getting better like it should or you seem to be a little bit more confused than others or you’re having balance issues or some other things so yes. Yes, that is very possible. And then the last question I have is what about teen years where? Teens can be their behaviors can be up and down Extreme or not? Are there any differences between teens with concussion younger kids with concussion that you see in terms of presentation very much so it’s all it’s all very much individual dependent as well but yes the irritability or even the mood swings would tend to be a little bit more prevalent in kind of the teenage years not something we typically see in the emergency department but it can put swelling we educate parents about at least in the short-term Are there materials that you typically hand out to to families if they’ve come in and had? Yes, exactly. And so what we have here is what we call the the REAP packet and this is a quite comprehensive brochure that we put together about the signs and symptoms of a concussion, what to expect on the the back end the criteria we use to get individuals back to their school to their hopefully to physical activities sports activities so quickly as possible. Thank you So this is this is the Iowa REAP manual. It is the Department of Public Health and Department of Education endorsed protocol for both return to learn and return to play used also here at UnityPoint St. Luke’s in Cedar Rapids. It is available in Iowa concussion dot o-r-g Thank you so much for taking time today with us to talk about emergency department urgent care. I’m Geoffrey Laurer with the Brain Injury Alliance of Iowa talking this morning with Dr. Baumgartner a specialist in emergency medicine affiliated with UnityPoint – St. Luke’s here in Cedar Rapids. Again, for more information about concussion and other brain injury, please see Iowa concussion dot o-r-g.