Guide Pediatric and Adolescent Concussion: Diagnosis, Management, and Outcomes

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While traumatic brain injury can be a major cause of death and disability, most children have mild, non-life-threatening events. Children with a possible concussion frequently first present in the ED. Thus, its diagnosis, management, and aftercare are significant issues in the pediatric ED. A wide variation exists in definitions for pediatric head injuries. For the purpose of this article, pediatric head trauma will be divided into three categories: mild head trauma, mild traumatic brain injury, and clinically important traumatic brain injury.

Diagnostic criteria for mild traumatic brain injury are listed in Table 2. The term concussion has been used interchangeably with mild traumatic brain injury, although a universally accepted definition still remains elusive. The current international definition of concussion, as determined by the Fourth International Conference on Concussion in Sport, has multiple components; it is defined as a brain injury induced by biomechanical forces resulting in short-lived impairment of neurologic function that resolves spontaneously.

According to the definition, the acute clinical symptoms of concussion reflect a functional disturbance as opposed to a structural injury; therefore, no abnormality is seen on standard structural neuroimaging studies.

Concussion the Hidden Injury

Clinically Important Traumatic Brain Injury. Head trauma associated with disorientation, vomiting, or brief loss of consciousness. Adapted from: Schutzman S.

by Springer

Minor head trauma in infants and children: Management. In: Post TW, ed. Accessed Aug. A patient with mild traumatic brain injury has had a traumatically induced physiologic disruption of brain function, as manifested by 1 or more of:. More than , cases of pediatric head trauma present to EDs annually. Falls are the most common cause in children younger than 10 years of age.

Sports-related concussions are the most common cause in children ages 10 years and older. Concussions cause a constellation of functional symptoms in the absence of structural damage. Symptoms can begin with the trauma or in the subsequent hours and may evolve slowly over days to weeks. See Table 3. Headache is the most commonly reported symptom. Early symptoms of concussion may also include dizziness, amnesia to the event, confusion, nausea, and vomiting. The incidence of post-traumatic dizziness or vertigo, thought to be caused by direct injury to the cochlear, labyrinthine, or vestibular structures, has not been well-characterized in the literature.

Adapted from : Centers for Disease Control and Prevention. Accessed July 30, Over the next hours to days, patients may develop mood or cognitive disturbance, light and noise sensitivity, and sleep disturbance. Occasionally, there may be transient cortical neurologic deficits, including cortical blindness, global amnesia, and slurred or incoherent speech, thought to be due to vascular hyperreactivity, a migraine-equivalent phenomenon.

Short-term predictors of prolonged symptoms vary across studies but appear to include increased number of initial symptoms, older age adolescent vs child , loss of consciousness and amnesia, and premorbid conditions including previous concussion, learning difficulties, and psychiatric illness.

In the ED, all patients with head trauma should have a full medical assessment with a thorough history from both the patient and witnesses to the event.

Current Concepts in Concussion: Evaluation and Management - American Family Physician

This includes number of previous concussions or head injuries and the dates they occurred. The physical exam should pay special attention to the head, neck, and neurologic exam, including mental status, gait, balance, and evidence of associated extracranial injury. Management of serious brain injury, cervical spine injuries, and major trauma are outside the scope of this article. The differential diagnosis for a concussion includes intracranial injuries such as a contusion, hemorrhage, or edema. Ultimately, the diagnosis of a concussion can be made only after the exclusion of these more serious, structural brain injuries.

Thus, a common diagnostic dilemma in children with head trauma is the decision to obtain computed tomography CT imaging, an imaging modality both highly sensitive and specific for the detection of epidural and subdural bleeds, and subarachnoid hemorrhages. However, as practitioners and families have become increasingly aware of the possible long-term sequelae of ionizing radiation, researchers have developed algorithms to help guide practitioners in imaging children with head trauma.

The Pediatric Emergency Care Applied Research Network PECARN consortium produced the largest study to date that derived and validated a clinical prediction rule to identify children with very low risk for clinically important traumatic brain injury who, therefore, do not require CT imaging.

Of note, 10, children were younger than 2 years of age. Children are divided into two categories: those between the ages of 2 and 18 years and those younger than 2 years of age. Identification of children at very low risk of clinically important brain injuries after head trauma: A prospective cohort study.

Lancet ; Moans to pain. Cries to pain. Coos, babbles, smiles, interacts. Withdraws to touch. In children older than 2 years of age, symptoms in which shared decision-making should be employed regarding CT imaging vs observation either at home or in the ED include history of vomiting, loss of consciousness, severe headache, or severe mechanism of injury. Recent studies have demonstrated that isolated brief loss of consciousness and minimal vomiting are rarely associated with clinically important traumatic brain injury.

In children younger than 2 years of age, risk factors in which imaging should be considered include a non-frontal scalp hematoma, abnormal activity according to the parents, or a severe mechanism of injury see definition above. CT imaging should be more strongly considered in infants younger than 3 months of age, as the absence of clinical signs of brain injury is not as reliable. A summary of decision rules for avoiding CT in children with head trauma is presented in Table 5.

Two other studies have developed clinical guidelines regarding when to image children with head trauma. Using these criteria, the group achieved a sensitivity of See Table 6. High risk need for neurological intervention. Once the diagnosis of structural brain injury has been excluded with or without imaging , concussion can still be difficult to identify, as there is currently no objective measure with which to make the diagnosis. Given that the majority of concussions do not result in dramatic symptoms such as loss of consciousness, a concussion can go unrecognized by both the patient and medical providers.

Thus, a number of cognitive diagnostic tools have been developed to aid in the identification of a concussion. The SAC, which was part of the predecessor for the SCAT3, was developed for the sideline evaluation of athletes who sustained head trauma, and includes measures of orientation, immediate memory, delayed recall, concentration, neurologic testing, and exertional maneuvers, with lower scores associated with concussion.

It is important to note that while the scores were found to be slightly lower in children with concussion, it only reached statistical significance in the age group of years. Furthermore, it should not be used in isolation to determine return to play. It assesses subjective symptoms, includes the SAC cognitive assessment, and evaluates coordination and balance. It differs from SCAT2 in that it includes a neck exam.

SCAT3 can be time-consuming and ideally it is used as a tool for repeat assessment; therefore, it is not an ideal test to perform in the ED. However, there is general consensus that balance testing is the most specific finding for concussion. Patients can be discharged safely from the ED if the following criteria are met: a return to baseline level of function with a GCS of 15, tolerance of oral intake without significant nausea or vomiting, no other injuries warranting admission, and reliable caretakers.

Although there is still debate about periodically waking up the child from sleep during the night, providers now feel that there may be more benefit from uninterrupted sleep, and frequent awakenings may exacerbate symptoms. Typically, if a child has not been imaged and continues to be symptomatic or returns with increased symptoms, he or she should be imaged.

If the child has been imaged, it is important to note that delayed clinically important traumatic brain injury after a normal CT scan is extremely rare. A retrospective cohort study of more than 17, children in Canada with a normal CT or asymptomatic 6-hour observation period identified delayed clinically important traumatic brain injury in 0.

Rather, further imaging is best coordinated, if indicated, through the care of an outpatient physician evaluating the child. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November J Athl Train. Concussion is a common injury that has emerged as a major health care concern in the United States.

AAP Updates Management of Sport-Related Concussion

Consequently, management of concussions has changed significantly. Concussion can be difficult to recognize, complicated by the lack of a universal definition. Additionally, there are no direct objective measures for diagnosis or recovery, no treatments with well-documented effectiveness, 14 , 16 and limited empiric prospective data to guide return-to-play decisions. Concussion is a functional rather than structural injury that can affect somatic, cognitive, and affective domains.

Headache is the most common symptom of concussion. Information from references 5 , 8 through 10 , 12 , 16 , 19 through 21 , 23 , and There is no consensus regarding classification of concussions. An ideal classification system would determine severity at the time of injury, provide prognostic information, and help guide return-to-play decisions. Because such a system does not exist, an individualized approach of monitoring symptoms to resolution is recommended, followed by a graded return-to-play strategy.

Previously, most reported concussions were a result of falls or motor vehicle collisions. Males seem prone to concussion through player-to-player contact, whereas concussions in females tend to be caused by contact with the playing surface or equipment. Concussion is caused by rotational and angular forces to the brain, and direct impact to the head is not required.

Resultant increases of calcium and excitatory amino acids are followed by further potassium efflux, leading to suppression of neuron activity. Disruptions of autonomic regulation can persist for several weeks, and the brain may be vulnerable to additional injury. Symptoms of concussion typically present immediately after injury, but may be delayed several hours.

Assessment of symptoms has traditionally been used to monitor recovery; however, the role of cognitive dysfunction has received significant attention. Although described inconsistently in the literature, 14 cognitive function likely recovers independently of symptoms.

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This raises concern for increased risk of additional injury even after symptoms have resolved. Factors predictive of recovery are poorly defined. Traditional markers i. Studies have demonstrated that brief loss of consciousness is not associated with prolonged recovery, 1 , 8 , 26 and that convulsions immediately after injury are benign. Recent findings suggest that prolonged headache more than 60 hours , fatigue, tiredness, fogginess, or presence of more than three symptoms at presentation may be associated with prolonged recovery. Most concussions lead to subtle changes; therefore, evaluation can be challenging.