Management of Concussions in Children – the ED approach

Sujit Iyer, M.D.DCMC Emergency Department

5 major features of a concussion1. Direct blow to the head, face, or neck or elsewhere on the

body with an “impulsive” force transmitted to the head2. Rapid onset of short-lived impairment of neurologic

function that resolves spontaneously3. May result in neuropathological changes, but the acute

clinical symptoms largely reflect a functional disturbance rather than a structural injury

4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness (LOC).

5. No abnormality on standard structural neuroimaging studies is seen in concussion

Why does it happen?

• Acceleration, deceleration and rotational forces to brain

• Neuronal membrane damage and release of free radicals and excitatory transmitters may contribute to neuronal injury

What are signs of a concussion?

• Physical – headache, most common of all symptoms– LOC occurs in less than 10%– Nausea, vomiting, balance, fatigue, photophobia, dazed

• Cognitive – fogginess, decrease concentration, forgetfulness,

answer questions slowly, etc.• Emotional– Irritable, sadness, nervousness

• Sleep disturbances

Shouldn’t we grade the concussion?

• There are more than 25 concussion grading scales

• These have not been found to helpful in prediction and delineation was not found to be useful in management

• SYMPTOMS are the key in guiding return to play recommendations

Assessing a concussion – AT THE SCENE

• ABCs – Airway, Breathing, Circulation AND C-Spine immobilization– Consider no c-spine immobilization if no LOC, no

neck pain and moving all 4 extremities with no symptoms

• “Sideline tests” – BESS, SCAT2, Maddocks questions– See references

Assessing a concussion – AT THE SCENE

• Anyone identified as having a concussion during game –DOES NOT return to the game– Goes to the ED if:

• Condition deteriorates• Has continued vomiting• Unsteady gait, slurred speech• Increasing headache• Signs of skull fracture• GCS < 15

Assessing concussions in the ED

• Neuroimaging usually normal. May need imaging if :– Continued vomiting– Seizures– Slurred speech, abnormal gait– Focal neuro findings– Poor orientation to person, events– Neck Pain– LOC > 30 seconds

Advice for Management for Parents

• Medication– Consider NSAIDS and acetaminophen for

continued headache, sleep problems, or trouble concentrating

– Before returning to play athlete must be symptom free OFF MEDICATION

• Need for continued medication indicates incomplete recovery

Advice for Management for Parents

• Cognitive rest– Must tell them that they will get MORE symptoms

with cognitive activities (homework, class, any reading) – this is a FUNCTIONAL not structural injury – so using your brain may cause more symptoms!

• Rest may include:– Absence from school– Decrease school workload– More time to complete assignments

Advice for Management for Parents

• Physical rest– Broad restriction of physical activity while still

symptomatic– Includes sport that caused it AND• Weight training • Cardiovascular activity• PE Classes

Return to Play

• No teenage or child should return to the same game

• Every child’s recovery will be different• “When in doubt, sit them out!” – good guideline• Nobody should return to play when having

symptoms at rest or with exertion• Younger children may take up to 7-10 days

longer to recover than older athletes

Concussion Rehabilitation

• Graded, stepwise approach to return to play• Endorsed by Academy of Sports Medicine and

international experts• Each step takes at least 24 hours • Should take a minimum of 5 days to progress through

protocol and return to play if no symptoms return• If symptoms return during protocol, must be

asymptomatic again for 24 hours before attempting previous step

Concusion Rehabilitation

Complications

• Long Term Effects – still more research needed– IF 3 or > concussions more likely to have LOC, amnesia,

confusion– Athletes with 2 or > concussions had lower GPAs then

similar students without concussions• Second Impact Syndrome – Second head injury occurs before symptoms of first

injury have cleared– Get cerebral congestion, edema and then DEATH– All reported cases have occurred in kids < 20 years old

Post Concussion Syndrome

• Many different definitions• Simple one:– Cognitive, physical or emotional symptoms lasting

longer than expected – usual threshold of at least 1-6 weeks of persistent symptoms after initial concussion

• AT DCMC can refer to Dr Reardon – Tell them when they call to schedule them for a concussion clinic follow up from the ED.

References for Coaches and Parents“Heads Up” – a toolkit developed by the CDC for

coaches, teachers, counselors and physicianshttp://www.cdc.gov/concussion/HeadsUp/youth.html

YOU’RE NOT DONE!

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