Concussion
Concussion: Excerpt from The 5-Minute Pediatric Consult
Daniel Licht, MDNicholas S. Abend, MD
Concussion - BASICS
Concussion - description
- Concussion is a mild traumatic brain injury (TBI) caused by impact to the head in which there is an alteration in mental status that may or may not involve a loss of consciousness.
- Most studies and guidelines require a Glascow Coma Score (GCS) of at least 14 and no neurological deficits at initial evaluation for diagnosis because otherwise there is a higher risk of intracranial lesions on neuroimaging and need for surgery.
- Concussion may suggest the presence of an acute intracranial injury and is associated with both early and late postconcussive symptoms.
- There are >20 published expert guidelines which differ slightly in grading, management, and return to activity recommendations.
Concussion - general prevention
Given that children my have a sense of invulnerability and desire to return to usual activities quickly, preparticipation medical visits should emphasize that reporting concussion immediately is essential and loss of consciousness is not the only manifestation.
Concussion - epidemiology
- >300,000 mild to moderate sport-related TBIs per year.
- Most common sports include football, ice hockey, soccer, wrestling, lacrosse, basketball, baseball, softball, field hockey, and volleyball.
- Risk of injury depends on game, position, and use of helmet.
Concussion - pathophysiology
- The brain is buoyed in the cranium by CSF that acts as protective insulation. In acceleration-deceleration accidents the brain continues to experience forward momentum and slams against hard bone. The temporal and frontal lobes of the brain are particularly prone to injury because of their location adjacent to irregular parts of the skull.
- Depressed level of consciousness is thought to be the result of rotational stretch injury to the reticular activating system in the dorsal aspect of the brain stem.
- Changes after concussion include changes in neuronal depolarization and neurotransmitter release, impaired axonal function, and altered brain autoregulation and glucose metabolism.
- Children may respond to brain trauma differently than adults due to developmental factors such as brain size, brain water content, myelination level, skull and suture geometry and elasticity, and differential skull to body proportions.
Concussion - DIAGNOSIS
Concussion - signs & symptoms
Postconcussive symptoms may be divided into 3 domains:
- Somatic: Headaches, fatigue, decreased energy sleep disturbance, nausea, vision change, tinnitus dizziness, incoordination and balance difficulty
- Emotional/Behavioral: Irritability, increased emotionality, personality change, depression, or anxiety
- Cognitive: Slowed thinking and response, impaired concentration and learning and memory and problem solving ability
Concussion - history
- Should include information regarding prior concussions.
- Grading scales have been established to determine the severity of injury but differ slightly between guidelines:
- Grade 1: No loss of consciousness and mental status changes resolve in <15 minutes.
- Grade 2: No loss of consciousness and mental status changes last >15 minutes
- Grade 3: Any loss of consciousness
- Some grading scales also consider posttraumatic amnesia with <1 hour in grade 1, <24 hours in grade 2, and >24 hours in grade 3.
Concussion - physical exam
A detailed neurological examination should be performed to detect signs and to allow accurate observation over time.
- Mental status: Including orientation (person, place, time), concentration (backword digits), and memory (anterograde and retrograde).
- Cranial nerves: Pupil reactivity, eye movements, visual fields, face movement and sensation, tongue protrusion.
- Motor
- Sensory
- Cerebellar: Agility: Finger-to-nose-to-finger, rapid alternating movements (finger tapping, toe tapping), heel/toe/tandem gait
- Exertion provocative tests: 5 push-ups, 5 sit-ups, 5 knee bends, 40-yard sprint; look for change in exam
Concussion - tests
Concussion - imaging
- Computed tomogram of the head (HCT) is essential to rule out intracranial lesions if there is abnormal mental status, neurological signs, evidence of a skull fracture, loss of consciousness, amnesia, if not improving, or if symptoms persist for more than 1 week.
- Clear indications for HCT have not been elucidated and children may have intracranial lesions with asymptomatic head injury, so a relatively low threshold for neuroimaging is appropriate.
- Children <1 year of age should be imaged since symptoms may be difficult to detect and nontraumatic etiologies must be considered.
- Children <2 years of age should be imaged unless there was a low energy mechanism and no symptoms/signs for at least 2 hours.
- MRI may be necessary in patients experiencing long-term effects of repeated head injury.
Concussion - TREATMENT
- On site acute evaluation should include the usual ABCs and evaluation for potential associated injuries such as cervical spinal injury.
- Standardized, validated instruments for mental status testing are available and can be administered quickly on the sideline.
Concussion - general measures
- Grade 1:
- Remove from contest.
- Examine the patient immediately, 5 minutes after the injury, and serially thereafter until after return to baseline. Observation may occur at home.
- Some guidelines suggest that the patient may return to the contest if all postconcussive symptoms clear within 15 minutes and it is a 1st concussion while others suggest no return to the contest that day because symptoms may evolve more slowly.
- Grade 2:
- Remove from contest and disallow return to competition that day.
- Examine patient frequently for signs of evolving intracranial pathology. Observation may occur at home or in the hospital.
- Follow-up examination by a trained physician on the day after injury
- Grade 3:
- Transport the injured player to the nearest emergency room by ambulance with cervical spine immobilization.
- A thorough neurologic examination should be performed with the appropriate neuroimaging.
- Hospitalization is indicated if any signs of pathology are detected on physical exam, on neuroimaging, or if the mental status remains abnormal.
- If the findings are normal at the time of initial medical evaluation, the patient may return home with explicit written instructions on observation.
- Neurologic status should be assessed daily until all symptoms have stabilized or resolved.
- Prolonged unconsciousness, persistent mental status alterations, worsening postconcussive symptoms, or abnormalities on neurologic examination require urgent neurosurgical evaluation or transfer to a trauma center.
- Children <2 years of age may need more prolonged observation in an ED or inpatient setting.
Concussion - nursing
If observation is required, nursing staff must be able to perform specific neurological assessments at regular intervals.
Concussion - surgery
Neurosurgical evaluation or transfer to a trauma center should be considered for symptoms of prolonged unconsciousness, persistent mental status alterations, worsening postconcussive symptoms, abnormalities on neurologic examination, or abnormalities on neuroimaging.
Concussion - FOLLOW UP
Concussion - disposition
Concussion - admission criteria
If the child is not improved to baseline they should be observed as an inpatient with serial neurological examinations since some intracranial lesions may take time to develop.
Concussion - discharge criteria
- The child and guardian should receive return to play guidelines to avoid second impact syndrome, in which a second concussion occurs soon after a first concussion. Concussions have a cumulative effect and result in increased vulnerability to future injuries.
- Many guidelines differ slightly in their recommendations.
- The concussion in sport group describes that no athlete should return to play while still symptomatic from a concussion (either physical, cognitive, or behavioral symptoms). There must be no symptoms or signs at rest or during exertion.
- Guidelines generally based on concussion grade and number of prior concussions. Times refer to duration of time after symptoms have fully resolved.
- Grade 1: 1st concussion = 15 minutes, 2nd concussion = 1 week, 3rd or more concussions = next season or retire.
- Grade 2: 1st concussion = 1 week, 2nd concussion = 2 weeks, 3rd or more concussion = next season or retire.
- Grade 3: 1st or 2nd concussion = at least 4 weeks, 3rd or more concussion = next season or retire.
- In contrast to older athletes, young athletes may experience evolving symptoms after being seemingly symptomfree suggesting that it may be best not to ever return to play during the same competition.
- Retirement should occur after repeated concussions with ongoing symptoms, or when recovery requires an increasing amount of time, or when concussions occur with less forceful injury.
- Planning must be individualized if intracranial lesions are present.
- Return to play should occur in a gradual fashion since symptoms may be aggravated with exertion. Consider in sequence light aerobic activity, noncontact sport related activity, full practice, and then game play.
Concussion - issues for referral
- Neuropsychological evaluation should be considered in children with multiple concussions or when recovery is not progressing as expected to document impairment, identify factors contributing to persisting difficulties, and guide school accommodations or formal intervention.
- If admitted for observation, consults by speech therapy, physical therapy, and physiatry should be considered to evaluate subtle sequelae.
Concussion - prognosis
- In general, the prognosis is excellent but depends on the severity of the injury.
- The typical adult patient with a concussion will recover to baseline function in 6–12 weeks.
- Athletes and children usually recover in 48 hours. However, children with previous head injury, learning difficulties, or neurologic, psychiatric, or family problems may continue to show significant ongoing problems at 3 months.
- Chronic headaches, persistent difficulty with short- and long-term memory and episodic confusion are common sequelae of the cumulative damage that occurs with repeated concussive injuries.
Concussion - complications
- Postconcussion symptoms such as confusion, altered concentration and memory and problem solving, irritability, emotional changes, and headaches may take several months to resolve.
- Serious head injury may occur and requires immediate neurosurgical evaluation, neurocritical care, and often serial HCT imaging because intracranial lesions, such as contusion or hemorrhages (epidural, subdural, intraparenchymal), can expand.
- These may occur with or without skull fracture, and may occur without an initial loss of consciousness.
- These may occur with or without fracturing the skull.
Concussion - patient monitoring
If the patient is discharged home for observation, the guardian should have detailed instruction regarding reasons to return to the ED. These include difficult to awaken or quickly falls back asleep, worsening headache or dizziness, emesis, seizures, blood or clear fluid from the ears or nose, major changes in behavior, any focal weakness/sensory/vision changes.
Concussion - bibliography
- American Academy of Pediatrics. The management of minor closed head injury in children. Pediatrics. 1999;104(6):1407–1415.
- Hinton-Bayre AD, Geffen G. Severity of sports-related concussion and neuropsychological test performance. Neurology. 2002;59:1068–1070.
- Kelly JP, Rosenberg JH. Diagnosis and management of concussion in sports. Neurology. 1997;48:575–580.
- McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med. 2005;15(2):48–55.
- Ponsford J, Willmott C, Rothwell A, et al. Cognitive and behavioral outcome following mild traumatic head injury in children. J Head Trauma Rehabil. 1999;14(Aug):360–372.
- Report of the Quality Standards Subcommittee. Practice parameter: The management of concussion in sports. Neurology. 1997;48:581–585.
- Schutzman SA, Barnes P, Duhaime AC, et al. Evaluation and management of children younger than two years old with apparently minor head trauma: Proposed guidelines. Pediatrics. 2001;107(5):983–993.
Concussion - CODES
Concussion - icd9
- 850 Concussion
- 850.9 Concussion, unspecified
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Concussion
More Medical Textbooks Online about Concussion
Review other book chapters online related to Concussion:
Medical Books Excerpts
- Concussion
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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