Pediatric Concussion: ED Evaluation and Beyond

Thomas Hellmich, MD

Mayo Clinic Hospital - Rochester

Department of Emergency Medicine & Pediatrics

Emergency Nurses Association Annual Conference

April 8, 2014

Objectives

• Describe initial ED evaluation, management of concussions

• Review neuroimaging and concussion assessment tools

• Describe key elements of ED disposition for concussion

Outline• Case cases

• Epidemiology / Definition

• Evaluation: • Signs & Symptoms• Diagnosis

• Management: • Guidelines, Neuroimaging• Concussion assessment tools

• Disposition• Return to play• Referral, resources

Case #115 yo – fall from horse

• Fell off horse. +/- LOC. Acting quiet per mom

• Dazed, memory loss, HA (8-10), nausea

• Exam GCS=14 (-1 Verbal)

Patient wants to know if this is a severe concussion?

Mom wants to know about CT scan risk and if there are alternatives?

Case #216 mo - fall down stairs

• Fell down 6 stairs at a playground

• Cried immediately, dad said daughter is acting normal now. No vomiting. Seen at urgent care and referred to ED.

• Exam: Alert & playful, forehead contusion

• Resident is worried about injury and orders a CT of head

Dad ask you if this is usual practice?

Mom wants to know how often I should wake her up?

Case # 313 yo - hockey player

• Brought to ED by coach for shoulder evaluation from fall in hockey state tournament. Nurse notices he seems little confused to event details.

• Patient denies HA, N/V. Feels little sluggish. Dad said sideline ACE test by trainer showed no concussion.

• Exam: GCS=14 (-1 verbal), shoulder contusion

Dad tells coach his son will be at the game tomorrow. Coach agrees, sideline ACE was negative. Mom shakes her head. Who is right?

What are recommendations for return to play?

Case #417 yo – HA after MVC

• A 17 yo involved in MVC 2 days ago. Head CT negative. Sent home, Dx: Concussion

• HA improved initially, today worse. Teacher recommended go to ER

• Exam: GCS=15, HA (6/10), crying – thinks she flunked test.

Are her symptoms worrisome?

How do you explain cognitive rest?

Mom wants a referral to a specialist

Traumatic brain injuries are the leading cause of death and

disability in children.

CDC, National Center For Injury Prevention and Control

Head Trauma in Children

• Annually, in the US:

• 7,400 deaths

• >60,000 hospital admissions

• > 600,000 ED visits

CDC, National Center For Injury Prevention and Control

Epidemiology

• Estimated 3.8 million concussions annually

• As many as 50% may go unreported

• ~ 144 000 ED visits annually for children with concussion

• Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer and basketball

• Girls higher than boys

American Medical Society for Sports Medicine position statement: concussion in sport ,

Br J Sports Med. 2013 Jan;47(1):15-26. doi: 10.1136/bjsports-2012-091941.

Definition

• Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiological process.

• Concussion is a subset of mild traumatic brain injury.

American Medical Society for Sports Medicine position statement: concussion in sport ,

Br J Sports Med. 2013 Jan;47(1):15-26. doi: 10.1136/bjsports-2012-091941.

Definition

• A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works.

• AKA as “mild” brain injury because concussions are usually not life-threatening.

http://www.cdc.gov/Concussion/

Concussion Sxs by Category

CDC

Repeat Concussions

• Athletes with a hx of concussions may have more severe subsequent concussions and may take longer to recover

• The time interval between concussions may be an important factor in the risk for and severity of subsequent concussions

Sports-Related Concussions in Youth: Improving the Science, Changing the Culture (2014)

National Academy Sciences publication

Glasgow Coma ScaleTotal 3-15

Eye Opening Verbal Motor

6 Obeys verbal commands

5 Oriented, conversant Localized painful stimuli

4 Spontaneous Confused Withdraws from pain

3 To command Inappropriate Flexor postruring

2 To Pain Incomprehensible Extensor posturing

1 None None None

Pediatric Glasgow Coma ScaleTotal 3-15

Eye Opening Verbal Motor

Child Infant Child Infant Child Infant

6 Obeys commands

Spontaneous movement

5 Oriented Coos/babbles

Purposeful (pain)

Withdraws (touch)

4 Spontaneous Spontaneous Confused Irritable cry Withdraws (pain)

Withdraws (pain)

3 To voice To Speech Inappropriate Cries (pain) Flexion (pain) Abnormal flexion

2 To Pain To Pain Incomprehen-sible

Moans (pain) Extension (pain)

Abnormal extension

1 None None None None None None

Diagnosis

• No single diagnostic test or biomarker for concussion*

• The current cornerstone of concussion diagnosis is confirming the presence of a constellation of signs and symptoms

• Avoid the temptation to grade concussions

• Sideline tests are not always reliable• e.g. The Standardized Assessment of Concussion (SAC) and the

Sport Concussion Assessment Tool (SCAT) 3• Symptoms may be delayed• Under reporting by athletes

Acute Concussion Evaluation

• Encourage use of standardized evaluation

• Acute Concussion Evaluation (ACE)

• ACE – modified for ED

• Increase the chance that parents will follow discharge recommendations

CDC, PEDIATRICS Volume 133, Number 4, April 2014

Acute Concussion Evaluation

CDC

Management

• Evidenced-base management• PECARN Guidelines: • Indications for neuroimaging

• Radiation concerns

• Role of MRI

PECARN Study Children with Minor Head Trauma • Identify low risk group that does not need CT

• Rules developed prospectively on >33,000 children (<18yo) with GCS 14-15

• Validated on >9,000 children (25% <2yo)

• Outcomes – Clinically Important Brain Injury• Death (none)• Neurosurgical procedures (0.1%)• Intubated 24 hrs for TBI• 2 days in hospital (0.9%)

Pediatric Emergency Care Applied Research Network (PECARN) – Mild Head Injury Study.

Kupperermann al., The Lancet, Volume 374, Issue 9696, Pages 1160 - 1170, 3 October 2009

PECARN – Mild Head Trauma Predictors of CIBI < 2 yo

No CT Necessary if ALL are negative:

• Altered Mental Status / Not acting normal

• Scalp hematoma (frontal OK)

• LOC > 5 sec

• Palpable skull fracture

• Severe mechanism of injury• Fall > 3ft• Head struck by high impact object• MVC ejection, death of passenger, or rollover• MVC vs Peds or bicycle

Sensitivity 100%, NPV 99.9%

PECARN – Mild Head Trauma Predictors of CIBI > 2 yo

No CT Necessary if ALL are negative:

• Altered Mental Status / Not acting normal

• LOC

• Hx of vomiting

• Clinical signs of basilar skull fracture

• Severe headache

• Severe mechanism of injury• Fall > 5ft• Head struck by high impact object• MVC ejection, death of passenger, or rollover• MVC vs Peds or bicycle

Sensitivity 96.8%, NPV 99.5%

Estimated 650,00 Children/adolescents Annually with MBTI

• 90% with seemingly mild injuries

• 325,000 will have CT scans

• 90% of these scans are negative

CT Use in Children

• US is second only to Japan in per capita CT exams performed 

• 7 million CT studies annually performed in children

• CT are increasing approximately 10% per year  

• Approximately 50% of children who visit hospital ED with a head injury are given a CT scan

National Cancer Institute, AAP

Radiation Exposure RisksUnique Considerations in Children

• Children are considerably more sensitive to radiation than adults

• Children have a longer life expectancy than adults

• Radiation dose is accumulative over time

• Children may receive a higher radiation dose than necessary if CT settings are not adjusted for their smaller body size

Estimated Medical Radiation Doses for a 5 yo child

Imaging Modality Effective Dose (mSV) No of CXRs

3–view ankle XR 0.0015 1/14th

2–view CXR 0.02 1

AP & lateral abd XR 0.05 2.5

Head CT 4 200

Chest CT 3 150

Abdomen CT 5 250

Brody et al, Radiation Risk to Children From Computed Tomography, Pediatrics 2007;120;677

CT Imaging Summary

• Radiation is an essential component of medical imaging in the ED

• Experts agree there is a small lifetime risk that increases with increasing doses

• The amount of radiation dose from a CT depends on many factors, e.g. equipment, set up

• There is no known lowest radiation threshold for risk of cancer

• The potential benefit is greater than the risk for an indicated CT

MRI

• MRI avoid ionizing radiation

• For concussions, little diagnostic value in diagnosis

• Usually structural imaging are normal in concussions unless complicated by fractures, bleeds

Parental Choice• Parents of Children with Minor Head Trauma in

ED• If not told specifically of the risks of radiation,

90% of parents "very willing/willing" to proceed with head CT

• After disclosure, willingness decreased to 70% (p<.0001)

Boutis, Pediatrics 2013 August

• Observation vs CT• After reviewing the educational material on risks

and benefits, • 53 (40%) preferred immediate CT; • 77(57%) preferred observation; • 4(3%) did not indicate a preference Karpas, Pediatric Emergency Care, 2013 January

Recovery of Concussion

The majority (80–90%) of concussions resolve in a short (7–10 day) period,

although the recovery time frame may be longer in children and adolescents

British Journal of Sports MedicineConsensus Statement on Concussion in Sport

The 4th International Conference on Concussion in Sport Held in Zurich, November 2012

Recovery of Concussion

• Avoid the temptation to grade concussions

• The management of concussions must be individualized• Physical & Cognitive Rest• Graded return to activities

Cognitive Rest

• The cornerstone of concussion management

• Generally limit physical and mental activity for the first 3 to 5 days … then gradually increase as tolerated

• Newer research suggest: Do as much as you can without triggering your symptoms or without making them worse.

• Individualize (assess, adjust, monitor)

Brown et al., Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms, Pediatrics, Jan 2014

Neuropsychological Testing

• Long history of tracking recovery with NP test

• NP tests have the ability to detect cognitive changes in injured athletes

• There are mixed results of the diagnostic utility of NP testing immediately (<48hrs)

• NP test should not be used in isolation for diagnosis & decision to return to play

• Examples of NP testing include:• ImPACT, CogSport, HeadMinder, CRI

Sports-Related Concussions in Youth:Improving the Science, Changing the Culture (2014)National Academy Sciences publication

CDC“Head Up”

Concussion 101: A Primer for kids and parents

Case #115 yo – fall from horse

Patient wants to know if this is a severe concussion?

Avoid grading concussions

Mom wants to know about CT scan risk and if there are alternatives?

Medical radiation is a risk – risk vs benefit

No known lowest threshold for radiationObservation in some cases is an option

Case #216 mo - fall down stairs

Dad ask you if this is usual practice (CT Scans for mild head trauma)?

• EBM – PECARN guideline would NOT recommend CT in this case

• (No AMS, LOC >5sec, Palpable skull fx, Severe mechanism. Scalp hematoma OK)

Mom wants to know how often I should wake her up?

• Rest is important in concussion recovery. Waking children up after head injury is not recommended.

Case # 313 yo - hockey player

Dad tells coach his son will be at the game tomorrow. Coach agrees, sideline ACE was negative. Mom shakes her head. Who is right?

• Sideline ACE are helpful, but concussion symptoms can be delayed

• Patient should not return to play until eval by HC professional

What are recommendations for return to play?• Graduated return to play protocol

The Minnesota Legislature's "Concussion Law”

• All coaches (head and assistants) and officials receive concussion training and education by (9/2011) then at three-year intervals thereafter.

• Coaches must remove an athlete from activity if they exhibit signs, symptoms or behaviors consistent with a concussion and/or are suspected of sustaining a concussion.

• The law also requires an appropriate health care professional's signature to return to play if an athlete is removed due to a concussion or is showing signs or symptoms of a concussion

MN Senate: S.F. No. 612 - Establishing Youth Athletic Concussion Policies

Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport

Zurich, 2008

Br J Sports Med 2009;43(Suppl I):i76–i84. doi:10.1136/bjsm.2009.058248

Case #417 yo – HA after MVC

Are her symptoms worrisome?• Increasing HA (change in behavior, vomiting ) is always

a concern after a head injury

How do you explain cognitive rest?• Generally limit mental activity, e.g.

working on a computer, watching television, reading, playing video games, text messaging, and listening to loud music.

Mom wants a referral to a specialist• Know your local resources

5 - Take Home Points

• Concussions are a clinical diagnosis

• Use standardized guidelines• Acute Concussion Evaluation • PECARN – mild head injuries• CT – “image gently”

• Dispo: S&Sx to return, cognitive & physical rest, graded return to activity

• F/u is essential with PCP (or “Sports

Med/TBI/Concussion” clinic)

Additional Resources• CDC Concussion Education/Heads Up

http://www.cdc.gov/concussion/sports/

• NCAA Concussion Programhttp://www.ncaa.org/health-and-safety/medical-conditions/concussion-sports

• IOM Report: Sports-Related Concussions in Youth: Improving the Science, Changing the Culturehttp://www.iom.edu/Reports/2013/Sports-Related-Concussions-in-Youth-Improving-the-Science-Changing-the-Culture.aspx

• Mayo Clinichttp://www.mayoclinic.org

• Alliance for Radiation Safety in Pediatric Image Imaging (the Image Gently Alliance)http://imagegently.dnnstaging.com/

• A Hit on the Head and Where it Lead by Jennifer Therese Cooper-Trent (video)• https://www.youtube.com/watch?v=5ULz9biDayc

• Concussion 101: A Primer for kids and parents (video)• https://www.youtube.com/watch?v=zCCD52Pty4A

• Thomas Hellmich, MD email: hellmich.thomas@mayo.edu