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PEM Pearls: Pediatric Concussions

2017-10-26T14:34:13+00:00

pediatric concussions canstockphoto0691281A 9-year boy was hit in the head during a soccer game and was out for a few seconds. He regained consciousness quickly, but was repetitive for EMS. By the time the patient arrived at the ED, he was back to his normal self. Did this patient sustain a concussion? If so, what discharge instructions, anticipatory guidance, and resources do you have for your patient and his family? Here’s a quick 170-second animated video tutorial to sum up some thing for you.

Animated Video on Pediatric Concussions

Background about Pediatric Concussions

About 1.6-3.8 million sports-related concussions occur yearly and account for 10% of sports-related injuries with many of these children presenting to the ED after the accident.1,2 Boutis et al. found that ED physicians tend to under-diagnose concussions.3 Common post-concussive symptoms include any of the following symptoms:

  • Headache
  • Confusion
  • Inattentiveness
  • Photophobia
  • Nausea
  • Tiredness

The Zurich Consensus developed guidelines (Sports Concussion Assessment Tool) to assist providers in determining if a child has had a concussion.4

Patient and Family Education

Worried parents may be concerned about chronic brain injury and will want to know what are the next steps to protect their child. The current recommendations encourage both cognitive and physical rest, followed by graduated return to activity. However, it is unclear what is the optimal balance between rest and play. The Zurich Consensus recommends that children should not return to play on the same day.4 A randomized controlled study by Thomas et al. found that patients who had strict rest for 5 days had slower resolution of their symptoms compared to those who were allowed to have a more liberalized recovery plan. Furthermore, while both groups had comparable return times to physical activity, those in the strict rest group had longer emotional symptoms, such as depression, compared to those that were in the control group.5

While most ED physicians are well-versed in the initial evaluation of pediatric head injury, we may be less familiar with resources and recommendations for care after concussion. Several models have been created for individualized treatment plans that take a multidisciplinary approach. The CDC has a website, called Heads Up, which provides resources for parents, coaches and providers. The ED assessment tool, Acute Concussion Evaluation, can help ED doctors objectively evaluate the patient and provide an initial medical assessment that can be used comparatively at the follow-up pediatrician visit. There is also a useful printout for discharge instructions to provide to parents. The California Interscholastic Federation (CIF) provides informational sheets (available in Spanish) and a letter-to-school form.

The Center for Concussion in Colorado created an integrative model, REAP (Remove-Reduce/Educate/Adjust-Accommodate/Pace). This well-coordinated program includes the initial ED evaluation and educational handouts for parents, as well as linked communication between the follow-up clinic and school to notify them that a post-concussive student has been evaluated.2

Most patients with concussive symptoms will improve within 7-10 days, while a majority will be asymptomatic after 3 weeks. About 10% will continue to be symptomatic after 3 months.4 Follow up should be arranged within a few days for re-evaluation. Some patients may have delayed onset or worsening of symptoms, therefore, it is important to address parental expectations and review strict return precautions (eg. the worst headache in their life, focal neurologic deficits, seizures, and repetitive vomiting).

Returning to School

Children do not need to have complete resolution of symptoms prior to returning back to school, but it is important to excuse children from over-doing homework and/or to notify teachers that the child will need to take frequent breaks. Some non-contact light exercise can also help in persistent symptomatic cases, though this should be discussed with the pediatrician. The Zurich Consensus also created a Graduated Return-to-Play Protocol that can be used to as a guideline (Table 1). If at any point, the patient develops symptoms, then it is recommended to back off and rest. Most states have laws that mandate medical clearance to return back to sports.

Rehabilitation Stage Functional exercise at each stage of rehabilitation
1. No activity Symptom limited physical and cognitive rest
2. Light aerobic exercise Walking, swimming, stationary cycling, 70% of max heart rate
3. Sport-specific exercise Can do drills but no head impact activity (e.g. running drills in soccer)
4. Non-contact training drills More complex training drills (e.g. passing drills in football)
5. Full-contact practice Following medical clearance, can participate in normal training
6. Return to play Normal game play
Table 1. Graduated return to play protocol4

Bottom Line

While the pathophysiology of concussions are not well-understood, the detrimental effects on cognitive and physical recovery has been frequently noted if a patient sustains another head injury too soon, AKA “The 2nd Hit”! ED providers are frequently the first physicians to evaluate the patient and provide guidance to the family. It is safe for children to return to school and non-contact play in a graduated process. There are many programs or resources available on post-concussive care. Link patients to appropriate follow-up care after a concussion and remind them that they will need medical clearance to return to play.

Addendum (3/9/16): JAMA just recently published on March 8, 2016 a study by Pediatric Emergency Research Center Canada Concussion Team, that created a clinical risk score that attempts to stratify pediatric post-concussive patients that may be at higher risk for persistent post-concussive syndrome (PPCS).This prospective, multicenter Canadian study, looked at patients (age 5-18) who presented to the ED with head injury within 48 hours and met concussion diagnostic criteria consistent with the fourth Zurich consensus statement. They created a risk assessment tool, PPCS risk score which was better than the ED physician prediction of identifying patients at higher risk compared to lower risk of developing PPCS. While this study has not yet been validated, it may be helpful in the ED setting to identify high risk patients that should have closer follow-up, and better educate patients and family about what to expect in terms of their symptoms.

Check the article on JAMA @  Zemek, 2016

Image © Can Stock Photo

1.
Meehan W, Bachur R. The recommendation for rest following acute concussion. Pediatrics. 2015;135(2):362-363. [PubMed]
2.
Kirelik S, McAvoy K. Acute Concussion Management with Remove-Reduce/Educate/Adjust-Accommodate/Pace (REAP). J Emerg Med. 2016;50(2):320-324. [PubMed]
3.
Boutis K, Weerdenburg K, Koo E, Schneeweiss S, Zemek R. The diagnosis of concussion in a pediatric emergency department. J Pediatr. 2015;166(5):1214-1220.e1. [PubMed]
4.
McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on Concussion in Sport – The 4th International Conference on Concussion in Sport held in Zurich, November 2012. Phys Ther Sport. 2013;14(2):e1-e13. [PubMed]
5.
Thomas D, Apps J, Hoffmann R, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):213-223. [PubMed]
Delphine Huang, MD

Delphine Huang, MD

Resident
Department of Emegency Medicine (EM) UCSF-San Francisco General Hospital EM Residency Program
Steven Bin, MD

Steven Bin, MD

Associate Clinical Professor of Pediatrics and Emergency Medicine
Division of Pediatric Emergency Medicine
University of California, San Francisco
  • Tim Davie

    Great post, thank you. Forgive my ignorance, but does anyone have a good evidence-based resources that addresses the question of whether a child should be woken up periodically to ensure they are still “doing ok.” I’ve read in books and heard that this old recommendation has gone away, but would love to see a consensus guideline or primarily literature source addressing this. Thank you! (Tim Davie, Maricopa Medical Center, Phoenix, AZ, USA)

    • Steven Bin, MD

      I believe the concept of “wake them up periodically to ensure they are ok” is for the period of observation (first few hours) after a closed head injury when someone is also likely to be tired or sleepy. If the patient is being observed in the ED, even if they fall asleep, at some point prior to discharge they will be woken up to see how they are doing and ensure a normal mental status and to assess GCS.

      For children that fall into the PECARN intermediate risk group, if the child looks well during my initial ED evaluation, has isolated findings, parents are reliable, and it is early in the day, I ask the family if they prefer to observe their child in the comfort of their home vs. stay in the ED. In this situation, I go over strict return precautions and tell the family that if their child falls asleep, which is fine, they need to be woken up at the 4 hour post head bonk mark to ensure they are acting appropriately.

      After this observation period, either in the ED or at home (or after negative head imaging), there is little benefit of periodically waking a child up.

  • Delphine Huang

    Great question and it looks like there is not much evidence on this topic that I was able to find. I imagine that once a child is medically cleared after a concussion, they do not need to be observed longer or woken up.

    Talking with Dr. Senter who is a sports medicine doctor and concussion specialist at UCSF Concussion Clinic, she does not recommend waking up children post-concussion. Hope this helps!

    • Tim Davie

      Thank you Delphine (and thank you, Steven). I wonder if there have been any consensus statements or guidelines on the topic, even if not any primary literature. I think it’s intuitive that if a child is “sleeping” immediately after a head injury, it makes sense to make sure they’re awake for an assessment. The question I always get is whether the child needs to be woken up once they’re home sleeping. Thanks for input from you both.