Diagnosis and Management of Pediatric Concussions in the ED

EXECUTIVE SUMMARY

• Headache is the most commonly reported symptom of concussion, with immediate loss of consciousness occurring in < 10% of cases. Early symptoms of concussion may also include dizziness, amnesia to the event, confusion, nausea, and vomiting.
• Short-term predictors of prolonged symptoms 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.
• Regardless of age group, PECARN recommends a CT scan in any child who presents with a Glasgow Coma Scale < 15, altered mental status, signs of palpable or basilar skull fracture.
• 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.
• In children younger than 2 years of age, risk factors in which imaging should be considered include a nonfrontal scalp hematoma, abnormal activity according to the parents, or a severe mechanism of injury.

Head trauma is a common pediatric presentation in emergency departments (EDs). While traumatic brain injury can be a major cause of death and disability, most children have mild, non-life-threatening events. In recent years, there has been increased public awareness of mild traumatic brain injury, or “concussion,” and its sequelae in children. Children with a possible concussion frequently first present in the ED. Thus, its diagnosis, management, and aftercare are significant issues in the pediatric ED.

— Ann M. Dietrich, MD, FAAP

Definition

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.¹ Definitions for these three distinct entities can be found in Table 1. 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.² Acute symptomology is thought to be related to transient axonal injury, alteration in cerebral blood flow, metabolic derangement, and microstructural change.

Epidemiology

More than 600,000 cases of pediatric head trauma present to EDs annually.³ Males in early adolescence are at the highest risk for concussion. 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.⁴

Clinical Manifestations

Concussions cause a constellation of functional symptoms in the absence of structural damage. Symptoms can begin with the trauma or in the subsequent 24-48 hours and may evolve slowly over days to weeks. (See Table 3.) Headache is the most commonly reported symptom. Immediate loss of consciousness occurs in < 10% of cases. 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.⁵

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.³ A surprisingly large percentage of patients can have continued symptoms for months, which can result in a phenomenon known as post-concussive syndrome described later in this article.

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.⁶ Interestingly, family history of headaches or migraines is not a predictor identified in the literature.

ED Evaluation

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. 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.

Diagnosis — Ruling Out Clinically Important Brain Injury

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.⁷

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.⁸ The study population included a combined 42,412 children in the derivation and validation populations. Of note, 10,718 children were younger than 2 years of age. Clinically important traumatic brain injury was defined as brain injury resulting in any of the following: death from traumatic brain injury, brain injury requiring neurosurgical intervention, intubation for more than 24 hours for the brain injury, and/or hospital admission of at least 2 days. Figure 1 describes the PECARN algorithm. Children are divided into two categories: those between the ages of 2 and 18 years and those younger than 2 years of age. Regardless of age group, a CT scan is recommended in any child who presents with a Glasgow Coma Scale (GCS) < 15 (see Table 4), altered mental status, or signs of palpable or basilar skull fracture. Severe mechanism of injury is defined as a fall greater than the child's height (typically < 3 feet for children younger than 2 years of age and > 5 feet for children older than 2 years of age); a motor vehicle collision with ejection, rollover, or fatality; a bike/pedestrian vs vehicle accident in which the patient was not wearing a helmet; or being struck by a high-impact object.

Figure 1. PECARN Algorithm for Imaging Children with Head Trauma
Suggested Algorithm for Children Younger than Age 2 Years
Suggested Algorithm for Children Older than Age 2 Years
Adapted from: Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically important brain injuries after head trauma: A prospective cohort study. Lancet 2009;374:1160-1170.

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.⁹

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. The children’s head injury algorithm for the prediction of important clinical events (CHALICE) study identified 14 high-risk criteria for clinically important traumatic brain injury that indicate the need for further imaging. Criteria included witnessed loss of consciousness > 5 minutes, > 5 minutes of amnesia, abnormal drowsiness, more than three episodes of emesis, suspicion of non-accidental injury, seizure, GCS < 14, signs of basilar or depressed skull fracture, focal neurologic exam, or high-risk mechanism. Using these criteria, the group achieved a sensitivity of 98.6% and a specificity of 86.9%.¹⁰ Similarly, the Canadian Assessment of Tomography for Childhood (CATCH) study identified four high-risk factors and three medium-risk factors for clinically significant head injury in children. (See Table 6.) The high-risk features include a GCS < 15 at 2 hours after injury, suspected open or depressed skull fracture, worsening headache, or irritability. The medium-risk factors include signs of basal skull fracture, large boggy scalp hematoma, and mechanism of injury (motor vehicle collision, fall from elevation ≥ 3 ft or five stairs, fall from bicycle with no helmet). The high-risk features were 100% sensitive and 70.2% specific in detecting clinically important traumatic brain injury, while the medium-risk features were 98.1% sensitive and 50.1% specific.¹¹ However it is important to note that these rules have not been as well validated as the PECARN rule.¹²

Diagnosis of Concussion

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 Standardized Assessment of Concussion (SAC) and the Sport Concussion Assessment Tool 3 (SCAT3) are the most commonly used cognitive screens. 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 12-14 years. Furthermore, it should not be used in isolation to determine return to play.¹³

Endorsed by the Consensus Statement on Concussion in Sport in 2014, SCAT3 increasingly has been used. 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. For children younger than age 12 years, a Child SCAT3 has been developed.² Checklists for the SCAT3, Child SCAT3, and SAC assessments can be found online: (SAC/SCAT3: http://bjsm.bmj.com/content/47/5/259.full.pdf, accessed Sept. 2015; Child SCAT3: http://bjsm.bmj.com/content/47/5/263.full.pdf, accessed Sept. 2015).

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.

Disposition

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. Discharge instructions should outline strict return precautions, including inability to awaken the child, seizure, vomiting that begins 4-6 hours after the injury or continued vomiting, a change in mental status, or new unsteady gait or clumsiness/incoordination. 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.¹⁴ Follow-up with a physician or an athletic trainer should be arranged within 48 hours for symptom re-evaluation and initiation of progression to return to activity if appropriate.¹⁵

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 17,000 children in Canada with a normal CT or asymptomatic 6-hour observation period identified delayed clinically important traumatic brain injury in 0.03% of patients.¹⁶ Magnetic resonance imaging (MRI) can detect cerebral contusion, petechial hemorrhage, and white matter injury at a superior level to CT; however, its use in a child with a negative CT and without severe or focal symptoms is not recommended in the ED setting, as the management of the patient likely would not change based on the results. Rather, further imaging is best coordinated, if indicated, through the care of an outpatient physician evaluating the child.¹⁴ Care and reimaging should be managed in conjunction with parents and considering the entire clinical picture. It is not unreasonable to admit a patient with a negative head CT for observation, hydration, and management of symptoms.

Headache is a frequent complaint after blunt head trauma, and is of particular concern to parents, patients, and practitioners when it is persistent or worsening over time. However, if mild-to-moderate headache is the only symptom, even if the patient was not imaged initially (in accordance with PECARN guidelines), imaging studies are not generally indicated, as the risk of a clinically important traumatic brain injury is low. A recent prospective multicenter cohort of approximately 28,000 verbal children with minor head trauma found that there was no associated clinically important traumatic brain injury when headache was an isolated symptom.¹⁷

Generally, acetaminophen is the recommended medication for treatment of post-concussion headache. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided for at least the first 48-72 hours after a head injury. It is generally recommended to also avoid narcotics to prevent changes in mental status or neurologic exam. A retrospective study in adolescent patients with concussion demonstrated that overuse of analgesics may exacerbate concussion-related headaches or prolong their duration.¹⁸ Nausea is also a common problem associated with concussion, so using non-sedating antiemetics, such as ondansetron, can be helpful in both the immediate and outpatient setting. Vertiginous symptoms post trauma can be treated with meclizine. Patients with ongoing and/or severe symptoms may require vestibular rehabilitation for their vertigo, although this determination will need to be done as an outpatient by a primary care physician or a provider specializing in concussion.¹⁹

Some patients may be asymptomatic initially and develop symptoms hours after the head trauma. A 2014 study by Eisenberg et al showed that fatigue, sleep disturbance, forgetfulness, and frustration often developed within 1 week of the initial head trauma.²⁰ Thus, in the ED, it is important to set expectations for possible occurrence and follow-up of the above-mentioned delayed symptoms. For the majority of patients, symptoms resolve within 2 weeks of injury. However, during this recovery period, symptoms can be debilitating, with more than two-thirds of patients reporting continued headaches 1 week after the injury, and the majority complaining of dizziness, fatigue, and slower thinking.²⁰

During counseling, it is important to discuss potential complications and provide thorough instructions regarding physical and cognitive rest. Pediatric patients have a higher risk of prolonged post-concussive symptoms and recurrent concussion when there is premature return to cognitive and physical activity. Furthermore, there is evidence that pediatric patients take longer to recover from mild traumatic brain injury compared to adults.^21,22

Patients diagnosed with concussion should be told to avoid any resistance and aerobic activities, including returning to sports, for a minimum of 48 hours or until evaluated by a medical provider, particularly when concussion symptoms are ongoing. Recent evidence has suggested that light cardiovascular activity, initiated 48 hours after head injury, may shorten duration of symptoms.²³ Although children should be told to see their primary physician prior to return to play, emergency practitioners should be aware of the general recommendations of Return to Play protocols (see Table 7). Once athletes are asymptomatic and their SCAT3 scores are at baseline (if one is available), they may begin the Return to Play protocol and should spend a minimum of 24 hours at each step of the pathway. If symptoms recur at any step, the patient should return to the previous asymptomatic step and should only attempt to progress after remaining asymptomatic for 24 hours. The Return to Play protocol was developed for high school and college-aged athletes; in younger children, a more prolonged progression through the protocol should be considered.²⁴

Cognitive rest is a more controversial topic. Strict cognitive rest, including the absence from school and avoidance of screen time, social activities, video games, loud music, and reading, has been part of the primary treatment for pediatric concussion. However, a recent study demonstrated that strict cognitive rest was associated with more daily reported post-concussive symptoms during the 10 days of follow-up, with no differences in neurocognitive function.²³ Therefore, a more individualized approach to cognitive rest — in which patients are instructed to avoid mental activities that worsen symptoms, with close follow-up by their outpatient provider — may be prudent. Patients who continue to have symptoms beyond 2 weeks may warrant neuropsychological testing, further follow-up with a concussion specialist, and potentially further imaging (e.g., MRI) at the discretion of that provider.

Complications

The long-term effects of concussions in the pediatric population are not well understood given the lack of long-term prospective studies. Studies have shown that 3 months after concussion, 35% of children between the ages of 8 and 16 years complained of difficulty with concentration and memory.²⁵ Another study indicated that > 60% of pediatric patients reported a decline in grades for that term.²⁶

Post-concussion Syndrome. While there is no universally accepted definition for post-concussion syndrome, the DSM-IV defines it as 3 months duration of three or more of the following symptoms: fatigue, dizziness/vertigo, headache, personality or behavioral changes, anxiety or depression, or apathy. There is often a decline in school performance and difficulty in memory or attention.²⁷ (See Tables 8 and 9.) Post-concussion syndrome is a common sequelae of mild traumatic brain injury, with studies citing anywhere from 29-43% of patients experiencing symptoms including headaches, dizziness, neuropsychiatric symptoms, and cognitive impairment.^25,28 Risk factors for developing persistent post-concussive symptoms include older age, headache as the initial symptom, high initial level of symptomology, post-traumatic amnesia, loss of consciousness, and premorbid conditions including previous concussions, learning difficulties, and underlying psychiatric difficulties.^29,30 Children with presumptive post-concussion syndrome should be referred to a concussion specialist for further management, which may include neuropsychiatric testing.

Second Impact Syndrome. Second-impact syndrome is a rare condition in which the brain undergoes rapid and severe swelling. It occurs when a second head injury occurs before the symptoms associated with the initial injury have resolved. The pathophysiology is poorly understood, but it is thought to result from a loss of autoregulation, causing cerebral vascular congestion that can progress to severe cerebral edema.³¹ Interestingly, all reported cases have been in athletes younger than 20 years of age, leading to the conclusion that pediatric and adolescent athletes are at higher risk for this complication.

Summary

Concussion is a common presentation in the pediatric population. Patients and parents should be made aware that symptoms can persist for some time and that recovery time can vary. After ruling out clinically important traumatic brain injury, the emergency physician should treat symptoms, counsel patients about the need for close follow-up, and provide discharge instructions to not resume exacerbating cognitive or physical activities until evaluated by their outpatient provider.

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