emergency department evaluation of concussion (traumatic brain injury)

Emergency DepartmentEvaluation of Concussion(Traumatic Brain Injury)

Sylvia E Garcia, MDAssistant Professor

Pediatric Emergency MedicineIcahn School of Medicine

At Mount Sinai

Department of Emergency Medicine

Disclosures

I have no financial disclosures to report.


Deaths 7,000/yr

Hospitalizations

95,000/yrED Visits

> 500,000/yr

Primary Care Office VisitsAssume numerous, No data

- Hospital care costs alone exceed 1 billion/year- 29,000 permanent disabilities annually

60%↑ in ED visits in last 10 years

Pediatric Head Trauma

Goals and ObjectivesRecognize the importance of obtaining a

comprehensive history that identifies previous injury / concurrent medical conditions

Know the importance of assessing vestibular balance

Understand the role of neuroimaging in the evaluation of the concussed patient

Recognize the importance of clear discharge instructions


Recognition of Concussion


Comprehensive history Comprehensive history should include documentation of previous

• Closed head injuries / concussions• Depression / anxiety• Sleep disturbances• Learning disorders• Attention deficit disorders • Headaches ( migraines )


Physical Exam

ABCsC-spine immobilization as neededGCS determinationNeuroimaging as deemed necessary Detailed neurological evaluation


Assessment Tools

Acute Concussion Evaluation ( ACE )

Brain Injury Survey Questionnaire ( BISQ )

Sport Concussion Assessment Tool ( SCAT )• SCAT 3• Child SCAT 3


Assessment ToolsThe Brain Injury Survey Questionnaire ( BISQ ) is a

screening tool that assesses for: • Any unidentified previous TBI• Persistent symptoms associated with a previous TBI • Events and conditions other than TBI that can cause

similar symptoms

Parent and / or patient is given Part 1 of the BISQ


Cantor J et al. Arch Phys Med Rehabil 2004;85(4 Suppl2):S54-60

Assessment Tools The Sport Concussion Assessment Tool is a

standardized tool utilized in the evaluation of concussion in patients ≥ 5 yrs of age

Child- SCAT3 ( ages 5 -12yrs ) SCAT3 ( age ≥ 13 yrs )

• Cognitive assessment• Neck examination• Balance and coordination examinations• Delayed recall


Assessment Tools Balance exam assesses vestibular system • Double leg stance• Single leg stance• Tandem stance • Tandem gait • Scored by error or deviations from proper stance

Specific, not sensitive, indicator of concussion Postural deficits last ~72 hrs

3Harmon KG, Drezner JA, Gammons M, et al. Br J Sports Med 2013,47,15-26


Assessment Tools

There’s an App for thatSway Balance SystemTM for iOS devicesUses the built in motion sensor for cell phonePatient is given instruction for vestibular examsBegin test button is tapped when ready and the

device is held against the chest


Assessment Tools


Neuroimaging

Conventional brain CT or MRI is usually normal in concussive injury

Prevalence of an abnormal CT increases with decreasing GCS


• Penetrating injury• GCS ≤ 14 • Focal neurologic

abnormalities• Signs of depressed or

basilar skull fracture• Prolonged loss of

consciousness (> 1min)

, <

• Clinical deterioration or worsening symptoms

• Seizure ( other than impact seizure ) or prolonged seizure

• Pre-existing condition increasing risk for bleeding


Jeff E. Schunk, Sara A. Schutzman. Pediatric Head Injury. Pediatrics in Review, Volume 33, Number 9 (September 2012), pp. 398-411

Emergent Head CT

Neuroimaging

Neuroimaging

The Pediatric Emergency Care Applied Research Network ( PECARN ) study identified children at very low risk for clinically important TBI after head trauma for whom CT scan is unnecessary


Kupperman et al. Lancet 2009;374:1160-70

Neuroimaging : PECARN Study

Children up to age 18 yrs old were enrolledAll subjects were seen within 24 hours GCS recorded was 14 – 15Preverbal ( ≤2 yo ) and verbal ( ≥2 yo )

groups were analyzed separately



PECARN Imaging Guidelines > 2yo



Neuroimaging The prediction rule for children ≥ 2 yrs had a

negative predictive value of 99.95% and sensitivity of 96.8%

• Normal mental status• No loss of consciousness• No vomiting• Non-severe injury mechanism • No sign of basilar skull fracture• No severe headache• No high-risk mechanism



Management Medications• Tylenol or Ibuprofen for headaches• Avoid drugs that can alter mental status • Anti-nausea medications used with caution• No medications for sleep, mood or attention

disturbances• Meclizine can affect cognitive function


Discharge Instructions Instructions should be clear on what to expect

after diagnosis of concussion Monitor for 24 – 48 hours No need for periodic awakening Majority of symptoms improve / resolve in 7 days


Discharge Instructions Patients should return to the ED • Worsening headaches • Increased drowsiness / not able to be awoken• Repeated emesis• Unusual behavior or seem confused or irritable• Seizures• Weakness or numbness in arms / legs• Unsteadiness• Slurred speech


Discharge and Follow-up Rest / sleep Avoiding activities requiring concentration Avoid strenuous activities No alcohol No sleeping pills No driving or play until cleared


Discharge Instructions Return to learn before return to play

School should be made aware of the need for reduced workload, frequent rest periods, extended time to complete tests or complicated tasks


Discharge and Follow-up No one should be cleared to ‘return to

play’ from the ED

Excuse should be given for delayed return to school / work


Summary Review past history for previous injury and

conditions that may exacerbate recovery

Motor domain of neurological function can be reliably assessed by vestibular balance testing

CT scan is rarely necessary

Discharge instructions should clearly outline expectations, and indications for follow-up


Summary

Patients should be reassessed by a physician in 3 to 5 days

Follow-up with a specialist if no improvement or recovery noted within 5 to 7 days


Play Safe

1-800-283-8481


emergency department evaluation of concussion (traumatic brain injury)

Documents

previous tbi events

child scat

standardized tool

screening tool

yrs scat3 age

yrs of age child scat3

vestibular balanceunderstand

yred visits