Dallas, Texas

Pediatric Concussions: Not a

Straight Forward Picture!

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Britney Cox, MS, RN, CPNP

Dallas, Texas

65% of all Concussions happen

between the ages of 5-18 years old

Dallas, Texas

Objectives

• What is a Concussion?

• How to diagnose a concussion in the pediatric patient

• Warnings, Red Flags, ED and Scans

• Management of a Concussion

• Returning to Life

• Not fitting the picture: Post Concussive Syndrome

• Our Role

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What is a Concussion

• Is it a Traumatic Brain Injury?

• The definition is “a complex pathophysiological process

affecting the brain induced by traumatic biomechanical forces”

• Caused by a direct blow to the head, face or neck or anywhere

on the body with an “impulsive” force transmitted to the head

• Acute symptoms reflect a functional disturbance not structural

injury

• Rapid onset of short-lived impairment of neurologic function

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Concussion Pathophysiology

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Symptoms of a Concussion

• Symptoms involve cognitive, physical, emotional and sleep related

problems

• Duration of symptoms can be minutes to years (average 2-3 weeks)

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Cognitive/Mental

Status: Inattention

Slowed Thinking

Amnesia

Confusion

Disorientation

Vacant stare

Loss of Consciousness

Physical: Headache

Nausea/vomiting

Photophobia

Phonophobia

Dizziness

Slurred Speech

Blurred Vision

Incoordination

Emotional: Emotionally unpredictable

Depression

Anxiety

Mania

Sleep: Difficulty falling

asleep

Frequent waking

Inc. sleep time

Dec. sleep time

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Who’s more prone to a Concussion?

Young Children

The developing brain is at more risk for injury

than the adult brain. -Smaller overall body

size

-Smaller neck and

shoulder muscle mass

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Who’s more prone to a Concussion?

Females

Studies show that girls have higher concussion rates

than boys

in similar sports!

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Who is Most At Risk?

• Girls > Boys

• Higher level of sport

• College>High school

• Competition > Practice

• History of Prior Concussion

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BOYS- Highest Risk Sports

-Football

-Ice Hockey

-Lacrosse

-Soccer

-Wrestling

-Basketball

GIRLS- Highest Risk Sports

-Soccer

-Ice Hockey

-Lacrosse

-Basketball

-Field Hockey

-Softball

-Gymnastics

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American Academy of Neurology

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Diagnosis: Assess the Background Information

• Assess the mechanism of injury

• Area of head and any other injuries noted

• Focus on immediate symptoms: loss of

consciousness, vomiting, memory loss, etc.

• Side line or Immediate assessment

• Prior Medical Triage and Treatments

• Current Symptoms

• Current school functioning and current activity

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How do you assess the patient?

THINKING EYES BALANCE

Symptom Checklist

Diagnosis: Use your Tools

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Acute Concussion Evaluation (CDC Heads-UP)

Diagnosis: ACE Symptom Checklist

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SCAT3 Assessment Tool

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Standardized Assessment of

Concussion (SAC) 4

Orientation (1 point for each correct answer)

• What month is it? 0 1

• What is the date today? 0 1

• What is the day of the week? 0 1

• What year is it? 0 1

• What time is it right now? (within 1 hour) 0 1

Immediate memory

• List Trial 1 Trial 2 Trial 3 Alternative word list

• elbow ,candle, baby, finger

Concentration: Digits Backward

• List Trial 1 Alternative digit list

• 4-9-3

• 0 1 6-2-9

• 5-2-6 4-1-5

• 3-8-1-4 0 1

• Total of 4/4

Concentration: Month in Reverse Order (1 pt. for entire sequence correct)

• Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan 0 1

• Delayed Recall: Repeat words

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• Attention span

• Working memory

• Sustained and selective attention time

• Response variability

• Non-verbal problem solving

• Reaction time

IMPACT testing Immediate Post-Concussion Assessment and

Cognitive Testing

Baseline Concussion Computer Testing

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Concussion affects the visual system in many

ways.

1. Basic eye exam and a few expanded

maneuvers needed

2. A good exam will help prevent missing

important problems…and it will help prove to

the patient they may have a problem

Eye Function Assessment

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1. Examine the eyes at rest

2. Examine the eyes with movement

3. Examine the eyes in the light or dark

4. Notice the eyelid

5. Notice peripheral field

6. Fundoscopic if able

7. Visual acuity

Eye Function Assessment

6th Nerve Palsy

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Extra eye concussion testing:

1. Smooth pursuit: “Follow my finger”

2. Saccades: “Move your eyes back and forth

and look at my held up fingers”

3. Vestibulocular: “Move your head back and

forth while looking at my thumb”

Abnormal response: poor performance,

symptoms occur with maneuver, eyes tear

Eye Function Assessment

Expanded

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Eye Function Assessment:

KING DEVICK

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• Cerebellar and vestibular dysfunction are

commonly seen in patients with concussion.

• Basic Balance Assessments: – Observe patient’s gait for any abnormal

movements

– Basic Romberg Test

– One legged stance

– Then tandem gait

Balance Basics

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Balance Basic

BESS: Balance Error Scoring System

Postural Stability

Flat and 10cm foam

20 seconds each

Count errors to score

Eyes opening

Movement

Hands off hips

Affected by environment

Test after 15 minutes

Footwear

Surfaces

Some rater reliability issues

Some practice effect noted

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Red Flags: Warnings

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Side Line Assessment: Indications for EMS

Glasgow Coma Scale less than 15 (eyes, verbal, motor)

Deteriorating Mental Status

Potential Spinal Injury

Progressive, worsening symptoms or new neurologic signs

Secondary Assessment:

Situational worsening vs. consistent worsening

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Who Needs to Be Imaged?

• Acutely Consider a Scan:

– loss of consciousness, seizure, post traumatic amnesia,

Persistently altered mental status, focal deficit on exam,

evidence of skull fracture, signs of clinical deterioration.

• After 24-48 hours: confusion, increasing sleepiness,

progressive headaches, suspected skull fracture, cranial

nerve injury, focal exam

• Weeks/Months after injury: specific cranial nerve injuries,

prolonged post concussive syndrome, failure to recover

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Choice of Neuroimaging

CT scan should be used in the

Emergency room setting to rule

out serious injury such as

bleed or skull fracture

MRI should be used in the

non-emergent setting for a

more detailed study

CT vs MRI

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Scientific advances

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Not concussion

Other explanation

exist to explain symptoms

Other explanation exists for

clinical exam findings

Event not witnessed

Concussion

Post-Concussion Syndrome

Persistent Symptoms

Cannot progress through recovery phases

Making the Picture More Clear…

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How do you treat the patient?

THINKING EYES BALANCE

Management and Treatment Plan

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Home

Rest

Low stimulation

75% restriction screen time

Gain ability to function at home

Gain ability to do basic reading

Medical

Get evaluated

Sleep: Melatonin or Pain control

Headache: OTC meds

Decide about therapies

School

Typically can't tolerate environment

Call school and inform them of

absence

Ask school to medically excuse nonessential work

Ask student to work up tolerance to 1 hour

sustained study

Play

Rest

Gain ability to tolerate walking 15 minutes

No Recess

No Back to play Protocol release

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Home

Provide more rest and quiet

Limit “extra” stimulation activities

(sleepovers, etc)

Support student and expect frustration

Medical

May be able to tolerate therapies

better

Weaning off of medications

School

Begin at 50% Load

Rest breaks during day and work in

quiet environment

Student may need counselor support

Complete at 100% load and previous

Play

Stay out of high sun and heat

Limited Recess/PE

No Back to play Protocol release

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Home

Rest

Should be able to do chores!

Medical

Should be off of symptomatic

treatments

Pain control ok

Therapies

School

Should be able to tolerate full

load at previous capacity

Continue with counselor support

Play

PE/Recess ok as tolerated

Ok Back to play Protocol

release

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Not fitting the picture: Prolonged recovery and Post Concussion Syndrome

Risk Factors for

Prolonged Recovery:

- Hx of prior concussions

- Younger age

- Headache

- Fogginess, Dizziness

- At time of accident:

Loss of consciousness,

post-traumatic

amnesia, or > 5 minute

alteration in mental

status

- Hx of prior headaches

or migraines

- Hx of learning disability

or mental health dx

- Family Dynamic

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Post-Concussion Syndrome

• Up to 15% of concussions can be associated with persistent symptoms

• Diagnosis of PCS should be considered with symptoms lasting > 3 weeks

• Symptoms may be prominent in one area or a blend of all four areas. “Sub categories”

• Unusual to develop symptoms that were not present with the original concussion

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Cognitive Mood Sleep Physical

Symptoms of

Post Concussion Syndrome

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1. Immediate headache at time of concussion is an important

marker for prolonged recovery

2. Focal head or skull pain can be associated with skull

fracture

3. Immediate or progressive headaches are worrisome in the

acute and sub-acute phases for progressive problems

4. Undertreated headache symptoms often prolong recovery

5. When post-traumatic headache is being evaluated, often the

neck is overlooked

6. Chronic post-concussion syndrome

often has similar symptomatology

as migraine

Headache

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Why the Push To Educate on Concussions

The brains of our children are precious, they are

our future! It is our job to help protect them!

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Why the Push To Educate on Concussions

Serious Complications:

• Second Impact Syndrome (SIS):

• Rare, all cases under 18, results in death

• No cases in NFL/NHL/MLB

• Documented ongoing symptoms until 2nd impact

• Witnessed 2nd impact followed by rapid deterioration

• Evidence of cerebral swelling without other cause

Long term effects

• Research

• Media

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Texas Law

On June 20, 2010, Texas governor Rick Perry signed into law the state's youth sports concussion safety law. Named Natasha's Law after Natasha Helmick, a moving force behind the law.

The law states:

Students must be removed from a practice or competition immediately if one of the following persons believes the student might have sustained a concussion:

A coach; A physician; a licensed health care professional; or

the student's parent or guardian (Note: Texas joins Arizona as one of only two states that give an athlete's parent the right to remove him or her from a game if they suspect a concussion).

Oversight committee- Helps to establish guidance for the district to follow the Texas law.

Released to Play Again – Must be released by licensed provider.

The return to play rules and guidelines must be detailed.

The student and the parents must sign off that they agree with

the return to play plan.

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Your Role

•Advocate for the student’s wellbeing

•Be knowledgeable about the law

•Recognize the symptoms of

concussion

•Work along with your concussion

oversight team

•Education parents on proper treatment

•Follow providers requested accommodations

•Offer understanding to students with concussions

•Recommend an evaluation from a concussion specialist

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Resources for You!!!!

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References:

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American Academy of Neurology website, www.aan.com/practice/sports-concussion-toolkit/

CDC Website Heads Up Program

Consensus Statement on Concussion in Sport-the 4th International Conference on Concussion in Sport Clin J Sport Med vol 23, 2,

March 2013

Giza, Christopher “Pediatric Issues in Sports Concussions” Continuum 2014; 20(6) 1570-1587

Giza, Christopher and Kutcher, Jeffery “An Introduction to Sports Concussions” Continuum 2014; 20(6) 1545-1551

Giza, Christopher and Kutcher, Jeffery “Sports Concussion Diagnosis and Management” 2014 Continuum 20(6) 1552-1569

Gioia, Gerard; Grady, Matthew; Leddy, John; Master, Christina “Importance of ‘Return-to-Learn’ in Pediatric and Adolescent

Concussion” Pediatric Annuals 41:9, September 2012

Halstead, Mark E., Walter, Kevin D., and The Council on Sports Medicine and Fitness “Sports Related Concussion in Children and

Adolescents” Pediatrics 2010; 126(3) 597-615

Malhotra, Raman “Legal Issues of Return to Play after a Concussion” Continuum 20(6) 1688-1691

Texas Education Agency, “Traumatic Brain Injury Resource Document: Re-Entry of Students with a TBI to the School Setting”

February 2012