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Management of Concussions in Children – the ED approach

Management of Concussions in Children – the ED approach. Sujit Iyer, M.D. DCMC Emergency Department. 5 major features of a concussion. D irect blow to the head, face, or neck or elsewhere on the body with an “impulsive” force transmitted to the head

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Management of Concussions in Children – the ED approach

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  1. Management of Concussions in Children – the ED approach Sujit Iyer, M.D. DCMC Emergency Department

  2. 5 major features of a concussion • Direct blow to the head, face, or neck or elsewhere on the body with an “impulsive” force transmitted to the head • Rapid onset of short-lived impairment of neurologic function that resolves spontaneously • May result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury • Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness (LOC). • No abnormality on standard structural neuroimaging studies is seen in concussion

  3. Why does it happen? • Acceleration, deceleration and rotational forces to brain • Neuronal membrane damage and release of free radicals and excitatory transmitters may contribute to neuronal injury

  4. What are signs of a concussion? • Physical – headache, most common of all symptoms • LOC occurs in less than 10% • Nausea, vomiting, balance, fatigue, photophobia, dazed • Cognitive • fogginess, decrease concentration, forgetfulness, answer questions slowly, etc. • Emotional • Irritable, sadness, nervousness • Sleep disturbances

  5. Shouldn’t we grade the concussion? • There are more than 25 concussion grading scales • These have not been found to helpful in prediction and delineation was not found to be useful in management • SYMPTOMS are the key in guiding return to play recommendations

  6. Assessing a concussion – AT THE SCENE • ABCs – Airway, Breathing, Circulation AND C-Spine immobilization • Consider no c-spine immobilization if no LOC, no neck pain and moving all 4 extremities with no symptoms • “Sideline tests” – BESS, SCAT2, Maddocks questions • See references

  7. Assessing a concussion – AT THE SCENE • Anyone identified as having a concussion during game • DOES NOT return to the game • Goes to the ED if: • Condition deteriorates • Has continued vomiting • Unsteady gait, slurred speech • Increasing headache • Signs of skull fracture • GCS < 15

  8. Assessing concussions in the ED • Neuroimaging usually normal. May need imaging if : • Continued vomiting • Seizures • Slurred speech, abnormal gait • Focal neuro findings • Poor orientation to person, events • Neck Pain • LOC > 30 seconds

  9. Advice for Management for Parents • Medication • Consider NSAIDS and acetaminophen for continued headache, sleep problems, or trouble concentrating • Before returning to play athlete must be symptom free OFF MEDICATION • Need for continued medication indicates incomplete recovery

  10. Advice for Management for Parents • Cognitive rest • Must tell them that they will get MORE symptoms with cognitive activities (homework, class, any reading) – this is a FUNCTIONAL not structural injury – so using your brain may cause more symptoms! • Rest may include: • Absence from school • Decrease school workload • More time to complete assignments

  11. Advice for Management for Parents • Physical rest • Broad restriction of physical activity while still symptomatic • Includes sport that caused it AND • Weight training • Cardiovascular activity • PE Classes

  12. Return to Play • No teenage or child should return to the same game • Every child’s recovery will be different • “When in doubt, sit them out!” – good guideline • Nobody should return to play when having symptoms at rest or with exertion • Younger children may take up to 7-10 days longer to recover than older athletes

  13. Concussion Rehabilitation • Graded, stepwise approach to return to play • Endorsed by Academy of Sports Medicine and international experts • Each step takes at least 24 hours • Should take a minimum of 5 days to progress through protocol and return to play if no symptoms return • If symptoms return during protocol, must be asymptomatic again for 24 hours before attempting previous step

  14. Concusion Rehabilitation

  15. Complications • Long Term Effects – still more research needed • IF 3 or > concussions more likely to have LOC, amnesia, confusion • Athletes with 2 or > concussions had lower GPAs then similar students without concussions • Second Impact Syndrome • Second head injury occurs before symptoms of first injury have cleared • Get cerebral congestion, edema and then DEATH • All reported cases have occurred in kids < 20 years old

  16. Post Concussion Syndrome • Many different definitions • Simple one: • Cognitive, physical or emotional symptoms lasting longer than expected – usual threshold of at least 1-6 weeks of persistent symptoms after initial concussion • AT DCMC can refer to Dr Reardon – Tell them when they call to schedule them for a concussion clinic follow up from the ED.

  17. References for Coaches and Parents “Heads Up” – a toolkit developed by the CDC for coaches, teachers, counselors and physicians http://www.cdc.gov/concussion/HeadsUp/youth.html

  18. YOU’RE NOT DONE! • Please click on the following link to receive full credit for this module: • https://www.surveymonkey.com/s/739QPK6

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