management of concussions in children – the ed approach
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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 - PowerPoint PPT PresentationTRANSCRIPT
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Management of Concussions in Children – the ED approach
Sujit Iyer, M.D.DCMC Emergency Department
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5 major features of a concussion1. Direct blow to the head, face, or neck or elsewhere on the
body with an “impulsive” force transmitted to the head2. Rapid onset of short-lived impairment of neurologic
function that resolves spontaneously3. May result in neuropathological changes, but the acute
clinical symptoms largely reflect a functional disturbance rather than a structural injury
4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness (LOC).
5. No abnormality on standard structural neuroimaging studies is seen in concussion
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Concusion Rehabilitation
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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
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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.
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References for Coaches and Parents“Heads Up” – a toolkit developed by the CDC for
coaches, teachers, counselors and physicianshttp://www.cdc.gov/concussion/HeadsUp/youth.html
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YOU’RE NOT DONE!
• Please click on the following link to receive full credit for this module:
• https://www.surveymonkey.com/s/739QPK6