Acute recognition and management of traumatic brain injury along the spectrum from mild to severe is essential in optimizing neurocognitive outcomes. Concussion is common following head trauma in children, and resulting symptoms can last for months if not diagnosed and managed properly. Emerging evidence and consensus demonstrate that a program of cognitive and physical activity with a graduated return to play, sport, and school may improve outcomes following concussion. “Return to Play” legislation for youth has been adopted by most states. Outcomes of patients with severe traumatic brain injury have improved.
Key points
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Head trauma and concussion are the cause of significant morbidity and mortality in childhood and are an important public health concern, increasing in incidence worldwide.
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Acute recognition and management of traumatic brain injury along the spectrum from mild to severe is essential in optimizing neurocognitive outcomes and preventing long-term sequelae in children.
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A thorough history and physical examination is the foundation for the acute diagnosis of head trauma, and has recently been incorporated into validated risk stratification to reduce unnecessary imaging and associated radiation and costs.
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Knowledge translation and widespread dissemination of these prediction rules for pediatric head trauma is the next step to obviate unnecessary computed tomography (CT) scans in children.
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Children with blunt head trauma and normal cranial CT results generally do not require hospitalization for neurologic observation.
Introduction
A 12-year-old boy is brought into the Emergency Department (ED) of the local community hospital by ambulance, following a rollover motor vehicle collision. The patient had a brief loss of consciousness and presents with mild headache and amnesia for the event. Emergency physicians order a computed tomography (CT) scan of the head. The head CT is normal, and the patient is discharged home and told to follow up with his pediatrician. One week later the child returns to school and complains of headache while playing basketball; he is removed from the field and brought to the ED by his parents, where a decision is made to obtain a head CT to rule out intracranial hemorrhage. The scenario described is not uncommon, despite emerging evidence and guidelines for imaging and concussion management for children with head trauma.
Traumatic brain injury (TBI) is an important public health concern in children. There are 1.4 million patients with TBI evaluated and discharged from EDs annually in the United States. Of these, nearly half are children or young adults younger than 19 years. This figure may represent the tip of the iceberg, as it is believed that up to 5 million patients incur TBI that is often neither recognized nor treated. The head is the most frequently injured area in a child, and the most common causes of TBI in the pediatric population are falls and motor vehicle collisions. TBI is also the most common cause of death following childhood injury. Football is the most common sport associated with TBI and with more than 1 million football players in the United States, many of whom are high school and collegiate players, it has evolved into an important area of national focus. Emergency physicians have become astute in the diagnosis of severe and moderate TBI. However, as described in the vignette for the 12-year-old patient, the evaluation and management of mild TBI (mTBI) is an area in need of knowledge translation.
This article discusses the general approach to pediatric head trauma, skull fracture, and TBI along the continuum from mild to severe. The focus is on updates to diagnostic and management modalities, including some of the most recent evidence-based medicine guidelines and research. The article begins with mTBI, as this is the area harboring the most advances in recognition and management.
Introduction
A 12-year-old boy is brought into the Emergency Department (ED) of the local community hospital by ambulance, following a rollover motor vehicle collision. The patient had a brief loss of consciousness and presents with mild headache and amnesia for the event. Emergency physicians order a computed tomography (CT) scan of the head. The head CT is normal, and the patient is discharged home and told to follow up with his pediatrician. One week later the child returns to school and complains of headache while playing basketball; he is removed from the field and brought to the ED by his parents, where a decision is made to obtain a head CT to rule out intracranial hemorrhage. The scenario described is not uncommon, despite emerging evidence and guidelines for imaging and concussion management for children with head trauma.
Traumatic brain injury (TBI) is an important public health concern in children. There are 1.4 million patients with TBI evaluated and discharged from EDs annually in the United States. Of these, nearly half are children or young adults younger than 19 years. This figure may represent the tip of the iceberg, as it is believed that up to 5 million patients incur TBI that is often neither recognized nor treated. The head is the most frequently injured area in a child, and the most common causes of TBI in the pediatric population are falls and motor vehicle collisions. TBI is also the most common cause of death following childhood injury. Football is the most common sport associated with TBI and with more than 1 million football players in the United States, many of whom are high school and collegiate players, it has evolved into an important area of national focus. Emergency physicians have become astute in the diagnosis of severe and moderate TBI. However, as described in the vignette for the 12-year-old patient, the evaluation and management of mild TBI (mTBI) is an area in need of knowledge translation.
This article discusses the general approach to pediatric head trauma, skull fracture, and TBI along the continuum from mild to severe. The focus is on updates to diagnostic and management modalities, including some of the most recent evidence-based medicine guidelines and research. The article begins with mTBI, as this is the area harboring the most advances in recognition and management.
Concussion/mild TBI
Description
The Centers for Disease Control and Prevention (CDC) use the term mTBI, which accounts for 88% to 92% of cases of TBI, interchangeably with the term concussion.
mTBI or concussion is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. mTBI is caused by a blow or jolt to the head that disrupts the function of the brain. mTBI results in a constellation of physical, cognitive, emotional and sleep-related symptoms. Duration of symptoms is variable and may last as long as several days, weeks, months or even longer in some cases.
This disturbance of brain function is typically associated with neurometabolic dysfunction with normal structural anatomy. The neurometabolic cascade following concussion consists of calcium influx, increase in glucose consumption, and increased metabolic demand.
Concussion can result in a variety of physical, cognitive, emotional, and sleep-related symptoms lasting from days to months. Table 1 lists these symptoms, including those most concerning, such as depression and anxiety. Unrecognized and poorly managed concussion can result in postconcussion syndrome, with duration of symptoms lasting beyond 2 weeks and up to several months. Research has demonstrated promise in early intervention and a program of graduated return to play, sport, and school work for youth with concussion.
| Physical | Cognitive | Emotional | Sleep |
|---|---|---|---|
| Headache Nausea Vomiting Balance problems Dizziness Visual problems Fatigue Sensitivity to light Sensitivity to noise Numbness Tingling | Feeling mentally foggy Feeling slowed down Difficulty concentrating Difficulty remembering | Irritability Sadness More emotional Nervousness | Drowsiness Sleeping less than usual Sleeping more than usual Trouble falling asleep |
Evaluation
The history and physical examination is the cornerstone of the diagnosis of concussion. Psychometrically validated concussion-screening tools based on the history and physical examination such as the Acute Concussion Evaluation (ACE) are effective, and have been coupled with management or “concussion care plans” available as head injury toolkits on the CDC Web site at http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html . A recent study found that very few EDs use any form of concussion screening in the evaluation of pediatric head trauma. It was noted that very few of the EDs surveyed had adequate patient education for the management of concussion. The CDC has established an effective Web site to make these concussion toolkits available to physicians, patients, parents, school personnel, and coaches, and has supported the work of investigators to adapt a previously psychometrically validated concussion-screening tool (the ACE) for use in the ED as the ACE-ED. Current work is ongoing to incorporate these concussion-screening tools into the electronic health record and normal workflow to initiate assessment of children with head trauma at the time of triage.
Sports Concussion
There are 1.1 million high school football players in the United States each year, of whom nearly 70,000 are diagnosed with concussion. However, it is widely believed that concussion is more prevalent in high school football. McCrea and colleagues found that although 30% of high school football players stated that they had a previous history of concussion, fewer than half had reported the injury. Reasons for failure to report concussions included lack of awareness that a concussion had been sustained and lack of understanding of the potentially serious nature of injury.
Recent media attention has focused on the fact that high school football players may be reluctant to report concussion because of fear of being removed from competition and loss of athletic scholarships http://www.npr.org/2012/08/07/158361384/love-of-sports-can-start-early-so-can-injuries .
Education of student athletes and parents on the impact of unrecognized and poorly managed concussion is extremely valuable, and should be a discussion the medical provider initiates at the time of the acute evaluation in the ED, at school, or on the field.
Legislation and Return-to-Play
Since 2009, 43 states and the District of Columbia have implemented legislation for concussion management in youth athletics with established return-to-play guidelines. If a student athlete is suspected to have a concussion, the athlete is removed from play and requires clearance, in most cases from a licensed medical professional, to return to play. The recommendation is for those on the sidelines such as coaches and athletic trainers to pull a child from the field when concussion is suspected and to have the player “sit it out, if in doubt.” The reasons for this proactive removal from play are to:
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Allow for healing
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Prevent “second-impact syndrome,” a serious diffuse axonal injury resulting in uncal herniation
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Prevent neurocognitive sequelae of reinjury
In addition to restrictions on physical activity, both the American Academy of Pediatrics and Zurich Consensus Statement on Concussion in Sport recommend limitation of scholastic and other cognitive activities for athletes following concussion ( Table 2 ).
| Restrictions | Return to Play | |
|---|---|---|
| Physical rest |
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| Cognitive rest |
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In addition, concussed players who continue to play are at increased risk of reinjury, have delayed symptom onset, and neuropsychological deficits.
Whereas prior return-to-play guidelines for concussion were based on static measures such as duration of loss of consciousness, current stepwise recommendations for return to play are individualized and include :
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Resolution of symptoms
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Return to baseline neurocognitive function
Subconcussive Injury
Talavage and colleagues were the first to present evidence of subconcussive injury in a cohort of high school football players. This prospective study using head-impact telemetry, neurocognitive testing, and functional magnetic resonance imaging uncovered functionally detected cognitive impairment in high school football players with repetitive head trauma, without clinically diagnosed concussion. This finding raises concern for athletes who suffer subconcussive impact, and highlights the need for safety regulations in high-impact sports.
Changes in Sports Regulation and Techniques
Student athletes participating in collision sports such as football may have as many as 2000 impacts to the head during the course of an athletic season. This fact is of particular concern, as high school football players appear to be more vulnerable and perform worse than collegiate athletes following concussion. Protracted recovery in high school players with concussion included prolonged memory dysfunction and worse performance on neuropsychological testing when compared with controls.
Helmets and mouth guards have not been shown to decrease rates of concussion, although helmets are effective in preventing skull fracture and more severe TBI. Ongoing research is aimed at understanding the mechanisms of injury and types of play most likely to result in head trauma during sport. Improving techniques for play and establishing regulation can decrease the rates of both head impact and concussion.
Chronic Traumatic Encephalopathy
The postmortem neuropathologic studies of McKee and colleagues on chronic traumatic encephalopathy (CTE) resulting from repetitive head trauma have gained widespread media attention. Blinded to the patient’s clinical history, McKee and colleagues have documented CTE and associated neuropathologic changes with tau-immunoreactive neurofibrillary tangles in the cortex, resulting in a progressive motor neuron disease. These changes have been noted in a series of professional and youth athletes and a host of others who have suffered repetitive head trauma. Table 3 lists some of the neuropathologic findings and symptoms associated with CTE.
| Neuropathologic Changes | Symptoms |
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Imaging
Nearly 700,000 children visit the ED for head trauma in the United States each year, most with mTBI. More than 300,000 cranial CTs are obtained to evaluate these children. Overall, a great deal of variation in practice exists in evaluation of mTBI with cranial CT. In addition, CT is not without associated cost and risk. Research on CT-radiation risk and extrapolated data from World War II atomic bomb survivors estimates that lifetime-attributable mortality from a single CT of the head in childhood is as high as 1 in 1200. More recently, Pearce and colleagues discovered a 3-fold increase in the risk of brain tumors following head CT (cumulative doses of 50–60 mGy to the brain). The study linked CT records for patients (birth to 22 years of age) in the British National Health Service to cancer registry data, and also found head CT to be the most common scan obtained in this cohort.
More than a decade ago, the National Cancer Institute and Food and Drug Administration disseminated a guide to physicians to minimize unnecessary CT scans in children. Despite this work, there was a dramatic increase in the use of CT scans for children over the past 2 decades.
Prediction Rules for Cranial CT after Head Trauma
In 2009, the Pediatric Emergency Care Applied Research Network (PECARN) published 2 validated prediction rules to identify children at very low risk of clinically important TBI (ciTBI), not in need of a CT scan. More than 40,000 children 0 to 18 years of age were prospectively enrolled in the PECARN study. Table 4 lists the two prediction rules, one for preverbal children (<2 years) and the other for verbal children (≥2 years). The PECARN prediction rules have excellent performance characteristics, and were derived by incorporating clinical findings that were readily available and had good interobserver reliability. If none of the 6 predictors in either prediction rule is present, the child is at very low risk of ciTBI, and CT can be avoided.
