This pediatric module is on pediatric concussion. Dr. Vova has no disclosures, except if you think his voice sounds high, it's because he isn't actually reading these. This is how children view themselves. They're superheroes. Nothing can happen to them. They will make crazy decisions because they never think that they can be injured or harmed. And when we grew up, most of us thought getting hit on the head wasn't really a big deal. You had to just get over it, get back to things that were going on. Fortunately, we've had a few changes over time and realized that concussions can cause significant problems, especially if you have more than one. Concussions are a very common diagnosis with millions of visits to the ER every year, many as a result of sporting events. And children are more vulnerable to having sequelae because their axons are not as well myelinated yet and they are more susceptible to chemical and metabolic changes. Concussions are now synonymous with mild traumatic brain injury, and they are generally diagnosed by a person reporting that they feel or function differently after having some type of force transmitted to their head either by direct contact or by a contracoup injury. It's important to note that you do not have to have a direct blow to the head to have sequela. A child who fell off of a chair or a teenager who got hit in the head during a soccer match would typically report symptoms of headache, confusion, disorientation, and irritability. They would have, by definition, had a loss of consciousness of less than 30 minutes. Lethargy, vomiting can occur, and in the worst scenario, a seizure. The three top causes of mild traumatic brain injury in children are motor vehicle accidents, falls, and sports. Falls account for about 44% and sports for about 40%. As you can see, football is the predominant cause of brain injuries, followed by girls soccer and girls basketball. Both outrank boys soccer and basketball in terms of creating injury, period. Pay attention. This chart is probably going to be a board question. Given the prevalence of soccer and football players in most schools, you can imagine that it would be a bit distressing to find out that almost three-fourths of kids that play sports have had a concussion previously. Unfortunately, they do not always get care immediately after because many do not realize that they have actually had a concussion or they have had previous concussions before and recovered without sequelae, so don't think it's that big of a deal. There are certain positions that are more likely to have difficulties, and while there have been advancements in helmets, these are still pretty dangerous for the underdeveloped brain. When screening patients who have had a concussion, it's important to ask whether they have had physical, cognitive, emotional, or sleep difficulties, the four main categories that are typical symptomatology. Ask if they've had a prior concussion because the effects can be cumulative, and find out if they have ADHD or some other learning disabilities in themselves or in their family that may predispose them to have a slower recovery. Attention deficit disorder or ADHD can also cause difficulties in terms of determining what may be related to a concussion and what may have already been present. When screening someone for concussion symptoms, it's important to consider the four major categories, physical, cognitive, emotional, and sleep. The history of prior concussion can exacerbate the symptoms of a current concussion, and the presence of ADHD can make the learning and attentional difficulties that the child may have already had even worse. It's important to get a good family history, a good past medical history from the patient, and look for any other factors that might slow their recovery. Where and how the concussion occurred is essential to know because you can have a higher risk for a subdural hematoma or a skull fracture if you fell further or harder or had a very focal injury versus a diffuse injury. The presence of post-traumatic seizures or a prolonged amnesia can also be significantly worse in terms of longer-term outcome, and other symptoms that they may report at this time from a legal perspective may be very important to document. Symptoms at the time of injury are variable, and they may not occur right away but may take a few days to occur. It's important to get a great developmental history because there are many things that can confound the diagnosis or the recovery from concussion. A prior history of migraines and headaches may prolong the occurrence of the post-concussive headaches, and a history of emotional or learning disabilities or attention difficulties can also make it difficult to discern what is premorbid and what is related to the concussion. These also can prolong the recovery if there are significant mental health or cognitive issues that make it more difficult for the child or teen to participate in therapeutic interventions. Symptoms tend to fall into these categories, and each should be discussed at each post-concussive visit. Physical symptoms are quite variable, and headache is probably the most common. Vision disturbances, whether when trying to track and reading a book or when driving and being sensitive to the bright lights coming toward them, can be very disabling. Sleep disturbances can also impact the attention and the ability to encode information at school the following day and need to be aggressively addressed. Many children with brain injury report problems at school in the weeks following their concussion. They may have difficulties with feeling fatigued and foggy, not knowing where they need to go to their next class, or not being able to find their books on time. They may be very distractible, have difficulty finding specific words, especially if they're on Topamax for headaches, and they may have difficulty organizing themselves where previously they did not. Multitasking and compiling volumes of information may be difficult for them, as well as sitting in front of a computer screen, which may visually be difficult, as well as having to attend to something that is not allowing them to get up and take a break. The most common emotional difficulties seem to be anxiety that they will not get better and irritability with emotional lability. A good general physiatric exam, including musculoskeletal issues, balance and coordination, short-term memory, and ability to interact socially as much to their prior personality as possible are important to define. A fundoscopic evaluation, as well as a good neurologic evaluation to look at cranial nerves, visual scanning, and any type of change in range of motion or spasticity are important. Coordination impacts every student's ability to learn and to get through their school day, and it affects balance and coordination as well. These are some tests that can be done quickly and easily in your clinic, and if there are any difficulties noted, typically a good occupational or physical therapist will be able to address these in therapy. Balance is also a big concern, especially for athletes. Romberg, tandem gait, and tandem stance can all be tested. There are at least two objective tools that can be used to assess balance in the clinic or on the sidelines, and physical therapists may have some advanced equipment to work on subtle changes in these areas for the more elite athlete. Deficits in cognition are probably the most concerning to patients and their parents. An in-office assessment can include a general cognitive screen, but school grades, teacher feedback, and family daily functioning should also determine whether neuropsychological testing needs to be done. The cognitive screening that can be done in the office is not often going to be able to pick up on subtle differences in processing time, but it will look particularly at concentration and attention. Neuropsychology screening is often done prior to sports participation so that you will be able to track if the child is having any more difficulties. The impact is one of the most common ones. It is also important to assess the overlay of the emotional impact of their concussion to their ability to learn. Formal neuropsychology testing by a PhD level pediatric neuropsychologist may be important if the patient has had prior learning or other disabilities, and it may be important if there are legal issues involved. It takes a lot of time and is expensive to do, so a screening test is typically most commonly done. Emergency rooms may do things differently, but the general recommendations are if there is a significant change in mental status, a palpable skull fracture, or a loss of conscious over five minutes, that a CT is done. If a child is less than three months of age, a CT is also done. Otherwise, serial exams with a return to home may be adequate. Signs requiring immediate medical evaluation would, of course, include significantly impaired cognition, loss of consciousness, repeated emesis, or worsening mental status. It's important to remember that a concussion may not be responsible for all the symptoms a patient is having. Even without a concussion, things like sleep deprivation, stimulant use, intense physical activity, and the stress of school exams, et cetera, can impact neuropsychology testing results and performance testing. Bed rest used to be the recommendation, but now brain rest for one to two days is what is suggested. This would mean that you would not return immediately to a classroom where you were supposed to read or pay attention to a computer for hours on end, as these are visually demanding tasks. You would not place yourself in a very stimulating, noisy environment where you have to try to filter out everything and concentrate. You would not return to play immediately, especially if you are continuing to have any type of cognitive or pain symptoms. We all know that our brains take us much farther in life than our athletic skills most likely will, so return to learn is a first priority. Teachers and counselors should be notified of the concussion so that they will be able to allow the teen or child to take a break during class to get up and move around so that they do not have to intensively concentrate for a long period of time. If they need to have a longer time to do assignments or exams or have preferential seating, those accommodations can be made. Usually, the child is dismissed from physical activity requirements until they have returned to cognitively normal. There is often a lot of anxiety after a concussive injury about being allowed to return to play, especially for higher level student athletes. It is well understood that prolonged bed rest is not a valuable thing to do anymore, but returning to a high contact environment is equally disastrous. Active rehabilitation in a low contact environment with a gradual return to play will take the benefits of exercise and cerebral blood flow and not the side effects of having exacerbated headaches or more difficulty with concentration that can lead to other injuries. Often some of the primary symptoms are vestibular and balance oriented and a physical therapist may need direction to look at coordination and balance testing, especially if their symptoms are not meeting a threshold of causing significant problems. Occupational therapists are very adept in cognitive and vision screening in most institutions and should be looking for the language and direction following tasks that a speech pathologist may also be addressing. Ocular motor and visual scanning is an area that they may have special expertise in as well, so going to a vision therapist or an ophthalmologist is not going to be perhaps as fruitful as going to the therapist. These are some simple examples of visual exercises that can be done at home that will help with some symptoms. Approximately a quarter of patients that have concussion will have some mood symptoms, including lability, aggression, and especially anxiety. These can impact their ability to concentrate at school and to re-enter sports activities. Sometimes medications can be helpful for the attention issues and medications for headache that are not in the narcotic category can also be helpful. There may be some word finding difficulties in particular with Topamax, so that should be used with a bit of caution. Impaired sleep can of course also cause cognitive difficulties, so that needs to be addressed as well as the depression that can come from having these changes occur at both at school and home in a busy teen's lifestyle. So return to regular activities needs to be graded with rest and light aerobic activities. Start a gradual return to non-contact play and then to full play practice and then to games. There are some adolescents that have a prolonged recovery and there are some specific demographics that can indicate this may occur. Often they are the older teens, specifically female, with a pre-morbid history of a prior TBI. They may have attention issues already, a history of headache and family stressors, and may have mood endocrine disorders or a lower socioeconomic status. Gender differences do exist in concussion. Females more frequently are concussed, have more neurologic symptoms with a delayed resolution, and it is unclear if this is hormonally based, core strength based, reporting bias, or simply because they did not complain as quickly initially. Second impact syndrome is a devastating syndrome caused when a second or third concussive injury after the first causes massive cerebral edema and increased ICP and can lead to death or significant brain injury. The initial injury caused brain dysregulation, which leads to the vascular engorgement, and the neurons are already vulnerable, so are more impacted. It is still unclear as to which patients are most susceptible to having this occur. The impact of pediatric concussive injuries can be devastating, and current research is focusing on ways to improve reaction time and visual issues so that you have the ability to avoid future injury, and also improving neck strength and head protection. It's important to remind all concussed patients that their brain is far more important than their physical sports and athletic ability is going to be in their future life, and that protecting their head, wearing helmets, playing non-contact sports, et cetera, is going to be far more helpful to them than the short-term benefits they may see from re-participating in a dangerous or concussive sport.

pediatric concussion

sports-related incidents

concussion symptoms

screening for concussion

treatment of pediatric concussions