Monday, March 26, 2012
Mark Meredith, MD
You’re covering a local high school football game when you witness a 16-year-old male get tackled after catching the ball and getting “blindsided.” He is slow to move but staggers to his feet. He appears confused and runs to the opposing team’s huddle, at which time the referee stops the game. You’re called to assess him on the sideline. What tools do you have to evaluate this patient, and how do you decide if they’re safe to return to the game? Does this patient need transport to the hospital?
When a football player has been knocked out and isn’t moving on the field, most EMS protocols recommend full immobilization and transport to the hospital. Over the years, however, the case of the player who is briefly knocked out or even dazed but is now awake and moving around has become tougher to manage. Even as late as 10 years ago, it wasn’t uncommon for patients who were diagnosed with a mild concussion to be returned to the game as soon as 15 minutes after their symptoms cleared. Research into concussions has shown that this isn’t in the best interest of the patient.
Although a clear definition of concussion has been difficult for EMS providers to agree on, most researchers agree that the terms “concussion” and “mild traumatic brain injury” can be used interchangeably. When a patient sustains a head injury and bleeding is noted on their computed tomography (CT) scan, it’s easy to say that the patient has a traumatic brain injury (TBI). A patient no longer has to have an intracranial bleed, such as a subdural or epidural hematoma, to be considered to have a TBI. However, a recent study highlighted the general misconception that a concussion is less severe than a mild traumatic brain injury, thus possibly resulting in the patient returning to school and activity prematurely.1
An international symposium on sports concussions was held in Zurich in 2008. Attendees at that conference defined a concussion as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” and includes five major features:
1. Concussion may be caused either by a direct blow to the head, face or neck or elsewhere on the body with an “impulsive” force transmitted to the head.
2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves itself spontaneously.
3. Concussion may result in neuropathological changes, but the acute clinical symptoms 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). Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it’s important to note that post-concussive symptoms may be prolonged in a small percentage of cases.
5. No abnormality on standard structural neuroimaging studies is seen
Over the years, different groups have tried to grade concussions based on varying patient conditions that include loss of consciousness, amnesia and confusion. More than 25 different grading systems try to define the severity of the concussion and the subsequent return to play. These grading systems have been abandoned because they’re arbitrary and not useful as a whole.
The diagnosis of concussion or TBI in pediatric patients is becoming more common in emergency departments (EDs) and physician offices across the country. It’s estimated more than 300,000 sports-related concussions occur each year. But a recent review noted that there may be upwards of 3.8 million recreation- and sport-related concussion annually.3 One report estimates that 8.9% of all high school athletic injuries are concussions.
In 2009, 250,000 children who were transported to EDs were diagnosed with a TBI.4 An especially big increase in this diagnosis happened in 2008–2009, probably correlating with increased public awareness. The Centers for Disease Control and Prevention (CDC) started the Heads Up: Concussion in Youth Sports awareness campaign in 2003 that mainly targeted physicians. During the past few years, that program has been expanded to coaches and school officials as well. Other organizations, such as the National Football League (NFL), have also come out with educational tools and advertisements discussing the importance of recognizing patients with concussions.
High-profile cases, such as the lawsuit by former NFL players, including Hall of Fame running back Tony Dorsett, against the NFL and helmet-maker Riddell, have helped highlight the problems some athletes face when they sustain multiple concussions over their lifetime. During the past two years, concussion management of starting quarterbacks Colt McCoy and Aaron Rodgers has been front and center in the news because they’ve been kept out of important games because of their head injuries.
Incidence & Causes
In October 2011, the CDC published a study on the incidence of pediatric concussions. It included data from 66 hospital EDs on children less than 19 years old who suffered non-fatal TBIs from 2001–2009.
Of these patients, 70% were boys and 70% were 10–19 years old. Younger children were more likely to be injured on playgrounds and in bicycle crashes. Older children were more likely to be injured playing sports, with football being the leading source for boys. Older girls were more likely to have brain injuries from biking, soccer and basketball.
Even though the total number of TBI cases has increased from 153,000 in 2001 to nearly 250,000 in 2009, the number of admissions hasn’t increased. This shows that more parents and coaches were concerned about children with mild concussions and blows to the head, which resulted in more visits to the ED. This is probably secondary to increased awareness rather than an increase in the number of head injuries.2
Another interesting study published in the November 2011 issue of Pediatrics suggested a physiologic cause for the patient’s symptoms after a head injury.5 In the article, the authors showed that pediatric patients suffering from a concussion had alterations in the cerebral blood flow.
They recruited patients aged 11–15 years old who had suffered a concussion and put them through computerized neurocognitive testing that assesses different cognitive factors and reaction time, called immediate post-concussion assessment and cognitive testing (ImPACT), and multiple imaging modalities less than 72 hours after injury. They also tested them at 14 days and 30 days or greater after onset of concussion. They then compared them to patients who had not suffered a concussion.
There were statistically significant differences in initial total symptoms score and reaction time between the concussion group and the control group. At 14 days, the difference had resolved in regard to total symptom score, but it took 30 days for the reaction time difference to resolve. Cerebral blood flow was also affected in the concussion group, yet no structural injuries were noted on any of these patients. Only 27% of concussion participants had their cerebral blood flow improved toward control values by 14 days, and only 64% at more than 30 days. This shows that pediatric sports-related concussion is primarily a physiologic injury and further study is needed to explain patterns of recovery.
With so many head injuries occurring, how is the field provider to know who needs to be seen immediately and who is safe for discharge home? The 2008 Zurich statement concluded that the suspected diagnosis of concussion can include one or more of the following clinical domains (see Table 1, above):
>> Physical signs: Loss of consciousness or amnesia;
>> Behavioral changes: Irritability;
>> Cognitive impairment: Slowed reaction times; and
>> Sleep disturbance: Drowsiness.2
If one or more of these components is present, a concussion should be suspected. Be aware that loss of consciousness occurs in less than 10% of concussions.
To help further evaluate the patient for a concussion, this group developed the Sport Concussion Assessment Tool 2 (SCAT2), a 22-point symptom checklist that could be used by any provider, from athletic trainers to EMS and ED personnel, when evaluating a patient who’s 10 years old or older for concussion. The SCAT2 checklist is partially completed by the patient to evaluate the patient’s symptoms.
After the patient fills out the SCAT2 checklist, a trained professional then tests their balance and cognitive function. In a perfect world, all participants would have a baseline SCAT2 score EMS could referred to when the participant is injured. Even though some patients won’t score perfectly at baseline, the checklist still gives the healthcare provider assessing the patient an idea of the severity of the injury.
Remember that not all of a patient’s symptoms will be present immediately after the event. It can take a few hours to a few days for all of them to present.
Sideline assessment tools are available as well. These include the Maddocks questions, standardized assessment of concussion (SAC), and the balance error scoring system (BESS). Some schools and athletic teams also use ImPACT to assess patients with concussions.
Any patient suspected of having a concussion should immediately be pulled from any further activity and shouldn’t be allowed to return to the game. The phrase, “When in doubt, sit them out” is paramount in the management of a pediatric or adolescent concussion.3 If there’s concern that the patient may be suffering from an intracranial bleed, there’s a C-spine injury or the patient has a Glasgow Coma Scale score of less than 14, the patient should be transported to an ED for further testing. If there’s no concern for a bleed, the patient needs close follow up with either a concussion specialist or their primary care provider within 48 hours.
The cornerstone of concussion management is physical and cognitive rest until symptoms resolve.3 Attending school and focusing on schoolwork is often difficult for patients with concussions. Even such simple things as watching TV, reading for leisure or texting can exacerbate symptoms of concussion and prolong recovery.
For this reason, full cognitive rest has to occur. This rest may even include an absence from school for a few days until symptoms improve. Taking standardized tests while recovering from a concussion should be discouraged because the patient’s memory and cognitive ability may be impaired.
After medical clearance, the patient can embark on a gradual return to play. There’s a step-wise return to play strategy that takes 24 hours for each step to be accomplished. These steps include increasing the heart rate, adding sport-specific movements, adding coordination and a cognitive load, restoring confidence assessing functional skills and returning to normal game play. If the patient has a return of symptoms, they are to return to the prior step for 24 hours.
The majority of concussions (80–90%) resolve in seven to 10 days, but recovery can be prolonged in children and adolescents.2 All patients and parents should be counseled on post-concussion syndrome. Symptoms can include short- or long-term changes that can affect the following abilities:
>> Thinking: Memory and reasoning;
>> Sensation: Touch, taste and smell;
>> Language: Communication, expression and understanding; and
>> Emotion: Depression, anxiety, personality changes, aggression, acting out and social inappropriateness.
These symptoms can last weeks, months or sometimes even years.
Some states, such as Tennessee, are doing innovative things to help bridge the gap between patients and schools. In 2000, the Tennessee Disability Coalition launched Project BRAIN, which has established brain injury transition liaisons at a few of the children’s hospitals in the state.
These brain injury transition liaisons perform follow-ups with patients and their families two weeks, three months, and six months after an injury. If the patient is having significant symptoms, then the liaison helps coordinate care and services through the primary care provider and the school.
Concussions are common in not only sports but also in recreational activities. The goal in concussion management is to avoid having them in the first place. EMS field providers should remember that they don’t have to see an injury for there to be one, and a patient’s head doesn’t have to hit something to sustain an injury. Once an injury occurs, however, recognition and proper treatment are the keys to getting the patient back to their normal activities. JEMS
, MD, is an assistant professor of pediatrics and emergency medicine at Vanderbilt University Medical Center. He serves both as the director of pediatric EMS at Vanderbilt Children’s Hospital and as an assistant medical director for Nashville Fire Department. Contact him at firstname.lastname@example.org
1. Dematteo CA, Hanna SE, Mahoney WJ, et al. My child doesn’t have a brain injury, he only has a concussion. Pediatrics. 2010;125(2):327–334.
2. McCrory P, Meeuwisse W, Johnston K, et al. Consensus Statement on Concussion in Sport: The 3rd international conference on concussion in sport held in Zurich, November 2008. Br J Sports Med. 2009;43(Suppl I):i76–i90.
3. Halstead ME, Walter KD; Council on Sports Medicine and Fitness. American Academy of Pediatrics Clinical report: Sport-related concussion in children and adolescents. Pediatrics. 2010;126(3);597–615.
5. Maugans TA, Farley C, Altaye M, et al. Pediatric sports-related concussion produces cerebral blood flow alterations. Pediatrics. 2012;129(1):28–37.
>> CDC Heads Up: Concussion in Youth Sports: www.cdc.gov/concussion/HeadsUp/youth.html
>> Center on Brain Injury Research & Training: www.cbirt.org
This article originally appeared in April 2012 JEMS as “Rough Play: Pediatric concussions require early recognition & proper field treatment.”