2018-19 TOW #7: Concussions

In addition to summer recreational activities, youth around our area are doing camps and early practices for the fall sports season. This is an opportune time to review concussions, a very timely topic in pediatrics (and society-at-large). We as pediatricians are called upon to address these injuries in clinic and clear youth for return to activities, as mandated by the Lystedt law in Washington.

Links for this week’s materials:

Key take-home points for concussions:

  1. What is a concussion? A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces with 5 common features:1) induced by traumatic forces to the head, either directly or indirectly, 2) rapid onset of short-lived neurologic impairment that resolves spontaneously, 3) may have neuropathological changes but these are functional more than structural, 4) a graded set of clinical symptoms which resolve following a sequential course, however, symptoms may be prolonged, and 5) no structural abnormality on standard neuroimaging.
  2. What’s the epidemiology of concussions? Concussion accounts for an estimated 8.9% of high school athletic injuries, and this is likely a low estimate due to underreporting. Football has the highest incidence of concussion, followed by girls’ soccer. Girls have higher concussion rates than boys do in similar sports (possibly due to both physiologic reasons and higher reporting). Loss of consciousness occurs in about 10% of concussions, but may signal a more severe injury.
  3. What work-up should be done when concussion is suspected? Workup should include history of event including loss of consciousness, amnesia, prior injuries, and current symptoms. Assess 4 broad categories of symptoms–physical, cognitive, emotional, and sleep. Be sure to ask parents, not just patients. Review any assessments done at the time of injury (e.g. on-field SCAT5, etc). Physical exam should include GCS scoring, and examinations of the head, neck, pupils, and a full neurologic exam including gait, balance, coordination, and orientation. Consider using standardized tools to complete the evaluation, such as the SCAT5 and Child SCAT5 for ages 5-12.
  4. When should imaging be done? CT scans are not routinely indicated unless there are significant symptoms including severe headache, vomiting, worsening symptoms, or neuro changes suggestive of more serious injury. See the HMC algorithm for determining need for CT after head injury, based on the national Pediatric Emergency Care and Research Network (PECARN) criteria. This helps avoid unnecessary imaging, while covering those who still need it.
  5. How should we treat? Fortunately, most people recover from concussions within 7-10 days, but youth may take longer than adults. After concussion diagnosis, we recommend moderate cognitive rest and a gradual return to play with 24 hours at each stage (e.g., rest, walking, light aerobic activity, higher exertion, practice, scrimmage, games); this generally means about a week before full return. Do not progress if there are symptoms at any stage. Here’s a handout that reviews symptoms and return to play. We should also recommend gradual return to learning, and youth may need accommodations before returning to full cognitive performance, such as test-taking. Check out sports concussion resources from our sports medicine experts here.