TOW #6: Concussions

In addition to summer recreational activities, youth around our area are starting camps and early practices for the fall sports season. This is an opportune time to review concussions, a very hot 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 Zachery Lystedt Law in Washington. Below are teaching materials for this week. Recent grad Emilie Weigel did a great RCP on concussions last year.

Links for this week's materials: Concussion Case and Discussion and AAP Statement on Concussion and powerpoint

Key take-home points for concussions:

  1. Epidemiology: 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, but girls have higher concussion rates than boys do in similar sports (possibly due to higher reporting). Loss of consciousness occurs in about 10% of concussions-but may signal a more severe injury.
  2. Concussion definition: 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.
  3. Work-up 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. Also review any assessments done at the time of injury (e.g. SCAT3, etc). You can also complete these in the office, such as the SCAT3 version used at HMC. Physical exam should include GCS scoring, and examinations of the head, neck, pupils, and a full neurologic exam including gait, balance, coordination, and orientation.
  4. Imaging: 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 HMC algorithm for determining need for CT after head injury. This HMC algorithm is 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. Treatment: Fortunately, most people recover from concussions within 7-10 days, but youth may take longer than adults. After concussion diagnosis, we recommend 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 to use that reviews 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.

TOW #5: Sports participation screening

As we hit the 2nd half of summer, this is primetime for sports physicals! There has been much debate as to what should be included in routine testing and screening. Generally, we follow the AAP guidance for screening, and encourage use of the standardized tool adopted by multiple medical organizations, as below. We have a guideline developed for our UW General Peds division as well. Remember to refer to our wonderful local sports meds experts (like our esteemed APD, Dr. Celeste Quitiquit!) if you have questions.

Teaching materials for this week:

Take-home points for sports physicals:

  1. In addition to routine history and physical, sports physicals should include specific questions: personal and family history, especially cardiac, bone and joint, asthma (and inhaler use), concussion or seizures, sickle cell, and infectious histories. Review weight and diet including attempted weight loss or gain, supplements to gain weight/muscle, and hydration and eating patterns. With females, review menstrual history.
  2. Cardiovascular screening is key: the American Heart Association recommends a 12-element screening tool that encompasses personal history, family history, and physical exam. This tool is incorporated into the Preparticipation Physical Evaluation, Fourth Edition (PPE-4) recommended by the AAP. A positive response or exam finding on any item should prompt referral to cardiology. A goal is to identify risk for and prevent sudden cardiac death, which happens in about 100 young athletes annually in the US. Unlike in other countries we have not adopted routine ECG due to cost and number needed to screen.
  3. Critical parts of the exam include: vision, BP, thorough cardiac exam (murmurs-do valsalva, PMI, pulses, Marfan stigmata), musculoskeletal exam (strength, ROM, functional/sport specific movements), neurologic exam (especially if previous concussion), and skin exam to look for infectious lesions.
  4. Contraindications to full participation include
  • some cardiac disease (discuss with cardiology)
  • Atlanto-axial instability (especially in Down syndrome or JIA)
  • Infectious diarrhea, conjunctivitis, or actively contagious skin lesions (e.g., HSV, MRSA)
  • Fever–increased risk of heat related illness and hypotension
  • Acute splenic enlargement-increased risk of rupture
  • Poorly controlled seizure disorder-especially for swimming, weight-lifting, sports involving heights
  • Hypertension–if> 5mm Hg above 99th percentile for age, avoid heavy lifting & high-static component sports

TOW #4: Injury Prevention

Next up in TOW-land is reviewing injury prevention, a timely topic for summer months, which are known as "trauma season" to all those at Harborview. Please offer appreciation to your colleagues who are spending their time taking care of the high volume of injured children. We also owe gratitude to our amazing team of injury prevention experts including Drs. Beth Ebel, Brian Johnston, and Fred Rivara, who dedicate their time to making kids safer across our nation/globe.

Materials for review:

Take-homes points:

  1. Epidemiology: Injury is the leading cause of death among children and adolescents > 1yr in the US, and ~1 in 4 children has an unintentional injury that requires medical care each year. In the US, injuries cause 42% of deaths in children ages 1-4 and 65% of deaths ages 4-18.  Injury peaks during the toddler years (ages 1 to 4) and again during adolescence and young adulthood (ages 15 to 24). The problem is even more profound in developing countries.
  2. Improvements in injury rates due to multiple public health and health care efforts: Between 2000 to 2009, the unintentional injury death rate for American children <19 declined by 29%. This decline is attributed to seat belts and child safety seats, reduced drunk driving, increased use of child-resistant packaging, better safety awareness, and improved medical care. The highest death rates remain from motor vehicle accidents, so we will cover that more in-depth in another topic. 
  3. Injury prevention is most effective with 4 components: Mace and colleagues describe the “four E’s of injury prevention”-education, engineering (modifying environmental or product design), enforcement (mandating appropriate laws), and economics (creating financial incentives and disincentives). In general passive interventions that don't require someone to act (like air bags, road design) work better than active ones that require users to choose them (like seatbelts, helmets).
  4. Our role in education (and advocacy): In the primary care setting, education is the primary method of providing anticipatory guidance, and the AAP recommends that every well-child visit include age-appropriate injury prevention counseling. However, only approximately 50% of pediatric residents and practitioners provide injury prevention counseling at well-child visits. We have to be strategic because we can't cover every topic every time. Bright Futures helps guide which injury prevention topics are most appropriate at each age. We also have to extend our role to advocacy to address the other "E's."
  5. Teachable moments after injury: There may be more opportunity for a “teachable moment” soon after an injury, when injury-specific information can be distributed (e.g., bicycle safety info for an unhelmeted cyclist with a head injury). Due to the lack of data, there is some controversy that the “teachable moment” has an added effect, but disseminating information in general can be effective.

TOW #3: Agenda setting

This topic is included early in the year to review the importance of setting an agenda in outpatient visits, which by nature have fixed times and require prioritizing. Agenda setting allows us to make sure we have addressed the most important concerns for the family, and balance these with our own agenda for the visit. This is really important in building relationships with families and helping them feel that we are responsive to their needs.

Materials for this week:

Take-home points for setting the agenda:

  1. What is agenda setting? A brief dialogue at the beginning of the visit between patient/family and clinician to ensure we can agree on the most important priorities for the visit. It can be as simple as opening with "What concerns do you want to be sure we discuss today?" or "What are your priorities for today's visit?" Asking "what else?" until no more concerns come up can help us elicit all concerns and set priorities. We can then follow with adding ours: "Thank you. That's really helpful – I agree those are important. I also want to be sure we talk about X today. Is that okay?"
  2. Why agenda setting is important? Multiple reasons: Agenda setting helps us 1) address the most important family concerns (we can easily fill the time with our own agenda/priorities in well child checks), 2) avoid trying to do too much with one visit and running behind, and 3) not hearing about a major issue until the end of a visit – "the doorknob complaint." Some studies have found that up to half of patient complaints and symptoms were not elicited in an interview. The likelihood of psychosocial complaints being brought up without asking about them is especially low.
  3. What are barriers to agenda setting? Our biggest concern is that it will take too much time. Actually, doing agenda setting well has been found to add just seconds to the visit and helps avoid the doorknob complaints that can take a lot of time. Another concern is that too many issues will be elicited. Adult studies have found that patients typically have 2-3 concerns (up to 5), and this seems to be similar for pediatric visits. When a long list does occur, this may have some diagnostic meaning – like parental anxiety/depression.
  4. What if there are too many issues to address in one visit? This is important for us to acknowledge if we can't get to everything and work with parents to prioritize. Parents will accept addressing some items later if their importance is validated, an attempt is made to deal with the most pressing ones, and it is discussed at the outset. We can also use respectful interruption to get back on track when parents digress.
  5. How do we use this in a way that still keeps us on time? The 5-step patient-centered beginning of interview is one suggested approach: 1) Set stage with welcome, introductions, privacy/ confidentiality, ensuring comfort, 2) elicit chief concerns and set agenda (may be helpful to inform them how much time you have available), 3) use open-ended questions and attentive listening (this is where it's really important to not interrupt right away), 4) elicit more specifics, 5) check accuracy, ask more questions, summarize, then move into clinician-centered phase (exam, etc.)