Concussions and closed head injuries are incredibly common in the Pediatric Emergency Department and in general Emergency Department, especially as we head into fall contact sports season. In this episode, featuring Brielle Stanton, MD, a Pediatric Emergency Medicine fellow from The UPMC Children’s Hospital of Pittsburgh, you will learn how to differentiate clinically important traumatic brain injuries from milder trauma – specifically when to get a CT, and how to diagnose and manage concussions.
Full transcript of this episode below…
Listen
Metabolic Disorders – PEM Currents: The Pediatric Emergency Medicine Podcast
Subscribe
Episode Transcript
Closed head injuries, bump on the head, fall: These are very common chief complaints in the pediatric emergency department. Question is – how do you differentiate the one with the subtle bleed between the one that just has a little goose egg?
Today, we’re going to take a quick dive into the different ways we can categorize head injuries in the emergency department. We’re going to take a quick look at one of the most commonly used clinical decision rules in the PED, the PECARN head injury rule, as well as take a look at concussions – how to diagnose, how to manage them, and what to tell your patients to give them good anticipatory guidance.
As with all pediatric patients, you want to really take into account how they first look: what’s their general appearance when you walk into the room? Are they interacting with the parents? Are they making noises? Are they playing? are they staring off ? Those quick details you take in can help clue you into whether a) I need to jump to my neuro exam with just a brief history or b) I have time to get more of the full history from the pt/parent.
One of the things you want to look at on exam are any type of hematoma that’s on that parietal occipital, or temporal region. Frontal bone hematomas are much less concerning because it’s the strongest bone in your skull. Check for signs of skull fracture, including hemotympanum and battle sign. As for the other aspects, you are going to look at is if the child is back to their baseline. This is when it really is important to get a sense of how the parent feels their child- they’re going to be the best indicator, especially when you have those difficult in the middle of the night cases where it’s difficult to parse out if is this normal toddler sleepy time or is this child actually just kind of lethargic.
For older kids, you’re going to tap more into their described symptoms and clinical exam; they can tell you more about what they’re actually feeling in a reliable way.
The PECARN Head Injury Prediction Rule provide a well validated clinical decision rule for these kinds of CC. PECARN is the Pediatric Emergency Care Applied Research Network. It’s a combination of many children’s hospitals across the nation that gather data together and do clinical research, and also provide evidence-based medicine for us to use a practice with the current head injury rule.
The original study was an RCT that looked at over 46K pediatric patients at 25 Children’s hospitals in the US. The study helped derive clinical features to help risk stratify who might be safely observed vs who warrants immediate head imaging. It is important to note that the PECARN rule provides a fair amount of confidence and percentages of risk of clinically important brain injury. Most people don’t realize though, that clinically important brain injury as defined in the study isn’t just any bleed. In this study, ciTBI is specifically described as a bleed that was leading to intubation >24 hours, hospitalization of more than 48 hours, neurosurgical procedure, or of course any head injury that led to death.
Now for the rule:
The main distinguisher as we look here is age and 2 is the golden number: the group that’s less than two years old, and the group that includes age two and up.
For the less than 2 group, does the patient have a GCS 14 or less, palpable skull fracture or signs of AMS (agitation, somnolence)? If so, PECARN recommends a CT as there is a 4.4% risk of ciTBI.
If not, move to question two – is there occipital, parietal or temporal scalp hematoma, history of LOC for 5 or more seconds, is the patient not acting normally per the parent or was there a severe mechanism of injury (meaning MVC with patient ejection, death of another passenger, rollover, bicyclist w/o helmet struck by motorized vehicle, fall from > 3 feet or head struck by high impact object. If yes, you can observe the child for 4-6 hours depending on provider comfort as there is 0.9% risk of ciTBI. If the answer is no to all questions, risk is exceedingly low <0.02%)
For the 2 & up group, first ask the same initial question: does the patient have a GCS 14 or less, palpable skull fracture or signs of AMS (agitation, somnolence)? If so, PECARN recommends a CT as there is a 4.3% risk of ciTBI.
If not, move to question two – is there a history of LOC, vomiting, severe headache or severe mechanism (here severe is the same definition as above with the exception of a 5 foot fall rather than 3 foot).
If not, risk is again exceedingly low (<0.005%). If yes, risk is 0.9% and observation is recommended (Kupperman).
Now the next thing I think about with closed head injury is concussion. Often times, concussion and mild traumatic brain injury will be used interchangeably, but concussions really are a type of mild traumatic brain injury.
In 2018, the CDC came out with guidelines for how to manage concussion and this has made mostly being based on expert opinion. They did a very thorough review of the current literature to date and made recommendations based on the level of evidence available. I’m going to highlight some of the most salient aspects for that pertain to us here in the ED as we run through the concussion details.
In terms of diagnosis, there are tools like the Acute Concussion Evaluation ED tool to help your framework of diagnosing concussion when you have a blunt injury trauma to the head, with or without loss of consciousness, amnesia, or seizure.
The signs and symptoms can be broken down into 4 categories:
- observed signs (appears dazed or stunned, confused about events, repeats questions, answers questions slowly)
- physical symptoms: headache, nausea, vomiting, balance problems/dizziness, blurry or double vision, fatigue, drowsiness, photo/phonophobia, numbness or tingling
- cognitive symptoms: difficulty concentrating, remembering or feeling foggy
- emotional symptoms: irritable, more emotional, just don’t feel “right”
Additional symptoms can include sleep disruptions or drowsiness.
Things you want to check on physical exam: do a throughout head/neck exam, as well as a complete neurologic exam. You may see some imbalance or gait instability with concussions, though you wouldn’t truly expect to have focal deficits with a concussion. Don’t forget to check facial bones and dentition in a patient who has fallen. Also, look for things that might clue you into other diagnoses, like the influence of drugs or alcohol.
The downside to CT as we all know is the radiation risk. While low, the risk of cancer (mainly brain malignancy or leukemia with head CTs) is not inconsequential. Data has shown that 2-3 head CTs could triple the risk of brain tumors and 5-10 triples the risk of leukemia (Pearce). Risk increases with radiation dose and decreases with patient age, with kids < 5 at highest risk. One large retrospective study in 2014 projected a lifetime attributable risk of solid cancer of up to 17.5 per 10,000 head CTs and of leukemia of to up to 1.9 per 10,000 head CTs (Miglioretti). For solid cancers, females had higher risks of solid tumors than males. That being said, the radiation dose is not always standardized so become familiar with your hospitals protocol and if lower, pediatric dosed CTs are possible.
Honestly, no head imaging is indicated at the acute period for concussions at this time, not a head CT, not a conventional MRI. Those aren’t really going to add any benefit as head imaging is normal in the acute setting of concussion, unless you’re trying to rule out a traumatic hemorrhage. In that case, you should just get a head CT.
There aren’t any current lab markers that have been validated to diagnose concussion; however, the FDA recently did approve glial fibrillary acidic protein and ubiquitin C-terminal hydrolase-L1 in TBI. More research is needed to see if these will have use in kids with mild TBI / concussion (Mannix). Right now, the CDC guidelines state there is insufficient evidence for any biomarker use.
Most patient will recover within 14 days of concussion, but as many as 30% of patients seen in the ED may develop prolonged post-concussion symptoms as demonstrated in a recent large, multicenter study (Zemek). Risk factors for prolonged post-concussion symptoms include prior concussions (increases with #), chronic headaches or migraines. Patients with neuro or psych disorders, LD, lower cognitive ability or family/social stressors, along with older patients or more severe initial symptoms may also have prolonged recovery courses.
Additionally, it is important for patients in terms of management to discuss what things to look out for, what things to be expected, and what they could do at home. Some patients will need to give be given information on pain medications such as ibuprofen & acetaminophen, not to use those for longer than five to seven days, as this can lead to further rebound headaches. Some patients may need a few doses of ondansetron to get over the initial nausea, so that they can stay hydrated during this period.
Return criteria should include worsening pattern of vomiting or severe headache, change in mental status, new unsteady gait, or seizure.
The classic teaching was to give mostly rest & recover instructions in the emergency department. They should be able to be home and not partake in school work for the first 24-48 hours, after which they can take a stepwise approach to returning to schoolwork and activity. As an emergency physician, you shouldn’t necessarily be the person who’s going to clear a patient to go back to sports because you don’t know what their exam is going to be like at that time. Given that, what I will typically do is say, take it easy for the next 2 days. Try to really limit the screen time, reading, and eye strain in general over the next 48 hours. If your symptoms are completely gone, light activity is probably fine, but you should still see your primary care doctor so they can clear you for activities. More recent studies are showing that earlier aerobic activity may lead to better outcomes and additional RCTs are underway. So if they can get that follow up appointment within 48-72 hours, that’s probably a great idea. The biggest thing you want to avoid with concussions, is that re-injury and second impact syndrome, which is why it’s so important to avoid sports and any increased chance of getting another injury or blow to the head in the acute window. That’s why it’s imperative for kids with concern for a concussion during practice or a game to really sit it out rather than just play through. It can be more damaging than you think.
Additionally, for those patients that have had multiple concussions, persistent symptoms, or for those that are high performance or elite athletes, it is probably beneficial for them to see a concussion specialist which may include neuropsych evaluation. These aren’t always available in the community hospital setting, but there are certainly lots of recommendations on the AAP & CDC websites, which we have linked here and information regarding surrounding academic institutions is also a possibility in your area. It would be worthwhile to know who the people are who are managing the concussions. Well, I hope you enjoyed this podcast and hope you learned a bit more on pediatric head injuries.
Resources
MD Calc: Pediatric Head Injury/Trauma Algorithm
Healthy Children: Concussions: What parents Need to Know
References
Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0. Epub 2009 Sep 14. Erratum in: Lancet. 2014 Jan 25;383(9914):308. PMID: 19758692.
Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014 May;99(5):427-31. doi: 10.1136/archdischild-2013-305004. Epub 2014 Jan 15. PMID: 24431418.
Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O’Connor RE, Timmons SD. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr. 2018 Nov 1;172(11):e182853. doi: 10.1001/jamapediatrics.2018.2853. Epub 2018 Nov 5. Erratum in: JAMA Pediatr. 2018 Nov 1;172(11):1104. PMID: 30193284; PMCID: PMC7006878.
Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014 May;99(5):427-31. doi: 10.1136/archdischild-2013-305004. Epub 2014 Jan 15. PMID: 24431418.
Zuckerbraun NS, Atabaki S, Collins MW, Thomas D, Gioia GA. Use of modified acute concussion evaluation tools in the emergency department. Pediatrics. 2014 Apr;133(4):635-42. doi: 10.1542/peds.2013-2600. Epub 2014 Mar 10. PMID: 24616361.
Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de González A. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4;380(9840):499-505. doi: 10.1016/S0140-6736(12)60815-0. Epub 2012 Jun 7. PMID: 22681860; PMCID: PMC3418594.
Miglioretti DL, Johnson E, Williams A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013;167(8):700-707. doi:10.1001/jamapediatrics.2013.311
Mannix R, Bazarian JJ. Managing Pediatric Concussion in the Emergency Department. Ann Emerg Med. 2020 Jun;75(6):762-766. doi: 10.1016/j.annemergmed.2019.12.025. Epub 2020 Feb 17. PMID: 32081385.
Zemek R, Barrowman N, Freedman SB, Gravel J, Gagnon I, McGahern C, Aglipay M, Sangha G, Boutis K, Beer D, Craig W, Burns E, Farion KJ, Mikrogianakis A, Barlow K, Dubrovsky AS, Meeuwisse W, Gioia G, Meehan WP 3rd, Beauchamp MH, Kamil Y, Grool AM, Hoshizaki B, Anderson P, Brooks BL, Yeates KO, Vassilyadi M, Klassen T, Keightley M, Richer L, DeMatteo C, Osmond MH; Pediatric Emergency Research Canada (PERC) Concussion Team. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA. 2016 Mar 8;315(10):1014-25. doi: 10.1001/jama.2016.1203. Erratum in: JAMA. 2016 Jun 21;315(23):2624. PMID: 26954410.
