Emergency DepartmentEvaluation of Concussion(Traumatic Brain Injury)
Sylvia E Garcia, MDAssistant Professor
Pediatric Emergency MedicineIcahn School of Medicine
At Mount Sinai
Department of Emergency Medicine
Disclosures
I have no financial disclosures to report.
Department of Emergency Medicine
Deaths 7,000/yr
Hospitalizations
95,000/yrED Visits
> 500,000/yr
Primary Care Office VisitsAssume numerous, No data
- Hospital care costs alone exceed 1 billion/year- 29,000 permanent disabilities annually
60%↑ in ED visits in last 10 years
Pediatric Head Trauma
Goals and ObjectivesRecognize the importance of obtaining a
comprehensive history that identifies previous injury / concurrent medical conditions
Know the importance of assessing vestibular balance
Understand the role of neuroimaging in the evaluation of the concussed patient
Recognize the importance of clear discharge instructions
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Recognition of Concussion
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Comprehensive history Comprehensive history should include documentation of previous
• Closed head injuries / concussions• Depression / anxiety• Sleep disturbances• Learning disorders• Attention deficit disorders • Headaches ( migraines )
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Physical Exam
ABCsC-spine immobilization as neededGCS determinationNeuroimaging as deemed necessary Detailed neurological evaluation
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Assessment Tools
Acute Concussion Evaluation ( ACE )
Brain Injury Survey Questionnaire ( BISQ )
Sport Concussion Assessment Tool ( SCAT )• SCAT 3• Child SCAT 3
Department of Emergency Medicine
Assessment ToolsThe Brain Injury Survey Questionnaire ( BISQ ) is a
screening tool that assesses for: • Any unidentified previous TBI• Persistent symptoms associated with a previous TBI • Events and conditions other than TBI that can cause
similar symptoms
Parent and / or patient is given Part 1 of the BISQ
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Cantor J et al. Arch Phys Med Rehabil 2004;85(4 Suppl2):S54-60
Assessment Tools The Sport Concussion Assessment Tool is a
standardized tool utilized in the evaluation of concussion in patients ≥ 5 yrs of age
Child- SCAT3 ( ages 5 -12yrs ) SCAT3 ( age ≥ 13 yrs )
• Cognitive assessment• Neck examination• Balance and coordination examinations• Delayed recall
Department of Emergency Medicine
Assessment Tools Balance exam assesses vestibular system • Double leg stance• Single leg stance• Tandem stance • Tandem gait • Scored by error or deviations from proper stance
Specific, not sensitive, indicator of concussion Postural deficits last ~72 hrs
3Harmon KG, Drezner JA, Gammons M, et al. Br J Sports Med 2013,47,15-26
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Assessment Tools
There’s an App for thatSway Balance SystemTM for iOS devicesUses the built in motion sensor for cell phonePatient is given instruction for vestibular examsBegin test button is tapped when ready and the
device is held against the chest
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Assessment Tools
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Neuroimaging
Conventional brain CT or MRI is usually normal in concussive injury
Prevalence of an abnormal CT increases with decreasing GCS
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• Penetrating injury• GCS ≤ 14 • Focal neurologic
abnormalities• Signs of depressed or
basilar skull fracture• Prolonged loss of
consciousness (> 1min)
, <
• Clinical deterioration or worsening symptoms
• Seizure ( other than impact seizure ) or prolonged seizure
• Pre-existing condition increasing risk for bleeding
Department of Emergency Medicine
Jeff E. Schunk, Sara A. Schutzman. Pediatric Head Injury. Pediatrics in Review, Volume 33, Number 9 (September 2012), pp. 398-411
Emergent Head CT
Neuroimaging
Neuroimaging
The Pediatric Emergency Care Applied Research Network ( PECARN ) study identified children at very low risk for clinically important TBI after head trauma for whom CT scan is unnecessary
Department of Emergency Medicine
Kupperman et al. Lancet 2009;374:1160-70
Neuroimaging : PECARN Study
Children up to age 18 yrs old were enrolledAll subjects were seen within 24 hours GCS recorded was 14 – 15Preverbal ( ≤2 yo ) and verbal ( ≥2 yo )
groups were analyzed separately
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Kupperman et al. Lancet 2009;374:1160-70
PECARN Imaging Guidelines > 2yo
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Kupperman et al. Lancet 2009;374:1160-70
Neuroimaging The prediction rule for children ≥ 2 yrs had a
negative predictive value of 99.95% and sensitivity of 96.8%
• Normal mental status• No loss of consciousness• No vomiting• Non-severe injury mechanism • No sign of basilar skull fracture• No severe headache• No high-risk mechanism
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Kupperman et al. Lancet 2009;374:1160-70
Management Medications• Tylenol or Ibuprofen for headaches• Avoid drugs that can alter mental status • Anti-nausea medications used with caution• No medications for sleep, mood or attention
disturbances• Meclizine can affect cognitive function
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Discharge Instructions Instructions should be clear on what to expect
after diagnosis of concussion Monitor for 24 – 48 hours No need for periodic awakening Majority of symptoms improve / resolve in 7 days
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Discharge Instructions Patients should return to the ED • Worsening headaches • Increased drowsiness / not able to be awoken• Repeated emesis• Unusual behavior or seem confused or irritable• Seizures• Weakness or numbness in arms / legs• Unsteadiness• Slurred speech
Department of Emergency Medicine
Discharge and Follow-up Rest / sleep Avoiding activities requiring concentration Avoid strenuous activities No alcohol No sleeping pills No driving or play until cleared
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Discharge Instructions Return to learn before return to play
School should be made aware of the need for reduced workload, frequent rest periods, extended time to complete tests or complicated tasks
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Discharge and Follow-up No one should be cleared to ‘return to
play’ from the ED
Excuse should be given for delayed return to school / work
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Summary Review past history for previous injury and
conditions that may exacerbate recovery
Motor domain of neurological function can be reliably assessed by vestibular balance testing
CT scan is rarely necessary
Discharge instructions should clearly outline expectations, and indications for follow-up
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Summary
Patients should be reassessed by a physician in 3 to 5 days
Follow-up with a specialist if no improvement or recovery noted within 5 to 7 days
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Play Safe
1-800-283-8481
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