Lifting the Fog on Concussions: Identification, Acute Management and Patient Education

Column Author: Kathleen Berg, MD, FAAP | Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Kelli Ott, OTD, OTR/L | Program Manager Evidence Based Practice

Column Editor: Kathleen Berg, MD, FAAP | Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Fall sports are well underway and winter sports will soon begin. Participating in sports is an excellent way for youth to exercise, learn new skills, and engage with their friends and community. To keep these activities fun and safe, health care professionals must recognize and effectively manage concussions. This effort includes making an evidence-based comprehensive assessment, determining the need for additional diagnostic evaluation, and providing education on post-concussion care and future concussion prevention.

A concussion, or minor traumatic brain injury (mTBI), is caused by a force applied directly or indirectly to the head. The hit or jolt causes sudden back-and-forth brain movement within the skull, leading to neurometabolic dysfunction.¹ Though the bulk of research on mTBI has focused on individuals who are high school age or older, some studies suggest a greater risk of mTBI in children. This risk may be due to incomplete myelination of the developing central nervous system, larger head-to-body ratio, weaker neck and shoulder muscles, or larger subarachnoid space. Each factor may put the developing brain at increased risk for shearing injury.²  

Concerns for concussion in pediatrics account for >800,000 acute care visits and result in approximately 200,000 diagnosed mTBI annually.^3,4 Common mechanisms of injury unrelated to sports are falls, head strikes or being struck by an object, and motor vehicle accidents.^4,5 Sports-related mTBI may result from a blow during any activity, but most commonly occurs during football, hockey, lacrosse and soccer.^2,6 In 2018, the Centers for Disease Control and Prevention (CDC) provided clinical practice guidelines on the diagnosis and management of mTBI, specifically for youth aged 18 years and younger.⁷ Its 19 recommendations assist in the identification, risk stratification, acute management, anticipatory guidance and longitudinal assessment. 

After an event, the presence of even one sign or symptom may indicate mTBI, or more severe brain injury. Signs and symptoms include, but are not limited to, amnesia, confusion, change in mood, headache or nausea. A complete list can be found on the CDC website Concussion Signs and Symptoms | HEADS UP | CDC Injury Center.⁸ Symptoms and signs may occur immediately following an event or hours to days later.

A thorough history and physical exam should include a head and neck exam, age-appropriate neurological exam, and balance assessment. While evidence supports using a standardized concussion assessment tool, there is not one universally agreed-upon tool. One option is the Acute Concussion Evaluation (ACE) available at HEADS UP to Health Care Providers: Tools for Providers | HEADS UP | CDC Injury Center. This tool prompts providers to obtain details of the injury, signs and symptoms, and concussion or headache history, and aids in developing a follow-up action plan.⁹ A sports-specific option is the latest version of the Sports Concussion Assessment Tool (SCAT6) or the pediatric version (Child SCAT5) specifically designed for children 5-12 years of age.^10,11 This tool is best used within the first 72 hours following injury, with diminishing reliability after five to seven days.¹²

The CDC guidelines discourage use of plain films of the skull and recommends that head CT not be routinely used for diagnostic purposes. In a systematic review that helped inform the guidelines, of patients with presumed mTBI who underwent CT head, 1.9% had intracranial injuries associated with clinically important outcomes, and 0.8% had intracranial injuries requiring neurosurgical intervention.¹³ Instead of routine neuroimaging, providers should use an evidence-based strategy such as the Pediatric Emergency Care Applied Research Network (PECARN) decision rules to determine the risk of clinically important intracranial injury for whom acute neuroimaging may be warranted. Risk factors include age younger than 2 years, recurrent vomiting, loss of consciousness, severe mechanism of injury, severe or worsening headache, amnesia, nonfrontal scalp hematoma, Glasgow Coma Scale score less than 15, or clinical suspicion for skull fracture.^7,14

Fortunately, most (70%-80%) children with mTBI do not show significant difficulties more than three months after their injury.¹⁵ Prognosis may be impacted by premorbid conditions such as learning difficulties or psychiatric diagnoses. More information on longitudinal assessment with symptom scales and cognitive testing can be found in the CDC guidelines. Patient and family education is essential and should include guidance on monitoring post-concussive symptoms, prevention of further injury, management of cognitive and physical activity and rest, and instructions regarding return to school and other activities.⁷

Children’s Mercy Kansas City provides an updated clinical pathway available at Concussion | Children's Mercy Kansas City (childrensmercy.org). In addition to guidance on the acute management of mTBI, the pathway provides patient and family educational materials on general post-concussion care, sleep tips, and academic accommodations.

References:

1. Sarmiento K, Waltzman D, Lumba-Brown A, Yeates KO, Putukian M, Herring S. CDC guideline on mild traumatic brain injury in children: important practice takeaways for sports medicine providers. Clin J Sport Med. 2020;30(6):612-615. doi:10.1097/JSM.0000000000000704
2. Committee on Sports-Related Concussions in Youth; Board on Children, Youth, and Families; Institute of Medicine; National Research Council. In: Graham R, Rivara FP, Ford MA, Spicer CM, eds. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. National Academies Press; 2014.
3. Corwin DJ, Arbogast KB, Haber RA, et al. Characteristics and outcomes for delayed diagnosis of concussion in pediatric patients presenting to the emergency department. J Emerg Med. 2020;59(6):795-804. doi:10.1016/j.jemermed.2020.09.017
4. Peterson AB, Xu L, Daugherty J, Breiding MJ. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths, United States, 2014. Centers for Disease Control and Prevention, US Department of Health and Human Services. Published 2019.
5. Master CL, Curry AE, Pfeiffer MR, et al. Characteristics of concussion in elementary school-aged children: implications for clinical management. J Pediatr. 2020;223:128-135. doi:10.1016/j.jpeds.2020.04.001
6. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747-755. doi:10.1177/0363546511435626
7. Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children [published correction appears in JAMA Pediatr. 2018 Nov 1;172(11):1104]. JAMA Pediatr. 2018;172(11):e182853. doi:10.1001/jamapediatrics.2018.2853
8. Concussion Signs and Symptoms. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Published February 12, 2019. Accessed November 2, 2023. https://www.cdc.gov/headsup/basics/concussion_symptoms.html
9. HEADS UP to Health Care Providers: Tools for Providers. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Published August 25, 2022. Accessed November 2, 2023. https://www.cdc.gov/headsup/providers/tools.html
10. Echemendia RJ, Brett BL, Broglio S, et al. Sport concussion assessment tool™ - 6 (SCAT6). Br J Sports Med. 2023;57(11):622-631. doi:10.1136/bjsports-2023-107036
11. Davis GA, Purcell L, Schneider KJ, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): background and rationale. Br J Sports Med. 2017;51(11):859-861. doi:10.1136/bjsports-2017-097492
12. Echemendia RJ, Burma JS, Bruce JM, et al. Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review. Br J Sports Med. 2023;57(11):722-735. doi:10.1136/bjsports-2022-106661
13. Lumba-Brown A, Yeates KO, Sarmiento K, et al. Diagnosis and management of mild traumatic brain injury in children: a systematic review [published correction appears in JAMA Pediatr. 2018 Nov 1;172(11):1104]. JAMA Pediatr. 2018;172(11):e182847. doi:10.1001/jamapediatrics.2018.2847
14. Lorton F, Poullaouec C, Legallais E, et al. Validation of the PECARN clinical decision rule for children with minor head trauma: a French multicenter prospective study. Scand J Trauma Resusc Emerg Med. 2016;24:98. PMID: 27488722; PMCID: PMC4973103. doi: 10.1186/s13049-016-0287-3
15. Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics. 2010;126(2):e374-e381. doi:10.1542/peds.2009-0925