Neurology

Head Injuries

Concussion is a traumatically induced alteration in mental status. There can be confusion, amnesia, and loss of consciousness. The amnesia may be instantaneous or delayed.

 

Features of Concussion

  1. Vacant stare
  2. Slow verbal and motor responses
  3. Confused and inattentive
  4. Disorientation
  5. Slurred speech
  6. Incoordination
  7. Unusual emotions and emotional lability
  8. Memory deficits
  9. Loss of consciousness
  10. Nausea, vomiting
  11. Malaise
  12. Headache

  Symptoms of Concussions

  1. Early
    1. Headache, dizziness, vertigo, nausea, and vomiting
  2. Late
    1. headache
    2. Light- headedness
    3. Poor attention
    4. Easy fatiguability
    5. Irritable
    6. Intolerant of loud noises and bright lights
    7. Sleep disturbances and anxiety or depression
    8. poor balance

Managing Concussion in Sports

Grade I

  1. Transient confusion without loss of consciousness.("bell rung" ) Symptoms resolve in minutes to hours. The patient should be checked every 5 minutes and if symptoms resolve within 15 min the patient may return to the game. If the person receives another Grade I concussion in the same contest, they may not return to the game and are out of action until they remain asymptomatic for 1 week. ( may last up to 6-12 weeks)

Grade II

  1. There is confusion and no loss of consciousness. May suffer from amnesia. The symptoms last for longer than 15 minutes. Patient is not allowed to return to the game and on-site frequent assessments should be performed. Will need ER evaluation and clearnacae by trauma MD. Most suggest evaluation by CT scan.

Grade III

  1. There is loss of consciousness. Transfer immediately to ER if remains unconscious or worrisome signs are detected. Patient should be admitted if signs do not improve and will require imaging studies. If the examination is normal the patient may be sent home with explicit instructions and patient should be checked daily. May return to play after brief loss of consciousness (seconds) after being asymptomatic for one week and if had prolonged LOC (minutes) after being asympotmatic for 2 weeks. Clearance should be done by a specialist, usually a neurosurgeon.

  2.  Repetitive mild head injuries may lead to catastrophic outcomes secondary to brain swelling. There may be autoregulatory dysfunction and vascular congestion designated as the " second impact syndrome. This may occur if the individual suffers another impact up to 3-6 months after the first impact. Repeated concussions may lead to permanent deficits ("punch drunk syndrome").

Evaluation on the sidelines for signs and symptoms of concussion

  1. Review of the mechanism of injury
  2. Mental status evaluation on the sidelines
    1. Orientation- time, place, person, situation
    2. concentration- months of the year backwards
    3. memory- current events, previous contests
    4. provocation of symptoms with running, sit ups, knee bends
  3. Eye examination including pupils
  4. Coordination- finger to nose, tandem gait
  5. Sensation- Romberg, finger to nose with eyes closed

Signs to watch for with minor head injuries without concussion

  1. Many children will vomit once or twice after head trauma. If the vomiting is persistent, the child must be evaluated.
  2. Decrease in activity. Many children will get tired after minor head trauma and fall asleep. 
  3. Extreme lethargy
  4. Seizures

After an isolated head injury , a child may be observed at home as long as close follow-up is attainable. The parents should call you regardless of the child's condition at frequent intervals

When to admit ?

  1. Unexplained injury to evaluate for possible abuse
  2. Neurological deficit
  3. Mental status is poor or changing
  4. Seizure
  5. Persistent vomiting
  6. Prolonged loss of consciousness
  7. Sever Headache
  8. Signs of basilar or other skull fracture

Instructions to Parents

  1. Call if there is persistent vomiting, child is acting weird, or has a seizure
  2. No medications should be given to child except acetaminophen
  3. Clear liquids
  4. Evaluate breathing, movement, reactivity every 2 hours.

References

  1. Practice Parameter. The management of concussion in sports. Neurology 1997
  2. Quayle K.S. Minor Head Injuries in the Pediatric Patient. Pediatric Clinics of North America 1999
  3. Patel D. Managing concussion in a young athlete.  Contemporary Pediatrics Nov 2006
  4. Ropper A. and Gorson K. Concussion.  NEJM Jan 2007
  5. Meehan W. Bachur R. Sport-Related Concussion.  Pediatrics Jan 2009
  6. Maguire J. et al. Should a Head-Injured Child Receive a Head CT Scan? A Systemic Review of Clinical Predication Rules. Pediatrics 2009 
  7. Halstead K.D. et. al. Sport-Related Concussion in Children and Adolescents. Council on Sports Medicine and Fitness.  Pediatrics September 2010
  8. Schunk J. Schutzman S. Head Injury.  Pediatrics in Review.  Sept 2012