Limit the activity of a child who suffers a concussion to avoid cumulative brain injury and to preventsecond impact syndrome

Limit the activity of a child who suffers a concussion to avoid cumulative brain injury and to preventsecond impact syndrome: Excerpt from Avoiding Common Pediatric Errors

Author: Michael Clemmens, MD

What to Do - Take Action

Concussion is defined as a closed head injury associated with transient alteration in mental status or neurologic function, which may or may not involve loss of consciousness (LOC). In the pediatric population, the etiology of concussion is variable and is influenced by age. Young infants and children commonly suffer concussion after a fall from a height. Older children and adolescents may suffer concussion as a result of sports activity. Child abuse shouldalways beconsidered inthedifferentialdiagnosis ofheadinjury, especially in children younger than 2 years of age who are at risk for both shaken baby syndrome and blunt head trauma.

A complete and detailed history, with emphasis on the mechanism of injury and the presence and duration of LOC, is an important part of the head injury and concussion evaluation. For fall injuries, the height of the fall and the composition of the surface that the head strikes are two major factors in determining the degree of force generated by a fall. The degree of force is an important factor in assessing risk for serious injury. For example, a 4-foot fall onto concrete may generate more force than an 8-foot fall onto wood chips. An inconsistent or implausible history should raise the suspicion of inflicted injury.

The most common immediate symptoms of concussion are confusion and amnesia, although a variety of other neurologic deficits may be seen. These include, but are not limited to, headache, dizziness, vomiting, slowing, poor coordination, LOC, and emotional lability. Following the injury, children may develop postconcussive symptoms (PCS), which may persist for days, weeks, or even months. These symptoms may manifest as somatic complaints, emotional or behavioral changes, or cognitive problems. A thoroughhistoryand age-appropriateneurologic exam,with emphasison mental status,shouldelicit any evidence ofongoingcentral nervoussystem dysfunction. If the exam is normal, the diagnosis of concussion or PCS can be made onthebasisofthehistory.Severaltoolsexistfortheassessmentofbothimmediate, on-site symptoms, and PCS, and these are reviewed in the references.

Computed tomography (CT) scan is useful in ruling out intracranial injuries that may require neurosurgical intervention. Historical factors that suggest the need for CT include severe mechanism of injury, LOC, seizure, persistent vomiting, and suspicion of child abuse. Persistence or worsening of PCS may also warrant an imaging study. Physical exam findings that may indicate the need for imaging include abnormal mental status, focal neurologic findings, skull fracture, scalp hematoma, and a full or bulging fontanel. Low-risk patients are those who do not have a severe mechanism of injury and do not have any of the signs and symptoms listed above. These low-risk patients likely do not need a CT scan.

Sports participants who sustain a concussion and wish to return to play should be advised carefully. Cumulative brain injury from recurrent concussions can occur. In rare circumstances, a child may develop second impact syndrome. This syndrome occurs when a child receives a second concussion before having fully recovered from the first, and subsequently develops malignant cerebral edema. This syndrome is thought to occur as a result of disruption to the autoregulation of the brain's blood supply, leading to vascular engorgement, cerebral edema, increased intracranial pressure, herniation, and possibly death. Even though the exact relationship between a second impact and the resultant pathophysiologic response is unclear, immaturity of the brain is a documented risk factor.

To prevent these complications, several guidelines have been published that propose a grading system for concussions and detail when return to play is safe, and these are reviewed in the references. Among these guidelines, there is consensus that athletes should refrain from play until all signs and symptoms have resolved, including somatic, emotional or behavioral, and cognitive symptoms. Although there are some minor differences among the guidelines regarding other recommendations, the more severe the concussion, the longer the child should refrain from play. Severity is gauged by the presence or absence of LOC and the duration of symptoms. If there has been any LOC, return to play should be delayed for approximately 1 to 2 weeks. If there is no LOC, but initial symptoms persist beyond 15 minutes, then the wait time is 1 week. Any ongoing symptoms preclude return to play until resolution is complete and a waiting period has been observed. Furthermore, in all cases, special consideration should be given to a gradual and step-wise increase in activity level.

Suggested Readings

Duhaime AC, Alario AJ, Lewander WJ. Head injuries in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics. 1992;90(2 Pt 1):179–185.
Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics. 2006;117:1359–1371.
The management ofminor closed headinjuryin children.Committee onQualityImprovement, American Academy of Pediatrics. Commission on Clinical Policies and Research, American Academy of Family Physicians. The management of minor closed head injury in children. Pediatrics. 1999;104:1407–1415
Wojtys EM, Hovda D, Landry G, et al. Current concepts. Concussion in sports. Am J Sports Med. 1999;27:676–687.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

 » Next page: Refer children for supportive services when recovering from severe illnesses such as traumatic brain injury (TBI) and burns. These conditions require multimodality support for the children to reaccommodate into their social position (Avoiding Common Pediatric Errors)

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