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Pediatric Concussions Approach to Out-Patient Management

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Pediatric Concussions Approach to Out-Patient Management Pediatric Concussions latest approach to management Sasha Dubrovsky MDCM MSc FRCPC Medical Consultant to MTBI Clinic Pediatric Emergency Medicine © 2013 Overview Concussion When to worry Brain rest When to refer Post-traumatic headache Occipital nerve blocks Case study 14 year old soccer injury Stunned x 5 minutes Headache persists x 24 hours Concussion Consensus statement on concussion in sports, 4th international conference, Zurich, 2012 McCrory et al. 2013 Concussion Brain injury … a subset of mild traumatic brain injury (mTBI) Spectrum of TBI Mild Moderate Severe Concussion Brain injury … a subset of mild traumatic brain injury Complex pathophysiologic process with a functional disturbance Functional MRI Pathophysiology 10 days Concussion Brain injury … a subset of mild traumatic brain injury Complex pathophysiologic process … functional disturbance Induced by biomechanical forces Direct blow to head or elsewhere with “impulsive” force to head Concussion Rapid onset of short-lived impairment in neurologic function … albeit may evolve over hours ± loss of consciousness Concussion Recovery usually within 2-3 weeks Pediatric often longer … 55% symptomatic at 1 month 14% symptomatic at 3 months 2% symptomatic at 12 months Management Goals Diagnosis Minimize likelihood for post- concussion syndrome and/or 2nd injuries Target therapies to improve speed and magnitude of recovery Acute injury Basic trauma assessment ABCDE Life threatening injuries Focal neurologic findings Glasgow coma scale < 14 On the field Loss of consciousness (LOC) Balance/motor incoordination Confusion Amnesia Blank/vacant look Maddock’s questions “I am going to ask you a few questions” Where are we at now? Is it before or after lunch? What did you have last class? What is your teacher’s name? ReturnReturn toto playplay == NONO Acute injury Basic trauma assessment ABCDE life threatening injuries Serial observation Appearance of symptoms might be delayed hours evolving injury acutely In the emergency department (ED) In the ED Goal #1: red flags for injury Is there an intra-cranial bleed? Is there a cervical spine injury? Risk versus benefit CT and radiation Risk ~1/1000 to 1/5000 When to image? CATCH r/o intra-cranial PECARN bleed Red flags GCS < 15 Worsening headache Worsening vomiting Irritable Severe mechanisms Suspected skull fracture (basal, depressed, open) Tincture of time Evolution of symptoms and signs since injury Canadian Pediatric Society When to image? CATCH r/o intra-cranial PECARN bleed r/o cervical spine NEXUS injury In the ED Goal #1: Red flags for injury Is there an intra-cranial bleed? Is there a cervical spine injury? Goal #2: Diagnosis Does this patient have a concussion? Acute Concussion Symptoms ex. headache, nausea Signs ex. loss of consciousness, pallor Behaviors ex. irritable, emotionally labile Cognitive ex. “foggy”/slow, confusion, amnesia Sleep ex. fatigue, insomnia Diagnostic criteria Any one or more: Initial obvious signs (LOC, convulsion, gait unsteadiness) Observer reports “off” (cognitive, behavior, emotion) Patient reports symptoms on concussion Abnormal neurocognitive and/or balance exam (McCrory et al. 2013) Assessment includes: Mental status Cognitive functioning Neurologic exam Gait Balance Standardized concussion assessment tool (SCAT3 & Child SCAT3) Neurologic exam Level of consciousness Pupil reactivity Extra-ocular movements Gross motor Coordination Gait Diagnostic criteria Any one or more: Initial obvious signs (LOC, convulsion, gait unsteadiness) Observer reports “off” (cognitive, behavior, emotion) Patient reports symptoms on concussion Abnormal neurocognitive and/or balance exam (McCrory et al. 2013) Cognitive assessment Orientation Immediate memory Concentration Delayed memory Balance Balance error scoring system (BESS) Diagnosis = Concussion …now what Brain Rest Headache Management (1st weeks) Rest Ibuprofen x 3 days Limit 3 days / week rebound Severe pain Maxeran IV, 0.5 mg/kg (max 10 mg/dose) May repeat x 3 Graded Return School Sports Back to case Assessment Reassurance Counseling Written documentation MD notes for school/sports Return to learn Attendance Restrictions: No school for 2 days thenTRAUMA progress to: Academic Recommendations & Restrictions Upon discharge from the Emergency Department following a Concussion Half-days to full daysStudent as toleratedname: Evaluation date: Allow for late arrival orIn order early to minimize departure post-concussive symptoms the following academic recommendations have been implemented to reduce cognitive load. These recommendations will help the student participate in academic activities throughout the recovery period. Accommodations may vary per course as well as according to the individual needs of the student. The student and parent(s) are encouraged to discuss and determine accommodations with both the school administration and teachers in order to ensure consistency. The student’s parents will inform the school administration when the restrictions are revoked. Attendance Restrictions: No school for 2 days then progress to: Testing: No testing for a minimum of two weeks Half-days to full days as tolerated Allow for late arrival or early departure Students who have sustained aTesting: concussion No testing for acan minimum experience of two weeks an increase in memory and attention problems. Highly demanding activities Students who have sustained a concussion can experience an increase in memory and attention problems. Highly demanding activities such as testing can significantlysuch increa as testing canse significantly these increase symptoms these symptoms and and cause headaches cause and fatigueheadaches subsequently making and testing fatigue more subsequently making testing more difficult. While the student is symptomatic, it is recommended that he/she have: difficult. While the student is symptomatic, it is recommended that he/she have: No exams, tests or quizzes No oral presentations Workload reduction: A concussed student may require more time to complete assignments due to an increase in memory problems and decreased speed of processing. It is therefore recommended to reduce the cognitive load, which may include reducing homework during the first week, and Workload reduction: allocating additional time for projects and assignments. Note taking: A concussed student may requireAs a result more of impaired time multitasking to abilities complete and increased assignmentsymptoms, taking notes mays duebecome ato difficult an task. increase Provide the student in memory problems and decreased speed of with lecture notes/outlines ahead of time in order to assist with organization and reduce multi-tasking demands. If this is not possible, permit the student to photocopy notes from another student. processing. It is therefore recommended to reduce the cognitive load, which may include reducing homework during the first week, and Breaks: allocating additional time for projects and assignments. If headaches worsen during class time, allow the student to be excused from class in order to seek a quiet area to rest until symptoms have decreased. Allow breaks as needed in order to control symptom levels (i.e. rest for an entire period in between classes as needed) Allow the student to leave class early to avoid hallway noise Allow the student to eat lunch away from the cafeteria When the student is symptom-free The student for should one not participateconsecutive in, or observe extracurricular week, activities a gradual approach to testing is important: Other accommodations/restrictions: Limit reading, using computers, and looking at smart boards while the student is very symptomatic Additional time to complete Allow tests the use of audio books if the student is very symptomatic while reading Testing in a quiet environment No music, drama and physical education (should not be in the same room during class) Allow the student to bring a water bottle to class and wear sunglasses if light-sensitive Allow testing across multiple Students sessions may have been advised to take analgesics for headache management, please allow them to do Reducedso length of tests Open book/take homeWhen tests the student when is symptom-free possible for one consecutiv e week, a gradual approach to testing is important: Allow 1-2 days between tests Additional time to complete tests Testing in a quiet environment Reformat from free response Allow testing to acrossmultiple multiple sessions choice Reduced length of tests Open book/take home tests when possible Allow 1-2 days between tests Reformat from free response to multiple choice Emergency Department MD Signature:Emergency Department MD Signature: For more information: http://www.thechildren.com/trauma/_pdf/en/trauma-concussion-flyer.pdf For more information: http://www.thechildren.H:\Public\Protocols and forms\Academiccom/trauma/_pdf/en/trauma-concussion-flyer.pdf Recommendations Rev. Sept 2013 H:\Public\Protocols and forms\Academic Recommendations Rev. Sept 2013 Return to learn Return to sports When to refer Worsening/concerning symptoms Persistent symptoms (> 10 days) Prolonged LOC (> 1 minute) Elite athletes (> 6 hours/week) Multiple concussions Risk factors Migraine, premorbid conditions MCH Trauma Program’s MTBI Clinic Team with clinical expertise Comprehensive and proactive approach Evidence-based MCH’s MTBI CLINIC Inter-professional approach Novel management strategies Active rehabilitation at 1 month Medical consultant to MTBI clinic Confirm diagnosis http://www.condenaststore.com
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