Introduction: A concussion can occur with any sort oftrauma to the head or anything that causes forceful acceleration of the brainwithin the skull, causing brain injury and temporary neurologic dysfunction(Armsby, C.). Concussions are more prevalent in children who play contactsports, but they can occur with falls, collisions with moving and non-movingobjects or persons, and even rapid acceleration or deceleration.
A lot of timeschildren who play contact sports such as hockey and football are required towear helmets, which can help aid in the deterrence of concussions. Sports wherehelmets are not a part of the uniform such as soccer or basketball also haverisk of concussion with out the added barrier for protection. In any sort ofenvironment where there is a falling risk from a moving object, like dirtbiking or horse back riding, children should be strongly advised to wearhelmets. There are risks for concussion in truly anything a child does, evenwhen they are not in a sport, which makes concussions very difficult andhazardous. Though each of these activities aredifferent in the mechanism of injury for a concussion, the general ideaclinicians need to be concerned with is both recognizing and treating a childwith a concussion.
Although unconsciousness may transpire, it is not requiredfor a child to be diagnosed with a concussion. Any child that has a concussionneeds to be treated in a very serious manner, because no concussion can betaken lightly. Children with a concussion need to be assessed by a doctorbefore they return to playing any sports (Bloom, J.). There has not been anyresearch to quantify how many concussions cause irreversible and serious damageto a child’s brain. Therefore prevention, recognition, and treatment are key.
Presentation and Scope: Patients suffering from a concussiontypically present with confusion, mild memory impairment, a headache, andoccasionally unconsciousness succeeding the concussion event. Some children maysuffer from difficulty walking, disjointed speech, poor concentration, vertigo,and vomiting (Meehan, W.). Concussions alone are serious, but other dangerousconditions also need to be ruled out after any sort of trauma such as possiblebrain hemorrhage, fractures, or spinal injuries. These sorts of diagnosesrequire emergency department assessment for pathology.
For injuries involving contact sports,clinician’s or designated health personnel are able to assess patients withoutimaging, either on the side-lines of a field immediately after incidents, or ina clinical setting. It is helpful to establish a neurologic function baselinein each child that will be participating in contact sports, to better assist inthe comparison if injury does occur (Meehan, W.). If a baseline for thespecific child has not been established, then the clinician must gauge thepatients performance on an age related basis. In a sports setting, helpfultools for assessment of concussion are as follows; by asking the child to placetheir hands on their iliac crests, close their eyes, and perform a single legstance, double leg stance, and tandem stance.
By testing if the child becomesunsteady, has to open their eyes, or take their hands off of the iliac crest inorder to maintain balance, you can assess if there is in issue with theirstability, which can reflect underlying brain injury (Bloom, J.). . “The American Academy of Neurology has identified the PostConcussion Symptom Scale and Graded Symptom Checklist as tools that canaccurately capture concussion symptoms” as stated by Pamela Mapstone, DNP. Thisscale helps to set a scoring system to assess symptoms and their severity toprovide accurate and rapid management of pediatric concussions in a nonclinicalsetting such as sporting events or in school offices (Mapstone, P.). Any child suspected to have a concussionshould be removed from the sport or activity immediately and should not returnuntil thoroughly and properly assessed by a healthcare provider. As a clinician performing an examinationto diagnose or rule out the occurrence of concussion, there are certain aspectsof the history and physical that should be the primary focus.
For the history,pertinent information involves recollection of mechanism of injury, the timingin which the event occurred, the onset of symptoms relative to the incident,the symptoms following the incident, and if the patient has had any concussionsprior (Meehan, W.). The criterion in place for diagnosing a concussion is inthe form of a scale known as, the Post Concussion symptom scale, or PCSS(Howell, D.). This scale lists 22 symptoms which asks the patient to rate theseverity on a scale from 0, being unaffected, to 6, being very severe (Howell,D.). This scale is very subjective, but has proven reliable in aiding aclinician to establish a diagnosis of concussion based off of symptom involvementand severity. It is pertinent to emphasize focus on neurologic symptoms,temporary paralysis, paresthesia, and numbness, to name a few.
These symptomsmay indicate possible spinal cord injury, which would need immediate attention.Another important entity to rule outinvolves injury to the neck. Any pain in this area would require measures to betaken for C-spine immobilization and visualization with X-ray to make surethere is no pathology. With trauma to the brain or head it is always importantto rule out hemorrhage manifesting as a subdural or epidural hematoma, forexample.
These can be life threatening and need to be excluded via imagingmodalities. Aneurologic examination of the patient should be performed thoroughly,encompassing assessment of the cranial nerves, mental status with cognitivefunction, cerebellar function of gait and balance, and sensory and motortesting. In the majority of patients with a concussion the findings of theneurologic exam will be within normal limits; however, if anything tested isabnormal, immediate assessment of brain or spinal cord injury needs to ensue(Meehan, W.
). After complete evaluation to exclude injury to the brain orcervical spine, and thorough neurologic testing, patients should be advisedthat they do not return to play any sports until all symptoms have resolved andthere is solid evidence of recovery. Immediately after incidents of concussion,the brain is at a higher risk for increased injury, which is why precautionsneed to be taken very seriously in such children. Etiology and Prevalence: As aforementioned, concussions canarise from anything causing a gyratory force to the brain within the skull. Studieson the mechanism and symptoms of concussion have been mainly carried outthrough the study of animals, thus the injury to the brain is the same, butvariations of severity in trauma and magnitude of symptoms can differ betweenspecies (Mapstone, P.). The most common etiology of pediatric concussions istrauma within contact sports.
Trauma inflicted does not have to be directly tothe head for a concussion to occur. Contact sports such as basketball, football,lacrosse, soccer, and rugby have higher occurrence rates for concussion, andthus children who partake in these activities have a higher incidence rates. Butconcussions are not exclusive to sports, which involve contact. Horse backriding, dirt biking, skate boarding, and anything involving moving objects alsocarry a risk due to prospect of falling. Children playing outside, whom happento run into something, fall from heights, or even just tripping and falling tothe ground, all have a risk of experiencing concussion. A child, who wasinvolved in a car accident, could have a concussion concomitant with whiplash,due to the sudden deceleration. There are many mechanisms of injury that cancause the brain to move within the skull, which all encompass the possibilityof resulting in minor brain trauma and neurologic disruption.
Prevention, Treatments,and Recommendations: Children partaking in an organizedactivity of any kind, where concussion is a risk, should have their baselinecognitive and neurologic status assessed and recorded. By doing so it allowsthe clinician to evaluate if injury has occurred and if so, how bad the injuryis. A step to help aid in concussion prevention is the use of helmets.
Multiplecontact sports have helmets as a part of their uniform, as it is recognized howimportant it is to protect the head. It should also be stressed for a child towear a helmet whenever they are riding on a moving object, whether it is abike, scooter, or even skates. Helmets do not stop the brain from experiencingan injurious rotational force, but they do help to lessen the impact withtraumatic contact and also protect the skull. Rest is the corner stone of therapywhen treating concussions. Children with concussions are advised to take a24-48 hour period of rest (Meehan, W.).
After this time period children mayease slowly into physical activity that does not involve contact. Children whoresume sports or physical activity too soon have amplified chance ofintensification of symptoms and risk for more damage (Howell, D.). Oncesymptoms have completely resolved the child may see a clinician to be clearedto return to sports.
Children that have symptoms of concussion should be warnedthat these symptoms might persist and even worsen after the initial event.Anything that exacerbates these concussion symptoms should be avoided. Somechildren may lie about the symptoms they are experiencing or not admit to suchsymptoms due to the want to return to playing a sport and fearing that tellingthe truth will deter them from being able to do so. Children may also notrecognize that they are experiencing symptoms of concussion (Howell, D.).
It iskey to emphasize to both the child and the parent how important it is to takeprecaution, and that it will help them to return sooner if they do not compoundthe concussion with further injury. Repeat episodes can be detrimental to achild, especially when they closely follow a previous event (Howell, D.). It isalso important that in sports settings, if there is any event during play thatprovides a mechanism where concussion can occur, that the child be removed andevaluated.
Headache, vomiting, sleep disturbances and dizziness all can betreated symptomatically and with rest. NSAIDs or Tylenol can be used to aid inthe treatment of headache, and ondansetron can aid with vomiting (Meehan, W.).If any of these symptoms persist or worsen after an extended period of time, orpast 10 days, the child should be urgently reevaluated by a clinician andreferred to a specialist if necessary. With injury to the brain, great steps need tobe made by parents and clinicians to treat and prevent harm.
The mainstay oftreatment is rest, which includes rest cognitively and physically. It isadvised that children ease back into their curriculum and that the school isinformed about the concussion and the precautions to be taken post event (Meehan,W.). Physical and cognitive rest allows the brain’s neurophysiologic functionto normalize, and decreases chance for exacerbation of injury.
By making thepublic more aware of concussions and the serious threats they pose to one’shealth, we can help to take steps to prevent them and better recognize whenthey do, to allow more rapid and efficient treatment.Summary It seems that recently concussionshave been taken much more seriously. This is prevalent in not only the world ofsports, but within the home too. The public acknowledges the danger ofconcussions and has taken steps to promote prevention and awareness. Parentsmore often place helmets on their children when riding a moving object. Ruleshave been put into place for contact sports in attempt to deter injury to thehead.
Parents and authority figures have been educated on concussionrecognition, assessment, and the immediate steps to take after such an event.Emphasis has been placed on “When in doubt, sit them out” in order to preventfurther injury, as established by the motto from, The American Academy ofPediatrics in regards to concussions. As stated prior, there is no evidence thatallows us to assign a number to the amount of concussions that will result inpermanent brain damage. With that being said all of these steps listed abovethat have been taken to educate the public, and even clinicians on concussionsand their gravity, help to alleviate potential damage and raise awareness.