Mild Head Injury in Children and Adolescents Dr. Roger Thomas MD, Ph.D, CCFP, MRCGP Professor of Family Medicine Dr. Juan Antonio Garcia-R MD, MSc, CCFP (SEM), FCFP, Dip Sports Med. Assistant Professor Dept. Family Medicine

1. Definitions 2. Diagnosis: SCAT3 and SCAT3-child Imaging 3. Treatment Outline

Interchangeable terms: * Concussion * Mild traumatic brain injury * Mild head injury (MHI) * Minor head injury * Minor closed head injury

* What symptoms would you enquire about with a person with a concussion?

* A form of head injury characterized by any alteration in cerebral function and caused by a direct or indirect (rotation) force transmitted to the head. Acute signs or symptoms: * Brief loss of consciousness * Light-headedness, * Vertigo, tinnitus, blurred vision, photophobia * Cognitive and memory dysfunction, difficulty concentrating, amnesia * Headache, nausea, vomiting * Balance disturbance. Delaney J, Frankovich R. Discussion Paper. Head Injuries and Concussions in soccer. Canadian Academy of Sport and Exercise Medicine Definition:

Delayed signs and symptoms: * Sleep irregularities * Fatigue * Personality changes * Inability to perform usual daily activities * Depression or lethargy.”

* Disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-specific signs and/or symptoms and most often does not involve loss of consciousness. * Suspected if any one or more of: - Symptoms (e.g., headache), or - Physical signs (e.g., unsteadiness), or - Impaired brain function (e.g. confusion) or - Abnormal behaviour (e.g., change in personality)” Guskiewicz KM. Register-Mihalik J. McCrory P. McCrea M. Johnston K. Makdissi M. Dvorak J. Davis G. Meeuwisse W. Evidence-based approach to revising the SCAT2: introducing the SACT3. British Journal of Sports Medicine 2013;47(5): Definition:

* 1/3 of all mild head injuries in US occur in 5-19 year olds * For children > 1 year trauma is main cause of death, and head trauma is leading cause of disability and death * In high schoolers 9% of athletic injuries involve mild head injury

* 80% to 90% of MHI cases resolve within 7 to 10 days * 24.5% of 13 to 21 year olds still having disabling symptoms one month after head trauma (up to 3 months) * 5.9% remain symptomatic after six months * Symptoms of concussion can persist up to one year

* Pathophysiologic changes after MHI are more pronounced in immature brains * Mechanism of injury: Direct trauma to the face, head or neck or transmitted force from trauma to other parts of the body. The reaction to head trauma in the pediatric and adult population differs from the adult population.

* History of prior MHI * Younger age (children and adolescents) * Mechanism and force of the injury * The sport that is practiced and the position played on the field * Female gender

* Symptoms * Details of the mechanism of injury * The time line of symptoms * Aggravating factors Child abuse should be ruled out.

* What signs would you look for in a person with a concussion?

Full Physical exam, focused on * Head - Signs of trauma - Lacerations and abrasions - Skull irregularities - fractures (e.g. depression, determination of skull discontinuity through lacerations). - Signs of basilar skull fracture (Hemotympanum, drainage of fluid or blood from the nose or ears, Battle’s sign, or the “raccoon eyes” sign)

* Complete neurological exam (focal neurological signs are frequently not found) * A balance test * Mental status: Start with Glasgow Coma Scale

Instructions for the Balance Error Exam (also printed at end of the SCAT3) 3 stance tests timed over 20 seconds: * all without shoes, socks and trousers rolled above ankle so you can observe balance * all hands on hips, eyes closed 1. Double leg stance. Feet together. 2. Single leg stance. Stand on non-dominant foot, with dominant leg 30 degrees hip flexion, 45 degrees knee flexion 3. Tandem stance: heel-to-toe, non-dominant foot behind

Take off one point for each error during each 20 second test (max errors = 10 for each test) 1. Lifted hands off iliac crest 2. Opened eyes 3. Step, stumble or fall 4. Moved hip into > 30 degrees abduction 5. Lifted forefoot or heel 6. Remained out of test position > 5 seconds

Tandem gait * Walk heel-toe along 38 mm wide tape for 3 meters then return * 4 trials and choose best time (should complete in 14 seconds) * Fail test if step off the line, or separate heel and toe, or grab an object for support Finger-Nose * Starting position: sit on chair, shoulder flexed to 90 degrees, elbow and fingers extended * Now touch nose and return to starting position 5 x * Score 1 point for 5 correct repetitions in < 4 seconds

* Perform a SCAT3 pre sports-season exam on your colleague * If your colleague did not score 100 figure out why (explanations later)

* 1134 high school athletes, Arizona, preseason (262 female, 872 male) * Average SCAT2 score 88.3 (range ) * 12 th graders = 89, 9 th graders = 86.9 (p<.001) * No concussion history = 88.7, concussion history = 87 (p <.001)

* Average score = 89 * Average balance score 26 (max 30), all completed double leg stance * Only 67% could recite months of year backwards (55% footballers) * Only 41% could correctly sequence 5 digits backwards (32% footballers)

AverageMax possible Symptom score Physical signs score 22 Glasgow Coma Scale 15 Balance score Coordination Subtotal

AverageMax possible Orientation Immediate memory score Concentration score Delayed recall SAC subtotal SCAT2 total100

* Radiographs have low predictive value in patients with no loss of consciousness and no clinical signs of skull fracture. * CT if a major concern exists about intracranial lesion (Controversial) * No consensus exists about the use of neuropsychological testing. Possible indications: Persistent symptoms preventing return to academic or sport activities or determination of resolution of the concussion.

* It is done according to the status and progress of the individual patient rather than on grading as it was suggested in the past * Severe injury or complications have been ruled out * The main strategy of the management of MHI is rest and prudent observation for 24 to 48 hrs.

* Any deterioration in clinical status during at any should prompt further evaluation * Tests providing standardized symptom scores are helpful to assess the patient’s progress

* The child should be allowed to sleep but checked periodically for clinical deterioration * During the initial hours medications should be avoided that could affect evaluation of cognition (e.g. meclizine, benzodiazepines), mask symptoms (e.g. anti-emetics) or facilitate bleeding (e.g. ASA, NSAIDs). * Avoid participation in sports/physical activities and this decision should made clear to parents, coaches, trainers and teachers * Gradual return: Mental and Physical activities * F MD Roll: Acute phase, after the acute phase or as part of post- concussion syndrome

Abstain from intense mental activities: * Reading * Use of computers * Videogames * Solving puzzles or Sudokus * Texting * Watching TV * Schoolwork

 Regular assessment (clinic or at home)  Educate how to identify improvement, chronicity or worsening of the condition (Symptoms, time lines, course, how to cope with symptoms, access to medical services)  Are adequate resources available for that purpose?

* Geographical accessibility * Adequate transport * Assess for reliable caregivers or parents Impediments for parental participation: * Incompetence * Previous neglect of children * Intoxication * Unavailability * Language barrier. If conditions are not adequate observation to be done in a health care facility.

HeadacheAcetaminophen >6 weeks: Multidisciplinary mng Sleep disturbance If persistent: Sleep hygiene, observation Meds and cognitive therapy Daytime somnolenceNo meds in acute phase Mood disorders management If >6-12 weeks No meds Meds and counseling VertigoVestibular therapy Attention DeficitsNo meds Decrease academic demands Management After acute phase/PCS

* Key problems are attention, executive function, memory and social interaction * Cognitive training to improve attention performing everyday and work activities, including pacing, training on single tasks then combining them * Cognitive training in planning, problem solving, reasoning skills * Social communication with communication partners and in group formats * Improving memory skills and integrating them with external memory aids (e.g. cell phones)

1. A thorough history and physical are required to describe the trauma, symptoms and pre-trauma baseline status 2. The SCAT3 and SCAT3-child are evidence-based assessment tools 3. The CATCH and PECARN studies provide detailed guidance in ordering imaging and predicting outcomes 4. Pre-trauma baselines are variable and should be measured before the sports season 5. Studies of follow-up of concussion have marked attrition 6. There are many guidelines but minimal evidence how to accomplish full rehabilitation

Thank you for listening !

* 3866 children, median age 9 years (range 1-16) * Mechanism: 45% falls, 23% sports, 12% hit by object, 9 % bicycle, 4 % struck as pedestrian, 3% MVA Symptoms and signs: * 59% Amnesia * 54% Witnessed disorientation or confusion * 41% Vomited ≥ 2 * 33% Witnessed loss of consciousness * Glasgow Coma Scale score: 15 in 90%, 14 in 7%, 13 in 2.5%

Definition of minor head injury: * within past 24 hours * Glasgow Coma Scale * witnessed loss of consciousness, amnesia * witnessed disorientation * 1 episode vomiting * persistent irritability (in child < 2 years) Rule: CT of head required for children with any one high or medium risk finding

High risk signs: 1. GCS < 15, two hours after injury 2. Suspected skull fracture 3. Worsening headache 4. Irritability

* Your colleague’s 5 year old was hit hard at sports and has 2 high risk signs. Your colleague does not want to image but explain your decision.

Needed neurologic intervention Did not need neurologic intervention ≥ 1 high risk factor No high risk factors %CI Sensitivity100%86% to 100% Specificity70%69% to 72%)

Medium risk signs: 5. Any sign of basal skull fracture 6. Large boggy hematoma of scalp 7. Dangerous mechanism of injury (MVA, Fall ≥ 3 feet or 5 stairs, fall from bike no helmet

Needed neurologic intervention Did not need neurologic intervention ≥ 1 risk factor No risk factors %CI Sensitivity98%95% to 99% Specificity50%49% to 52%)

Results: * 5% (192) skull fractures * 4% (159) acute brain lesion * 1.4% (55) epidural hematoma * 1 % cerebral contusion * 1% pneumocephalus * 0.8% subdural hematoma 0.6% neurological intervention (20 craniotomy, 6 intubation)

* 42,412 children 25 US emergency departments * 35% (14,969) received CT Rule for children < 2 years: * normal mental status * no scalp hematoma (except frontal) * no loss of consciousness (or < 5 seconds) * non-severe injury mechanism * no palpable skull fracture * acting normally according to parents

95%CI Negative predictive value 100%99.7 to 100% Sensitivity100%86.3 to 100%

Rule for children ≥ 2 years: * normal mental status * no loss of consciousness (or < 5 seconds) * no vomiting * non-severe injury mechanism * no signs of basilar skull fracture * No severe headache

95%CI Negative predictive value 99.95%99.81 to 100% Sensitivity96.8%89.0 to 99.6%

* Discuss with a colleague the sensitivity and specificity of imaging and the likely outcome for the child based on these studies