Pediatric Mild Traumatic Head Injury

Pediatric Mild Traumatic Head Injury
Adapted from Illinois Emergency Medical Services For Children September 2009 Welcome to the “Pediatric Mild Traumatic Head Injury” educational module. 1 1 1 Illinois EMSC is a collaborative program between the Illinois Department of Public Health and Loyola University Medical Center. Development of this presentation was supported in part by: Grant 5 H34 MC from the Department of Health and Human Services Administration, Maternal and Child Health Bureau 1

Acknowledgements Illinois EMSC Quality Improvement Subcommittee 2 2 2
Susan Fuchs MD, FAAP, FACEP Subcommittee Chairperson Children’s Memorial Hospital Cathie Bell RN, TNS Methodist Medical Center of Illinois Leslie Foster RN, BSN OSF Saint Anthony Medical Center Jan Gillespie RN, BA Loyola University Health System Molly Hofmann RN, BSN OSF Saint Francis Medical Center Kathy Janies BA Illinois EMSC Dan Leonard MS, MCP Illinois EMSC Evelyn Lyons RN, MPH Illinois Department of Public Health Patricia Metzler RN, TNS, SANE-A Carle Foundation Hospital Anita Pelka RN The University of Chicago Comer Children’s Hospital Anne Porter RN PhD Loyola University Health System Demetra Soter MD John H. Stroger, Jr., Hospital of Cook County Sheri Streitmatter RN Kewanee Hospital John Underwood DO, FACEP Swedish American Hospital LuAnn Vis RNC, MSOD Loyola University Health System Beverly Weaver RN, MS Lake Forest Hospital Leslie Wilkans RN, BSN Advocate Good Shepherd Hospital Clare Winer M.Ed., CCLS Consultant, Healthcare & Education This educational module was developed by the Illinois EMSC. If you wish to cite any of the materials contained in this module, citation information is listed on this slide. Any information presented in this module may be used freely provided appropriate acknowledgement is cited. Finally, nothing in the module should be considered a replacement of prudent and cautious judgment of the healthcare provider treating a child. Every situation is unique and requires individualized care and independent treatment options. 2 2 2 Additional Acknowledgements Mark Cichon DO, FACOEP, FACEP Loyola University Health System Karl Cremiux BA, MLS Editor/Writer Chicago Jill Glick MD The University of Chicago Comer Children’s Hospital Yoon Hahn MD, FACS, FAAP University of Illinois at Chicago Carolynn Zonia DO, FACEP Loyola University Health System Suggested Citation: Illinois Emergency Medical Services for Children (EMSC), Pediatric Mild Traumatic Head Injury, September 2009 2

Table of Contents Introduction & Background Mechanisms of Injury
Child Maltreatment & Mandated Reporting Signs & Symptoms Assessment (with a Pediatric GCS Primer) Imaging Management Discharge Planning Potential Complications Conclusion Additional Resources Citations For More Information Appendix A: Abusive Head Trauma Appendix B: Information for Parents/Caregivers/Coaches This module is divided into chapters. You may view the presentation from start to finish. Or, you may jump to specific sections of the presentation by clicking on the corresponding link. This presentation includes many links to online references. To go to a link, click the link, and a separate window will open. You may also need to turn off pop-up blockers on your computer. The Illinois EMSC is not responsible for the content of these external Web sites. 3 3 3 3

Introduction & Background
Now, we will provide some background information and define mild traumatic head injury. 4 4 4

Purpose The purpose of this educational module is to enhance the care of pediatric patients who present with mild traumatic head injury. It will discuss a number of topics including: Assessment Management Disposition & Patient Education Complications This module was developed by the Illinois Emergency Medical Services for Children QI Subcommittee and is intended to be utilized by all healthcare professionals serving a pediatric population. This module is designed to help you, as an emergency care professional, appropriately assess, manage, discharge and educate your patients who present with a mild traumatic head injury. In addition, the module reviews how to recognize and manage potential complications, and provides additional useful resources. It intended to be used by all healthcare providers who care for pediatric patients. 5 5 5

What Is Mild Traumatic Head Injury?
The term, mild traumatic head injury (MTHI) has been applied to patients with certain types of head injuries for many years. However, despite its more widespread use, there is not a standardized definition. MTHI is commonly referred to as concussion or mild traumatic brain injury - the terms are used interchangeably. Throughout this module, we will refer to the condition of mild traumatic head injury by the acronym MTHI. Although a common occurrence, there is no formal agreed upon medical term for this condition. In addition to MTHI, other names for this type of injury are concussion or mild traumatic brain injury. 6 6 6 6

Common Features of MTHI
Most definitions of MTHI include the following elements: Involves an impact to, or forceful motion of, the head Results in a brief alteration of mental status such as: confusion or disorientation memory loss immediately before/after injury brief loss of consciousness (if any) less than 20 minutes Glasgow Coma Scale score of 13 – 15 If hospitalized, admission is brief (e.g., less than 48 hours) Possible amnesia – while amnesia does not need to be present, it is a good predictor of brain injury Although definitions of MTHI vary, common elements include the following: MTHI involves an impact to, or forceful motion of, the head. There is minimal or reversible brain injury. There may be a brief change in mental status such as memory loss, loss of consciousness, confusion or disorientation. However, these do not necessarily need to be present in MTHI. A common tool to assess the mental status of a patient is called the Glasgow Coma Scale. We will discuss this tool in detail later in the module. For now, a brain injury resulting in a Glasgow Coma Scale score of 13 to 15 is considered a MTHI. Because the symptoms of MTHI are considered minor, hospital admission, if necessary, is usually less than 48 hours. Amnesia is possible. While not every child will experience amnesia, experience shows that its presence is a good indicator of some form of brain injury. 7 7 7 7

MTHI vs. Traumatic Brain Injury (TBI)
In MTHI, the brain temporarily becomes functionally impaired without structural damage. In TBI, there is structural damage to the brain. Please note that this module discusses mild brain injuries. There are also more severe injuries that fall under the term “traumatic brain injury.” These injuries are beyond the scope of this education. The difference between the two is in the structural damage to the brain from the impact. In MTHI, the brain temporarily becomes functionally impaired, but does not involve structural injury. In traumatic brain injury, there is structural damage that has the potential to be permanent. 8 8 8 8

Simple and Complex Injury
Brain injury can be classified as simple or complex based on clinical presentation. Simple: symptoms resolve in 7-10 days Complex: Symptoms persist longer that 10 days Multiple concussions Convulsions, coma or loss of consciousness (LOC) greater than 1 minute Prolonged cognitive impairment Meehan 2009 Head injuries can be classified as simple or complex. Determining a simple versus complex brain injury is based upon the clinical presentation rather than anatomic findings. A simple brain injury usually takes less than 10 days to resolve. Cognitive impairments, if present, are brief and reversible. Conversely, hallmarks of a complex injury include: multiple concussions, convulsions, coma, or loss of consciousness that lasts more than one minute. 9 9

Atabaki 2007; Brener 2004; Berger 2006
National Statistics Head injury is a leading cause of morbidity during childhood in the U.S. More than 1.5 million head injuries occur in U.S. children annually, resulting in over 300,000 hospitalizations. Males are twice as likely as females to sustain a head injury. Up to 90% of injury-related deaths among U.S. children are associated with traumatic head injury (leading cause of death in traumatically injured infants). Cost of head injury in children living in the U.S. is $78 million per year (based on 2004 data). Atabaki 2007; Brener 2004; Berger 2006 Here are some alarming statistics about head injuries sustained by children in the United States. These statistics reinforce that this is a significant issue in children. 10 10 10 10

Objectives After completing this module, you will be able to:
Describe the mechanism of mild traumatic head injury in children Perform an assessment of a child suspected to have suffered a mild traumatic head injury Develop an effective management plan Appropriately educate children & parents/caregivers so they can recognize, care for, and prevent mild traumatic head injuries Understand common complications Now, let’s review the main objectives of this education. Upon completion, you will be better prepared in the following areas when a child presents with a mild traumatic head injury: describe the mechanisms of the injury, perform an initial assessment, create an effective management plan, provide appropriate education to your patients and families, and become familiar with common complications. 11 11 11 11

Key Concepts Mild traumatic head injury can occur as the result of even relatively minor impact to the head. When evaluating a pediatric patient for mild traumatic head injury, the Pediatric Glasgow Coma Scale is an accurate, easily reproducible, and commonly used tool in assessing neurologic status. Computed tomography (CT) is a valuable tool in diagnosing mild traumatic head injury, but should be used judiciously. Under appropriate circumstances, mild traumatic head injury can often be managed by observation alone. The effects of recurrent head injuries are cumulative - advise children and caregivers to avoid any situation in which the child may sustain additional blows to the head. Allow time to resolve - a mild traumatic head injury can take days and even weeks or more for the child to return to a normal state. In regards to returning to a normal activity level, When In Doubt, Sit Them Out. After completing this education, you will understand the following key concepts: Mild traumatic head injury can occur as the result of even relatively minor impact to the head. When evaluating a pediatric patient for mild traumatic head injury, the Pediatric Glasgow Coma Scale is an accurate, easily reproducible, and commonly used tool in assessing neurologic status. Computed tomography is a valuable tool in diagnosing mild traumatic head injury, but should be used judiciously. Under appropriate circumstances, mild traumatic head injury, can often be managed by observation alone. The effects of recurrent head injuries are cumulative. Advise children and their caregivers to avoid any situation in which the child may sustain additional blows to the head. Allow time to resolve - a mild traumatic head injury can take days and even weeks or more for the child to return to a normal state In regards to returning to a normal activity level, it is helpful to use a phrase coined by the CDC’s Heads Up: Concussion in Youth Sports program, which is “When In Doubt, Sit Them Out.” 12 12

Mechanisms of Injury Now, we will discuss the common mechanisms of injury for this diagnosis. 13 13 13

Biomechanics – Primary Forces
Impact or direct blow to the head Head can be fixed Head can move in a linear plane Inertial forces result in straining of the underlying neural elements Rotational force - when the brain is the center of the rotational axis Angular force - when the neck is the center of the rotational force Hypoxic injuries to the brain due to cessation of oxygenation (e.g., suffocation, strangulation, drowning) Evans 2008; Meehan 2009 Several types of forces come into play in MTHI. Force exerted on the child does not necessarily need to occur directly to the head to cause an injury. Forces to other parts of the body can cause the brain to change its state of motion. Angular forces cause injury when the body is struck forcing the head to move in an opposing linear fashion. A rotational force causes injury when the brain is in the center of the rotational axis. Hypoxic injuries, such as suffocation or strangulation, are also considered primary forces that can lead to MTHI. 14 14 14 14

Pathophysiology of Cellular Injury
Immediate disruption of neuronal membranes results in massive efflux of potassium into extracellular space Concentration of potassium triggers neuronal depolarization and neuronal suppression alters blood flow Sodium pumps work to restore homeostasis resulting in cerebral blood flow that increases or decreases Mitochondrial dysfunction with impaired cerebral glucose metabolism, and, if present, can persist as long as 10 days Evans 2008; Alexander 1995; Meehan 2009 This is a simplified description of what happens to the brain when it experiences an injury. Immediately upon impact, within the brain there is a massive out flow of potassium into the brain cavity which triggers neuronal suppression that alters the blood flow. The body’s sodium pumps work to correct this potassium imbalance that then results in increased or decreased cerebral blood flow. Mitochondrial dysfunction can occur along with impaired cerebral glucose metabolism, and can last as long as 10 days. 15 15 15 15

Pathophysiology of Cellular Injury
Predominantly neurometabolic and reversible when force is not significant Changes are a multilayer neurometabolic cascade: ionic shifts, abnormal energy metabolism, diminished cerebral blood flow and impaired neurotransmission Small number of axons involved; axons recover If injury produces LOC, cortex and subcortical white matter will be primarily affected The injuries are predominantly neurometabolic and reversible. There is no structural damage. There is a change in the neurometabolic cascade; cerebral blood flow may become impaired. A relatively small number of axons are involved, but they generally recover. If there is a loss of consciousness, the cortex and subcortical white matter will be the primary areas affected. Evans 2008; Alexander 1995; Meehan 2009

Acceleration/Deceleration
Forces causing abrupt changes in the speed or motion of the brain within the skull are called acceleration or deceleration. The movement of the skull through space (acceleration) and the rapid discontinuation of this action when the skull meets a stationary object (deceleration) causes the brain to move at a different rate than the skull. Different parts of the brain move at different speeds because of their relative lightness or heaviness. The differential movement of the skull and the brain when the head is struck results in direct brain injury. Acceleration - Deceleration injuries can be caused by linear as well as rotational impact. Traumatic Brain Injury.com Mechanically, the brain can be injured by two types of forces - acceleration or deceleration. These injuries occur when the speed or motion of the brain abruptly changes within the skull. Due to differences in relative weight, parts of the brain move at different speeds within the skull. Acceleration and deceleration injuries can be caused by linear impact, meaning the brain moves forward-or-backward or side-to-side in a direct angle of motion from the impact, or rotational impact, meaning the brain undergoes a twisting movement. 17 17 17 17

Acceleration Direct blow to the head Skull moves away from force
Brain rapidly accelerates from stationary to in - motion state causing cellular damage In a brain injury via acceleration, the skull moves directly away from the blow. The brain rapidly changes from a stationary to a moving state. The injury to the brain results in bruising from impact, as well as cellular damage due to the sudden change in motion. 18 18 18 Acceleration 18

Deceleration Head impacts a stationary object (e.g., car windshield)
Moving skull stops motion almost immediately However, brain, floating in cerebral spinal fluid (CSF), briefly continues moving in skull towards direction of impact, resulting in significant forces that damage cells When the brain becomes injured because of a sudden stop in motion, it is an injury of deceleration. An example is when the child’s head hits a car windshield. Here, the skull stops immediately, but the brain continues moving toward the point of impact resulting in cellular damage. 19 19 19 Deceleration 19

Coup/Contra-Coup Injury resulting from rapid, violent movement of brain is called coup and contra-coup. This action is also referred to as a cerebral contusion. Coup: an injury occurring directly beneath the skull at the area of impact Contra-coup: injury occurs on the opposite side of the area that was impacted Coup injury Coup and contracoup injuries, also referred to as cerebral contusion, result from a rapid, violent movement of the brain. In a coup injury, the brain is damaged at the impact site. In contracoup, the injury occurs on the side directly opposite the impact. Contracoup injury 20 20 20 20

Focal/Diffuse Injuries
Brain injuries can be classified as either focal or diffuse When an injury occurs at a specific location, it is called a focal injury (e.g., being struck on the head with a bat). A focal neurologic deficit is a problem in a nerve function that affects a specific location or function. Examples: - Numbness, decrease in sensation - Paralysis, weakness, loss of muscle control/tone In diffuse injury, the impact is spread over a wide area, such as being tackled in a game of football that results in a general loss of consciousness. Brain injuries can also be either focal or diffuse. In a focal injury, the injury occurs in a localized area of the head or brain, such as the area receiving an impact from a baseball bat. A focal neurologic deficit is a problem in a nerve function that affects a specific location or function. Examples of focal neurologic deficits are numbness, weakness or loss of muscle control. In a diffuse injury, the area affected is broader and extends well beyond the site of the actual impact. This would occur in a situation such as being tackled in a game of football resulting in a general loss of consciousness. 21 21

Level of Severity: High Risk
Certain conditions present a high risk for serious injury: Motor vehicle collision, particularly with ejection or rollover Pedestrian or un-helmeted bicyclist struck by motorized vehicle Fall from greater than 5 feet/1.5 meters Impact with or struck by an object Contact sports Child maltreatment Certain behaviors or situations present a greater likelihood that the child suffered a serious head injury. Consider the child to be at “high risk” in the following situations: - Motor vehicle collisions, especially when a passenger has been ejected or the car has rolled over. - When a pedestrian or unhelmeted bicyclist has been struck by a motor vehicle. - When a child falls from a height greater than five feet or 1.5 meters. - Whenever the skull strikes an object, such as a car windshield, or is struck itself by an object like a baseball bat. - Contact sports, particularly football, have a high rate of MTHI, even when the athlete is helmeted. - Finally, as we’ll learn about in later slides, child maltreatment is also considered “high risk” for a serious head injury. 22 22 22 Link to History (slide 48) 22

Short Vertical Falls: Incidence
Frequently, parents/caregivers bring their young children to the ED for an evaluation with a history of a short vertical fall (defined as 1.5 meters/5 feet in height). An extensive review of the literature showed that short falls account for less than 0.48 deaths per 1 million young children (0-5 years of age) per year. Remember: Suspect and evaluate for child maltreatment if a short vertical fall history does not match the severity of the injuries. Chadwick 2008 It is rare, but not impossible, for a child to sustain a serious injury from a vertical fall of less than 5 feet high. If the severity of the injury does not match the situation described, be suspicious during the examination. Make sure the story from the caregiver makes sense in relation to the severity of the injury. Every situation is unique, and children can become injured in many different ways. But, as statistics show, it is uncommon that a child will suffer a significant brain injury from a vertical fall of less than five feet high.

Children vs. Adults Children have greater disposition to head trauma:
Greater head mass relative to body weight ratio making them top-heavy Neck musculature has not been developed to handle relatively heavier structure Increased head weight results in increased momentum during falls or injuries Brain area has more fluid: more susceptible to wave- like forces Less myelination Thinner cranial bones more easily shattered Fuchs 2001 Like most conditions, there is a significant difference in the way MTHI affects children versus adults. This is mainly due to structural differences in the still developing head and brain of a child. The ratio of head mass to body size is much greater in children. Their heads weigh more in relationship to their overall weight than do adults. However, children’s neck muscles are not necessarily physically strong enough to control this excess weight. When the body receives an impact, their larger head size results in increased momentum, combined with a lack of control, causing a greater injury. Also, a child’s brain area has a greater percentage of fluid, which makes it more susceptible to wave-like forces that can cause greater injury. Now, let’s talk about the mechanisms of injury based on the child’s developmental status. 24 24 24 24

Sellars 1997; National Research Council 2000; Savage 1994
Infants & Toddlers Limited head control Open fontanels mean less brain protection More susceptible to seizures than older children Emerging motor and expressive language skills at risk for regression Synaptic connections become interrupted resulting in decreased functional processing Focal injuries may have better outcome Common mechanisms include: falls, child maltreatment, and motor vehicle collisions. Sellars 1997; National Research Council 2000; Savage 1994 We will start with infants and toddlers - an extremely vulnerable period of development. As previously stated, the ratio of the weight of their head to the rest of their body, and their underdeveloped neck muscles, put them at risk for injuries in situations that may not affect an older child. The infant’s fontanels are open, leaving the brain unprotected. Younger children have a higher incidence of immediate post traumatic seizures. At this stage, a child is at a critical juncture in the development of language and motor skills. The immature nervous system is rapidly acclimating itself to its changing environment. Synaptic connections between the nerves are just developing, and so are fragile. However, due to the rapidly developing connections, focal injuries have a greater chance for a good outcome. The most common types of injuries are falls and motor vehicle collisions. In all developmental age groups, always consider child maltreatment as a factor. 25 25 25 25

Elementary & Middle School Students
Functional and developmental risk Connections between the two hemispheres of the brain and within each hemisphere may become less efficient Brain injury during this time period may interrupt development of critical cognitive and communication skills Common mechanisms include: falls, sports, child maltreatment, bicycle injuries, motor vehicle collisions, and pedestrian-motor vehicle collisions. Sellars 1997; National Research Council 2000; Savage 1994 Like infants and toddlers, the elementary and middle school child’s body and brain continues to develop. An interruption of this process can have serious negative effects. At this developmental age, the connections between the two hemispheres of the brain are starting to ‘talk’ to each other. When this conversation is disrupted because of a brain injury, cognitive ability can suffer. The common mechanisms of injury for this age group are similar to infants and toddlers. Except now the older child participates in sports, starts bicycle riding, and is more at risk for pedestrian versus motor vehicle collisions. And, again, always be vigilant for signs and symptoms of child maltreatment. Unexplained brain injuries or injuries whose symptoms do not match the described event require further investigation. 26 26 26 26

High School Students Functional and developmental risk
Damage to cellular myelinization of the frontal lobes may reduce creation of efficient connections that facilitate development of logical thinking and ability to solve complex problems Psychosocial effects of brain injury such as slower response to stimuli threaten adolescent’s sense of self Common causes include: motor vehicle collisions (due to lack of driving experience) and sports injuries (due to increased participation). A marked increase in alcohol and/or substance abuse, predisposition to greater risk-taking behaviors, and greater exposure to violence can lead to more injuries. In all age groups, child maltreatment is a potential cause. Sellars 1997; National Research Council 2000; Savage 1994 Although developmentally older, a high school child’s brain is still developing. At this point, brain injury can damage the portions of the brain that are responsible for logical thinking and the ability to solve complex problems. Even mild head injuries can negatively affect an adolescent’s verbal and motor responses, as well as result in permanent emotional changes. Common causes of head injury in this age group are motor vehicle collisions, due to lack of driving experience, and sports injuries, due to increased participation in contact sports. In addition, there is a marked increase in alcohol and substance abuse, a predisposition to greater risk-taking behaviors, and greater exposure to violence – all conditions that can lead to more head injuries. Finally, you still must be vigilant for signs of child maltreatment. A child’s age is no guarantee against maltreatment. 27 27 27 27

Test Your Knowledge 1. Which of the following symptoms is an example of a focal neurological deficit? A. Loss of consciousness B. Amnesia C. Numbness D. Polydypsia Click the Answer button below to see the correct response. Answer What is the correct answer to this question? Click the answer button to see the correct response. C. Numbness is evidence of a focal rather than a diffuse injury. 28

Test Your Knowledge 2. Which of the following is a common mechanism of injury for all developmental levels? A. Motor vehicle collisions B. Bicycle riding C. Risk-taking behaviors D. Contact sports Click the Answer button below to see the correct response. Answer What is the correct answer to this question? Click the answer button to see the correct response. A. Motor vehicle collisions are a common mechanism of injury for children of all ages. 29

Child Maltreatment & Mandated Reporting
In this chapter, we will review the issue of child maltreatment, including abusive head trauma. In addition, we will briefly review the role and responsibilities of the mandated reporter. 30 30

Illinois Department of Children & Family Services 2009
Child Maltreatment Definition: Mistreatment of a child under the age of 18 by a parent, caretaker, someone living in their home or someone who works with or around children. Must lead to injury or put the child at risk of physical injury Can be physical (e.g., burns or broken bones), sexual (e.g., fondling or incest) or emotional Neglect: When a parent/caregiver fails to provide adequate supervision, food, clothing, shelter or other basics for a child Healthcare providers should always be aware of the signs & symptoms of child maltreatment and cautiously consider it in their assessment of the child Be on the alert to identify children with symptoms of abusive head trauma (detailed in Appendix A) Remember: Younger children are very resilient to mild head trauma. It usually takes a significant event to cause serious injury. EMSC – Indicators of Potential Pediatric Maltreatment Illinois Department of Children & Family Services 2009 Child maltreatment is an insidious problem. It can occur in any socioeconomic group, within any level of caregiver education, in urban or rural settings, and in any race or religious group. Child maltreatment comes in many forms – physical, sexual and emotional, including neglect. Because we are learning more and more about the causes of child maltreatment, much of our terminology and approach are changing. For example, the term Shaken Baby Syndrome is replaced by the term Abusive Head Trauma, which takes into account that malevolent physical actions can be much more that just violent shaking. Illinois EMSC has developed a guideline to help healthcare providers identify the signs and symptoms of maltreatment. Click on the icon to download a printable version of the resource. Also, click on the link to the Illinois Department of Children and Family Services, known as DCFS, Web site for more information. 31 31 31 (33 KB) 31

Texas Department of Family and Protective Services 2010
Mandated Reporting Reporting suspected abuse is mandated by Federal law for personnel in specific professions working with children (e.g., medical, school/child care, law enforcement, clergy, social work, state agency staff dealing with children, etc.). Mandated reporters must make reports if they have reasonable cause to suspect abuse or neglect (even if you are transferring the child). Hospitals must report suspected abuse even if transferring patient to another institution. Each state is responsible for providing its own definition of maltreatment within civil and criminal contexts (if outside of Texas, check your state’s definition). Members of the general public can report, but are not mandated. In Texas, the child abuse hotline number is or Texas Department of Family and Protective Services 2010 Reporting suspected abuse is mandated by Federal law for personnel in specific professions working with children for example: medical, school or child care, law enforcement, clergy, social work, and state agency staff dealing with children. As a mandated reporter, you must make reports if you have reasonable cause to suspect abuse or neglect. Child Maltreatment is a criminal and civil violation. Each state has its own agencies and guidelines to help a child suffering from abuse. Remember, you must report suspicions even if your patient is being transferred to another facility. Illinois’ child maltreatment hotline is ABUSE. 32

Mandated Reporting (cont.)
As a healthcare professional, call the hotline whenever you suspect a person who is caring for the child, who lives with the child, or who works with or around children has caused injury or harm or put the child at risk of physical injury. Some examples include: If a child tells you that he/she has been harmed by someone. If you see marks that do not appear to be from developmentally appropriate behavior (e.g., babies with bruises). If a child who sustains a serious injury where the history does not fit the sustained injury (esp. a non-ambulatory child). If a child has not received necessary medical care. If a child appears to be undernourished, is dressed inappropriately for the weather, or is young and has been left alone. What are the hallmarks of child maltreatment? Essentially, you may suspect abuse if the caregiver’s explanations of why the injuries occurred do not match the clinical possibilities of the child’s presentations. For example, if the history given is that a 2 week old infant rolled off the bed and sustained a broken arm, consider child maltreatment. Developmentally, a 2 week old infant is not yet able to roll, so it would be implausible for her to roll of the bed and break a limb on her own accord. To help diagnose abuse, Illinois DCFS has developed a guideline to help healthcare providers recognize and report child abuse. Click on the link to see more. 33

Test Your Knowledge 1. In which of the following situations are mandated reporters legally bound to report? A. History of a one-week-old infant presenting with a femur fracture rolling off a couch on to a carpeted floor. B. During an exam to rule out gastroenteritis, a six-year-old girl reports that her mom’s boyfriend hits her when mom is not home. C. History of two-month-old boy presenting for unexplained crying who is noted to have had no weight gain since birth. D. All of the above. Click the Answer button below to see the correct response. What is the correct answer to this question? Click the answer button to see the correct response. 34 Answer D. All of the above situations must be reported as instances of potential maltreatment or neglect.

Signs & Symptoms In this chapter, we will review the signs and symptoms of mild traumatic head injury. 35 35

Physical Headache Nausea/vomiting
Problems with balance/walking/crawling Dizziness Visual problems Fatigue or lethargy Sensitivity to light or noise Numbness or tingling Feeling dazed or stunned Any deviation from normal/baseline as per parent/caregiver CDC Heads Up: Facts for Physicians Your patient may present with any of the following physical signs and symptoms: headache, nausea and vomiting; problems with balance, walking or crawling; dizziness; visual problems; fatigue; light or noise sensitivity; numbness or tingling in the extremities; feeling dazed; or any deviation from the child’s “usual” behavior as reported by the parent or caregiver. 36 36 36 36

Cognitive Feeling mentally “foggy” Feeling slowed down
Difficulty concentrating Difficulty remembering Forgetful of recent information or conversations Confused about recent events Answers questions slowly Repeats questions Any deviation from normal/baseline as per parent/caregiver CDC Heads Up: Facts for Physicians Watch for these potential cognitive signs and symptoms: feeling mentally “foggy” or slowed down; difficulties with concentration; memory difficulties; forgetfulness or confusion about recent events; or slow response to questions. Again, be alert for any deviation from the child’s “usual” behavior as reported by the parent or caregiver. In addition, these signs and symptoms may be picked up by the child’s teacher or school staff. 37 37 37 37

Emotional Irritability Sadness Increased demonstration of emotions
Nervousness Loss of impulse control Difficult to console Shows lack of interest in favorite toys/activities Any deviation from normal/baseline as per parent/caregiver CDC Heads Up: Facts for Physicians Potential emotional signs and symptoms that may accompany MTHI include: irritability; sadness; an increased demonstration of emotions; nervousness; impulsivity; inconsolability; lack of interest in favorite toys or activities; or any deviation from the child’s “usual” behavior as reported by the parent or caregiver. 38 38 38 38

Sleep Drowsiness Sleeping less than usual Sleeping more than usual
Trouble falling asleep Any deviation from normal/baseline as per parent/caregiver CDC Heads Up: Facts for Physicians Sleep patterns may be affected by a MTHI. Check with the parent or caregiver for any changes in sleep patterns such as increased drowsiness; sleeping more or less than usual; trouble falling asleep; and any other changes from their “usual” patterns. 39 39 39 39

Conditions With Similar Symptoms
Not every child experiencing these symptoms has a MTHI. A careful history and assessment is necessary to confirm the diagnosis. Similar symptoms can also result from: Dehydration Heat related Overexertion Lack of sleep Eating disorders Reaction to medications Learning disabilities Depression Meehan 2009 Making the diagnosis of MTHI can be difficult. There are several other medical conditions whose symptoms mimic that of MTHI, such as dehydration, lack of sleep or depression. These confounding conditions can delay diagnosis and treatment. Again, it is critical to complete an accurate and in-depth medical history to distinguish MTHI from other conditions with similar symptoms. 40 40

Test Your Knowledge 1. Which of the following signs and symptoms should alert you to a possible MTHI? A. History of nausea and vomiting B. Having trouble remembering recent events C. Increased irritability D. All of the above Click the Answer button below to see the correct response. Answer What is the correct answer to this question? Click the answer button to see the correct response. 41 D. All of the above are signs and symptoms of a possible MTHI.

Test Your Knowledge 2. True or False: Similar signs and symptoms of MTHI can also be attributed to a patient with an eating disorder. Click the Answer button below to see the correct response. Answer What is the correct answer to this question? Click the answer button to see the correct response. True. An eating disorder is among several diagnoses with similar signs and symptoms to MTHI. A careful history and assessment is necessary to confirm the diagnosis. 42

Assessment (with a Pediatric GCS Primer) 43 43 43
Now, let’s review the elements that make up an appropriate assessment, including a refresher on how to calculate an accurate Pediatric Glasgow Coma Scale score. 43 43 43

History A detailed history is critical in assessing MTHI. Consider:
Age of child; developmental history/ability Medical history: Medications (prescription, OTC, herbal, etc.) Past illnesses Past hospitalizations Previous head injuries History related to event: Time of injury Emesis Loss of consciousness / Amnesia Severity and mechanism of injury Was injury witnessed by a reliable person? Fuchs 2001 Taking an accurate and complete history is critical to accurately diagnose MTHI. Ideally, you should obtain information about current medications, past illnesses, past hospitalizations, and overall health. It is vital that the patient’s history include the details of any previous head injuries. Recent recurrent head injuries have a cumulative negative effect, and substantially increase the risk of intracranial injury. In addition, you should ask about the event itself. What was the time of the injury? Did the child suffer any bouts of emesis? Did the child lose consciousness or suffer amnesia for any length of time? Was the injury witnessed by a reliable person? Having a reliable witness is important especially in children who may be too young to accurately describe the details of the event. 44 44 44 44

Primary Assessment Begin your immediate assessment by following the ABCs: Airway Breathing Circulation Always consider the possibility of cervical spinal injury. Determine the child’s orientation to people, place, and time. Perform a test of recent memory - does the child remember events just before injury? As with any trauma, the first objective is to insure that the ABCs are intact. During the initial assessment, you will assess the child to ensure that the airway is clear, they are breathing adequately, and that there isn’t any cardiovascular compromise. Other things to look for during the first contact with the child include observing the child’s orientation to their environment. Do they know where they are? Do they know what day it is? Can they remember the events leading up to the injury? Consider that the head injured child may also have a concurrent cervical spinal injury and take precautions. This is less likely in the child with MTHI, but, if suspected, take appropriate precautions and initiate spinal immobilization. 45 45

Cervical Spinal Injuries
With any head injury, be alert for cervical spine injuries. Most common cause is impact to the top of the head when the neck is held in flexion Occurs most frequently during contact sports and in motor vehicle or bicycle collisions Atabaki 2007 Due to the seriousness of c-spine injuries, always be alert for their possibility. An impact does not necessarily need to be overly harsh or vigorous to cause harm. C-spine injuries most commonly result from an impact to the top of the head while the neck is in flexion. C-spine injuries are particularly seen in contact sports, and motor vehicle or bicycle collisions. 46 46

Loss Of Consciousness (LOC)
LOC is not a reliable predictor of concussion or length of recovery. LOC is not as definitive a predictor of severity as the Pediatric Glasgow Coma Scale. Cognitive symptoms such as confusion and disturbance of memory can occur without LOC. However, when the patient does experience LOC, confusion and memory disturbance almost always occur. Gray 2009; Meehan 2009 As discussed earlier, cognitive changes can be seen with MTHI. Loss of consciousness can occur as a result of a MTHI, but it is not an accurate predictor of presence of brain injury, and does not predict the length of recovery. Many symptoms such as confusion, memory disturbance and other cognitive deficiencies can occur without the patient having a loss of consciousness. However, if a child does experience a loss of consciousness, then he will suffer from confusion and memory disturbances as well. 47 47 47 47

Amnesia Post traumatic amnesia (PTA) is more accurate than loss of consciousness in predicting functional recovery. Patients suffering from MTHI may have amnesia of events occurring immediately after injury. Classification of the severity of amnesia is measured by length of time it occurs: Very mild: Less than 5 minutes Mild: Less than 1 hour Moderate: hours Severe: Greater than 24 hours Very severe: Greater than 1 week Unlike loss of consciousness, amnesia is actually a better predictor of brain injury. The child who displays amnesia presents with difficulty recalling events that occur immediately after the impact. As seen in this slide, here is a score for ranking the degree of amnesia. 48 48 48 48

AVPU is not a replacement for the Glasgow Coma Scale.
AVPU is a quick test used to determine level of consciousness. It measures the reaction of the eyes, voice and motor activity in response to stimuli. In the scale, Alert represents the level of least injury and Unresponsive the most severe. Alert: fully conscious; may be mildly disoriented Voice: responds to verbal stimuli Pain: responds only to pain stimulus Unresponsive: unconscious AVPU is not a replacement for the Glasgow Coma Scale. McNarry 2005 In assessing any head injury, it is critical to assess the child’s level of consciousness. One simple and fast method to determine the level of consciousness is the AVPU scale. AVPU stands for Alert, Voice, Pain, or Unresponsive. Alert indicates the highest level of functioning. Next comes the child’s response to voice commands, then to pain and finally no response at all. AVPU is not a replacement for the Glasgow Coma Scale which will now review in detail. 49 49 49 49

Glasgow Coma Scale (GCS)
An accurate, commonly used, and easily reproducible tool Commonly used neurologic assessment tool for trauma patients since its development by Jennett and Teasdale in the early 1970s Is an accurate measure for trauma care practitioners to document level of consciousness over time Commonly used in adults - more recently used in children (Pediatric GCS score) Sternbach 2000 For over thirty years, the Glasgow Coma Scale, known as GCS, has been considered an excellent tool to measure an injured person’s mental status. It is accurate, reproducible, easy to learn, and easy to use. The scale is most valuable when it is measured at defined intervals of time with serial documentation. The GCS was originally designed for use in adult patients. However, a pediatric version was created for use in the pediatric population, known as PGCS. 50 50 50 50

The Pediatric GCS (PGCS)
Developed as an alternative to the original GCS Resulted because there are physiologic differences between adults and children Most adult field triage tools are not applicable to pediatric trauma victims The verbal response component of the Pediatric GCS better addresses the developmental capabilities in the young child than the adult GCS Most applicable to children five years old and younger Reilly 1988; Holmes 2005 Because of the physical and developmental differences between children and adults, the scale needed to be modified for use in the pediatric population. The pediatric scale is most applicable to children five years and younger. Most of the differences center on the child’s verbal abilities. Otherwise, it is very similar to the adult GCS. 51 51 51 51

Pediatric GCS: Application
Pediatric GCS (PGCS) is most effective when measured serially over time. Frequent assessment will indicate the progression of illness, helping to determine severity of injury. Actual time between measurements depends on institutional practices and the individual patient. The PGCS score can be classified as: Minor: 13-15 Moderate: 9-12 Severe: 3-8 The lower the score, the more severe the injury MTHI is typically with a PGCS score of 13 – 15. Like the adult GCS, it is most beneficial when scored serially to quantify the child’s changes in mental status over time. The PGCS scores range from 3 to 15. Three, reflecting the most severe score, represents a completely unresponsive patient. 15 is considered a normal mental status with the patient being fully awake and aware. In MTHI, the patient usually has a PGCS score of between 13 to 15. 52 52 52 52

Pediatric GCS: Components
The Pediatric Glasgow Coma Scale looks at three components: Eye Opening Motor Response Verbal Response Add the scores of all three components together to determine the total PGCS score for that interval. The following slides expand upon each component. The PGCS examines a child's eye opening, motor response, and verbal response. A score is assigned for each component examined that best reflects a patient’s response. Then, the scores from all three components are added to achieve an overall score. 53 53

Eye Opening Greater Than 1 Year Old Less than 1 Year Old Score
Spontaneously 4 To Verbal Command To Shout 3 To Pain 2 No Response 1 Let’s begin by looking at the eye opening component. Because of the different developmental skills in children, they may not have the capability to respond to verbal commands. For children less than one year of age, look for any type of response to loud talking. A completely responsive child who spontaneously opens her eyes would receive a score of “4.” No response at all earns the lowest score of “1.” 54 54

Motor Response Greater Than 1 Year Old Less than 1 Year Old Score
Obeys Commands Spontaneous Movement 6 Localizes Pain 5 Flexion- withdrawal 4 Flexion-abnormal (decorticate rigidity) 3 Extension (decerebrate rigidity) 2 No Response 1 Next, you examine the child’s motor response. Again, the scale reflects the developmental capabilities of the child’s response to the stimulus. Because of their verbal capabilities, older children should be able to move in response to a given command. In a child less than one year, spontaneous movement is considered a normal response and would receive a score of “6.” The other responses represent other possible movement characteristics. Does the child localize the pain, indicating a specific location on the body? Does the child flex away from applied stimulus or do they flex randomly regardless of the stimuli? Does a stimulus cause the child to exhibit rigid extension? Finally, no response receives the lowest score of “1.” 55 55

Verbal Response Older Than 5 Years Old 2 to 5 Years Old 0 – 23 Months
Score Oriented Appropriate words / Phrases Smiles/coos appropriately 5 Disoriented / Confused Inappropriate Words Cries and is consolable 4 Inappropriate Words Persistent cries and screams Persistent inappropriate crying and/or screaming 3 Incomprehensible Sounds Grunts Grunts, agitated, and restless 2 No Response 1 Thirdly, you measure the child’s verbal response. Since there is a wide range of linguistic skills in children, the scoring options are divided into three age groups. To receive a score of “5,” the child older than 5 years must be oriented to their surroundings, be able to talk completely and say where they are. A 2 to 5 year-old may not be able to describe their surroundings, but they should be able to formulate appropriate responses to questions asked. If the child is disoriented, using words that do not match the situation, or crying inconsolably, they receive a score of “4.” If a five-year-old uses inappropriate words to describe their surroundings, or the child persistently cries or screams, the score is “3.” Incomprehensible sounds or grunts earn a child a score of “2.” No response is scored as a “1.” Click on the pdf icon to view a sample PGCS form. Please note that this is only one sample. There are other PGCS scales with mild variations. Your institution may prefer using a different version from the one presented here. 56 56

Pediatric GCS Score Scenario 1
Brief Presenting History A 3-month-old female is brought to the emergency department by her father with a history of “not acting right” since falling out of her crib two days ago. You note multiple bruises are on the child’s face and rapidly complete the assessment and treatment in the trauma room. Eyes: The child’s eyes remain closed during painful stimuli. Motor: The child withdraws both arms during IV access. Verbal: The child is grunting. What PGCS score you would assign for each component for this patient? Click the Answer button below to see how we scored the patient. What PGCS score you would assign for each component for this patient? Click the answer button to see how we scored the patient. Eyes 1 4 2 7 57 Motor Answer Verbal Total

Brief Presenting History A 6-year-old male is brought into the emergency department fully immobilized by paramedics who report that he was a restrained front seat passenger. There was intrusion into the driver’s side of the car only. His left forearm is swollen. Eyes: The child opens eyes to his name being called. Motor: The child withdraws his right arm when his blood pressure is taken. Verbal: The child cries when his swollen forearm is touched. What PGCS score would you assign for each component for this patient? Click the Answer button below to see how we scored the patient. What PGCS score you would assign for each component for this patient in scenario number 2? Click the answer button to see how we scored the patient. Eyes 3 4 10 58 Motor Answer Verbal Total

Brief Presenting History A 3-year-old female is brought to the emergency department by her mother who claims that her child is lethargic after being pushed down by her 5-year-old brother (fighting over a toy). The mother states the red mark on her daughter’s forehead is where she landed head first on the tile floor. Eyes: The child is sitting on her mother’s lap curiously looking at you. Motor: The child accidentally drops her favorite toy so she quickly jumps off her mother’s lap crawls under the chair and grabs her toy. Verbal: The child states “Mine” clutching her favorite toy. She says,“I am this many” as she proudly tries to hold up three fingers. What PGCS score you would assign for each component for this patient? Click the Answer button below to see how we scored the patient. What PGCS score you would assign for each component for this patient in scenario number 3? Click the answer button to see how we scored the patient. 59 Eyes 4 6 5 15 Motor Answer Verbal Total

Putting It All Together
Take a detailed and complete history Consider the possibility of structural injuries such as cervical spine damage The pediatric specific GCS is more appropriate and accurate than the adult GCS in children The PGCS is commonly used to assess the severity of MTHI The PGCS measures three aspects of the patient: eye opening, verbal response, motor response More useful results are obtained when the PGCS is measured serially over time MTHI is typically associated with a PGCS score of 13 – 15 The PGCS is especially valuable when testing children aged five years and younger AVPU can be useful in determining LOC, but is not a substitute for the PGCS score Here are the main points in assessing MTHI in children - Take a detailed and complete history - Consider the possibility of structural injuries such as cervical spine damage - The pediatric specific GCS is more appropriate and accurate than the adult GCS in children - The PGCS is commonly used to assess the severity of injury and predict MTHI - The PGCS measures three aspects of the patient: eye opening, verbal response, motor response - More useful results are obtained when the PGCS is measured serially over time - MTHI is typically associated with a PGCS score of 13 to 15 - The PGCS is especially valuable when testing children aged five years and younger - AVPU can be useful in determining the level of consciousness, but is not a substitute for the PGCS score 60 60

Imaging In this chapter, we will discuss the types of possible imaging studies used in this population, as well as the risks and benefits of each. 61 61 61

Types of Imaging Studies
Many children presenting with a possible MTHI may not require an imaging study. However, if a physician determines the need, the most commonly ordered studies are: Computed Tomography Imaging (CT) - preferred diagnostic tool that comes with benefits and risks; main risk factor - concern for radiation overexposure X – Ray - useful to detect skull fracture, but not recommended in most cases Magnetic Resonance Imaging (MRI) - useful to detect skull fracture, but not recommended in most cases Imaging studies are an integral part of every healthcare provider’s repertoire. Unfortunately knowing when to image and what type of study to order is not always clear cut. The technology of imaging is constantly evolving. Our knowledge base is expanding related to the potential harmful side effects of the various studies. 62 62

CT: Benefits & Risks There is no consensus regarding the use of CT to diagnose brain injuries Benefits: Can help determine the difference between MTHI and the more serious condition of traumatic brain injury Offers definitive results in determining structural damage Risks: Exposes child to ionizing radiation (1 head CT scan can potentially equal over 200 chest x-rays) Transporting child to CT suite may take child away from ED skilled supervision and resources Pharmacologic sedation is often required in younger children (may increase overall health risk; requires additional monitoring) Prolongs time child spends in ED Incurs greater cost If imaging is indicated, CT scanning is considered the imaging of choice. CT imaging is able to rule out structural damage. It is also available in most EDs. However, there are some negative aspects. A CT exposes the child to a significant amount of ionizing radiation. Recent data equated the amount of radiation of 1 head CT to that of more than 200 chest x-rays. Also, the child may need to be transported away from the ED to the CT scanner, taking them away from direct access to ED resources and capabilities. Additionally, the child must remain still during the test. This may not be practical for a small child or infant, so patients in this age group may need sedation to enable the test to progress. Sedation requires careful, constant monitoring, and carries its own risks. Finally, ordering a CT prolongs the family’s stay in the ED and is a costly procedure. 63 63 63 63

Increased Use of CT The use of CT to evaluate children with head injuries has increased substantially over the past decade, almost doubling during that time and thus increasing the risks associated with radiation. 500,000 ED visits each year for children with head injury has resulted in an estimated annual usage of 250,000 CT scans used to diagnose potential head injury. Brenner 2001; NCIPC 2003 Despite these concerns related to CT, it is still often ordered. In fact, the use of CT imaging has doubled in the last decade. Half of all children presenting to the ED with a potential head injury will undergo a CT. The use of CT in head trauma has greatly increased over the years, primarily due to its wide availability. 64 64 64 64

Recommendations of Image Gently Campaign
The Alliance for Radiation Safety in Pediatric Imaging began a public health campaign in 2006 called Image Gently. Its goal is to change CT practice by raising awareness of the opportunities to lower radiation dose in the imaging of children. Examples of recommended techniques: Scan only the area required. Scanning beyond the body regions where there is clinical concern results in needless exposure. Reduce tube output (kVp and mAS). Exposure parameters should be reduced for the smaller patient size. Perform single phase studies. Most pediatric conditions are readily diagnosable with single phase CT; more phases unnecessarily increases radiation dose without adding substantial data to diagnoses. In 2006, in response to the increased use of CT, an organization called Alliance for Radiation Safety in Pediatric Imaging began a campaign called Image Gently. Their goal is to help increase the awareness of the risks associated with CT use, and present safer techniques and alternatives. Some of their suggestions include exercising judicious ordering of a CT. Technicians should only scan the specific area of interest, and subject the child to a radiation dose that is “as low as reasonably achievable” for that study. Whenever possible, order single phase studies. Finally, make sure the tube output of the scanner is adapted to the size of the child. 65 65 65 65

Use of CT: Need for Guidelines
There is considerable debate regarding the value of a head CT to determine MTHI. Internal discussion needs to take place in order to set hospital policy and ensure consistency when CT scans are ordered Common issues for institutional discussion: Are there any institutional guidelines suggesting general criteria for ordering pediatric head CT image in certain situations? Do the benefits of ordering a head CT outweigh the potential risks from radiation? Do you discuss risks and benefits with parents/caregivers? Despite the risks associated with CT use, many institutions do not have guidelines regarding the use of CT in pediatric patients presenting with MTHI. What is needed is internal institutional dialog. Here are a few topics to consider: Are there any current guidelines at your institution? Do the risks of ordering a CT outweigh the information learned from the study? Do you discuss risks and benefits with your patient’s parents and/or caregivers? Ultimately, all decisions must be evidence-based. To use or not use CT ultimately rests with the healthcare provider treating the unique patient in an ever-changing environment. 66 66 66 66

PECARN Study: Future CT Guidelines
In 2009, The Pediatric Emergency Care Applied Research Network (PECARN) will complete a large national prospective study of children with TBI to guide when it is appropriate to use head CT in diagnosing. Goal: Draw from the evidence a basis for appropriate use of head CT in children with acute head injury, hopefully reducing the number of unnecessary CT scans for children at very low risk for TBI. PECARN Having access to evidence-based guidelines on when best to use a CT will be helpful. Guidelines from the Pediatric Emergency Care Applied Research Network, known as PECARN, are still pending at the time of this publication. However, they are anticipated to help guide decision-making as related to use of CT for patients at low risk for TBI. 67 67 67 67

X-Rays X-rays can detect a skull fracture that may be missed by a CT.
X-rays will not reveal metabolic or soft tissue injuries that may be present in MTHI. If imaging is indicated, CT scanning is the imaging modality of choice to evaluate for brain trauma. The mechanism and history of the injury, and the PGCS score are better indicators of significant head injury in children than x-rays. Reed 2005 X-rays are a simple tool best used to assess for a skull fracture. However, they do not offer much benefit in determining the presence of any soft tissue injury to the brain. 68 68 68 68

Magnetic Resonance Imaging (MRI)
MRI is currently not as commonly used to image MTHI as CT. However, it is an evolving technology that may become increasing utilized in the future. MRI may help determine some types of neurological damage when performed several days post injury. Since performing an MRI may require the sedation of the child, extra caution needs to be observed. MRI is a more costly procedure, and may not be as readily available as CT. Risks and benefits of MRI mimic those of CT. MRI is a rapidly evolving technology whose potential we have not yet fully realized. Although it is not currently used to any great degree to diagnose brain injury, that may change in the future. Regardless, current MRI technology requires that the child remain motionless in a tight, loud tube. The child may require sedation, which, as previously mentioned, has a number of risks. It is also the most costly of the three imaging types reviewed by far. 69 69 69 69

Test Your Knowledge 1. If imaging is required to detect MTHI, what is the preferred method? A. X-ray B. MRI C. CT scan D. PET scan Click the Answer button below to see the correct response. Answer What is the correct answer to this question? Click the answer button to see the correct response. C. CT scan imaging can help determine the difference between MTHI and the more serious condition of traumatic brain injury, and also offers definitive results in determining structural damage. 70

Test Your Knowledge 2. True or False: There is very little one can do to limit a child’s exposure to ionizing radiation from a CT scan. Click the Answer button below to see the correct response. Answer What is the correct answer to this question? Click the answer button to see the correct response. False. Strategies to reduce radiation exposure include scanning only the area required, reducing tube output (kVp and mAS), and performing single phase studies. 71

Management Now, we will discuss appropriate ways to manage children who present with mild traumatic head injuries. 72 72

Emergency Department Management
Children may be managed in the ED through: Neurologic assessment - serially perform neurological assessment with using PGCS during ED admission: Children who appear neurologically normal (e.g., PGCS score =15) are at lower risk for subsequent deterioration Observation Pain management Imaging studies (if needed) There are several issues to consider when the managing a patient with a potential brain injury in the ED. First, you will need to conduct a neurological assessment to obtain baseline information, and then repeat this assessment using the PGCS to determine any changes. Closely observe the child for any signs and symptoms of a worsening condition. Don’t forget to assess and appropriately manage the child’s pain. If necessary, order the most applicable imaging study. Often, the most appropriate management plan is to simply observe the child over time. 73 73

Observation At Home Parents/caregivers require careful discharge instructions if they are to observe the child outside of a medical facility. Some factors to consider include: Healthcare professional must make a careful assessment of the parent/caregiver’s anticipated compliance with the instructions Must be without suspicion of maltreatment/neglect Must have ability to seek medical attention if condition worsens (access to telephone, transportation, etc.) Should be capable to assess and manage the child’s pain If parent/caregiver is not competent, or unavailable, or suspected of being intoxicated or otherwise incapacitated, other provisions must be made to ensure adequate observation of the child (including hospital admission) Fuchs 2001 In specific situations, the child can be observed at home by the parent or caregiver. This requires that you carefully assess the abilities of the parent or caregiver to perform accurate observations and have the ability to take action should it be necessary. First, you should not suspect any potential child maltreatment or neglect. The parent or caregiver must have the ability to communicate with the healthcare team should the child’s condition deteriorate. Do not assume that all caregivers have access to a car or telephone. Ask! The parent or caregiver must be capable of managing the child’s pain. Finally, if you assess the parent or caregiver is somehow not able to adequately observe the child, you need to make other arrangements, including admitting the child for observation. 74 74 74 74

Discharge Planning In this chapter, we will discuss the details of appropriate discharge planning. 75 75 75

Discharge Planning Discharge instructions & parent/caregiver education should include: Warning signs & symptoms of Post Concussive Syndrome Signs & symptoms that prompt a return visit to the ED for immediate care Emergency phone number to call Expected course of recovery Pain management measures Before discharging the child, make sure the parent or caregiver understands the key signs and symptoms of post concussive syndrome, which will be explained in detail. Further, they must understand when it is appropriate to return to the emergency department. Provide them with an emergency number to call should they have questions or need help. Be sure to review the expected course of recovery so parents and caregivers are aware if their child is not progressing as indicated. Provide detailed instructions and education regarding pain management. 76 76 76 76

Discharge Planning (cont.)
Referral to primary care provider for follow up care Guidelines regarding when to return to activity Safety information (proper helmet use, seatbelt use, etc.) Links to additional traumatic head injury resources EMSC - Patient Education Resources Upon discharge, ensure a referral to a primary care provider with instructions to take the child for a follow up visit. Carefully review the discharge instructions and guidelines indicating when it is safe for the child to return to normal activity. Take the opportunity to review safety equipment that can help prevent future MTHI, and provide a list of injury prevention resources to further educate parents or caregivers. We’ve included a sample of helpful web resources at the end of this module. Click the link to access a set of free patient education resources in both English and Spanish developed by the Illinois EMSC. 77 77 77 77

Return To Play Guidelines
Simple – an injury that progressively resolves without complication for 7-10 days. Management based on a step-wise approach until all symptoms resolve. Complex – persistent symptoms, specific sequelae (e.g., prolonged LOC), or prolonged cognitive impairment. Consider formal neuropsychological testing beyond return to play guidelines. McCrory 2005 When a child is diagnosed with an MTHI, they should not return to play until it is safe to do so. This may be several days after leaving the ED. The actual time restriction depends on the severity of the injury and the symptoms experienced. The Illinois EMSC published a brochure designed to help parents and caregivers know when it is safe to allow their child to return to active play. Click on the link to access this free resource. 78 78 78 EMSC - Return To Play Guidelines Brochure 78

Return To Play: A Step Wise Approach
Athletes are NOT be returned to play the same day of injury. Recommended stages of progression: Step #1. Rest until asymptomatic (physical and mental rest) Step #2. Light aerobic exercise Step #3. Sport-specific exercise Step #4. Non-contact training drills (start light resistance training) Step #5. Full contact training ONLY AFTER MEDICAL CLEARANCE Step #6. Return to competition (game play) There should be approximately 24 hours (or longer) for each stage and the athlete should return to previous step if symptoms reoccur. McCrory 2005 In all circumstances, no child should be allowed to return to active play on the same day as the injury. Both physical and mental rest is required. After a minimum of 24 hours of rest, the child can begin progressing through the recommended steps, provided the child is asymptomatic after each step. Step 2 consists of light aerobic exercise. In Step 3, the child engages in exercises specific to the sport or to a moderate level of play. Step 4 begins non-contact training drills or active play. After medical clearance, the child can begin full contact training, which is Step 5. Finally, in Step 6, the child returns to normal activity without restrictions. There should be a minimum of 24 hours between each step. If any symptoms reoccur, the child must revert to the previous step and continue the progress from that step forward. 79 79 79 79

Discharge: Time For Advocacy
The discharge process is a valuable time to provide information to the parent/caregiver regarding how to prevent future head injuries. Suggested topics may include, but are not limited to: Potentially harmful situations that may result in head injury (such as unsupervised sports, playing without necessary protective sports equipment, eliminating areas within home that could result in falls, etc.). How to recognize MTHI in children and the appropriate steps to take if an injury is suspected. Be alert for signs of child maltreatment. Use and proper fit of bicycle helmets. Importance of wearing seatbelts at all times within a moving vehicle. Appropriate use and fit of car seats. As a healthcare provider, you are in a unique position to educate parents and caregivers about safe practices to avoid future injury. Review the situations where the child is at most risk for head injury. Explain to parents, caregivers and patients the importance of wearing a bicycle helmet and seat belt. Children must be restrained in a motor vehicle using the age appropriate restraint device. Be sure to show the caregivers the correct method of installing the car seat. Many people have car seats, but they are not correctly anchored to the vehicle making their use compromised. Finally, make the parent and caregiver aware of signs of child maltreatment. 80 80 80 80

Advocacy in Action: The CDC Heads Up Tool Kit
The CDC, working in partnership with noted professional medical, sport, and educational organizations, has created a tool kit called Heads Up that is designed to help coaches prevent, recognize, and manage concussion in sports. It contains: A concussion guide for coaches; A coach’s wallet card on concussion for quick reference; A coach’s clipboard sticker with concussion facts and space for emergency contacts; A fact sheet for athletes in English and Spanish; A fact sheet for parents in English and Spanish; An educational video/DVD for you to show athletes, parents, and other school staff; Posters to hang in the gym or locker room; and A CD-ROM with additional resources and references. Coaches can use tool kit materials to educate themselves, athletes, parents, and school officials about sports-related concussion and work with school officials to develop an action plan for dealing with concussion when it occurs. The Heads Up tool kit can also be ordered or downloaded free-of- charge at: The Centers for Disease Control have assembled a free, comprehensive kit that helps coaches prevent, recognize and manage children with MTHI. Follow the link to visit the CDC Web site and learn about this, and many other resources.

Test Your Knowledge 1. Which of the following elements should not be included in your MTHI discharge instructions? A. Expected course of recovery B. Permission for the child to return to sports the next school day C. Warning signs & symptoms of Post Concussion Syndrome D. Injury prevention & safety information Click the Answer button below to see the correct response. What is the correct answer to this question? Click the answer button to see the correct response. Answer 82 B. Permission for the child to return to sports the next school day is not appropriate as a standard discharge instruction. Children need both physical and mental rest to recover. Medical clearance is required prior to returning to sports.

Potential Complications
Now, we will review potential complications related to mild traumatic head injuries. 83 83 83

Post Concussive Syndrome
One potential complication of MTHI is Post Concussive Syndrome. Clinical indications include: Dizziness, trouble concentrating Changes in sleep pattern Any deviation from normal behavior in the days or even weeks following the injury. Over time, the symptoms may eventually lessen. However, parents/caregivers must report any new, continuing, or worsening symptoms to their physician immediately. It is critical that parents / caregivers are made aware of this complication at time of discharge. Children diagnosed with a MTHI are at risk for a condition called “Post Concussive Syndrome.” It takes time for a MTHI to heal. A child may appear to be highly functioning when receiving care immediately after the injury. However, the situation can change hours or even days later. Signs and symptoms of Post Concussive Syndrome include: dizziness; trouble concentrating; changes in sleep pattern; or any deviations from normal behavior for that child. It is critically important to make your patient’s parents and caregivers aware of this potential complication. Include clear instructions to contact their healthcare provider immediately if they notice any of the symptoms. Post Concussive Syndrome is a serious condition that requires immediate, professional care. 84 84 84 84

Second Impact Syndrome
The effects of multiple injuries to the head are cumulative and potentially more damaging that a single incident. A second blow is more damaging than the “sum” of the two blows Second Impact Syndrome should be suspected in all children involved in high-risk situations (i.e., contact sports) and with a history of previous head injuries. Patients experiencing Second Impact Syndrome are: More likely to experience post-traumatic amnesia More likely to experience mental status disturbance after each new injury Often score lower on memory tests Second Impact Syndrome can result in fatal brain swelling. Researchers have found that children who sustain one MTHI may be at greater risk for a more serious brain injury, such as fatal brain swelling, if they sustain another MTHI before fully recovering from the initial injury. Children who suffer from multiple head injuries are more likely to develop memory problems, amnesia and other changes in mental status. Often, these conditions can be permanent. This is especially true for the young athlete participating in a contact sport such as football. There is the potential for the child to receive multiple MTHIs during the course of the sport’s season. Coaches must be educated about the risks of MTHI and Second Impact Syndrome. Click on the video link to watch CDC’s “Heads Up” video that tells the story of an athlete’s struggle to recover from the effects of Second Impact Syndrome. 85 85 85 CDC’s “Heads Up” video (11:38) 85

Conclusion: The Bottom Line
MTHI can occur as the result of even relatively minor injuries and should always be suspected during evaluation for head trauma. When evaluating a pediatric patient for MTHI, the Pediatric Glasgow Coma Scale is an accurate, easily reproducible, and commonly used tool in assessing neurologic status. CT is a valuable tool in diagnosing MTHI, but should be used judiciously. MTHI can often be managed by observation alone under appropriate circumstances. The effects of recurrent head injuries are cumulative - advise the patient to avoid any situation where they may sustain additional blows to the head. Allow time to resolve - MTHI can take days and even weeks or more to resolve. In regard to returning to a normal activity level, When In Doubt, Sit Them Out. In conclusion, listed here are key points for you to take away from this module. - MTHI can occur as the result of even relatively minor injuries and should always be suspected during evaluation for head trauma - When evaluating a pediatric patient for MTHI, the Pediatric Glasgow Coma Scale is an accurate, easily reproducible, and commonly used tool in assessing neurologic status - CT is a valuable tool in diagnosing MTHI, but should be used judiciously - MTHI can often be managed by observation alone under appropriate circumstances - The effects of recurrent head injuries are cumulative. Advise the patient to avoid any situation where they may sustain additional impacts to the head - Allow time to resolve. MTHI can take days and even weeks or more to resolve - In regard to returning to a normal activity level, “When In Doubt, Sit Them Out” 86 86 86 86 86

Additional Resources The protocols surrounding the diagnosis, treatment, and prevention of concussions are continually evolving. Keep up-to-date by routinely visiting authoritative resources such as: American Academy of Family Physicians American Academy of Pediatrics The Brain Injury Association of America The Brain Injury Recovery Network Brain Trauma Foundation The Centers for Disease Control: CDC Heads Up Center For Neuro Skills The Children's Hospital of Pittsburgh National Center for Injury Prevention and Control National Database of Educational Resources on Traumatic Brain Injury Here is a list of additional resources for your use. 87 87 87 87

Citations Alexander, M. P. (1995). Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology, 45(7), Atabaki, S. M. (2007). Pediatric head injury. Pediatrics in Review, 28(6), Berger, R. P., Dulani, T., Adelson, P. D., Leventhal, J. M., Richicha, R., & Kochanek, P. M. (2006). Identification of inflicted traumatic brain injury in well-appearing infants using serum and cerebrospinal markers: a possible screening tool. Pediatrics, 117(2), Brener, I., Harman J. S., Keller, K. J., & Yeates, K. O. (2004). Medical costs of mild to moderate traumatic brain injury in children. Journal of Head Trauma Rehabilitation, 19(5), Brenner, D., Elliston C., Hall, E., & Berdon, W. (2001). Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR American Journal of Roentgenology, 176(2), Centers for Disease Control. CDC: Heads Up: Facts for Physicians. Retrieved June 23, 2009, from Chadwick, D. L., Bertocci, G., Castillo, E., Frasier, L., Guenther, E., Hansen, K., et al. (2008). Annual risk of death resulting from short falls among young children: less than 1 in 1 million. Pediatrics, 121(6), Evans, R. W. (2008). Concussion and mild traumatic head injury. UpToDate. Literature review, version Retrieved January 31, 2008.

Citations (continued)
Fuchs, S. (2001). Making sense? Pediatric head injury & sports concussions: evaluation and management. From Power Point presentation given at the Improving Emergency Medical Services for Children (EMSC) Through Outcomes Research: an Interdisciplinary Approach Conference, held March 2001, Reston, Virginia. Gray, H. (2008). Mild traumatic head injury. From Power Point presentation Retrieved November 5, 2008, from Holmes, J. F., Palchak, M. J., MacFarlane, T., & Kuppermann, N. (2005). Performance of the Pediatric Glasgow Coma Scale in children with blunt head trauma. Academic Emergency Medicine, 12(9), Illinois Department of Children and Family Services. Retrieved March 12, 2009, from McCrory, P., Johnston, K., Meeuwisse, W., Aubry, M., Cantu, R., Dvorak, J., et al. (2005). Summary and agreement statement of the 2nd International Conference Concussion in Sport, Prague Clinical Journal of Sports Medicine, 15(2), McCrory, P., Meuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy, M., et. al. (2009). Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November Clinical Journal of Sports Medicine, 19(3), McNarry, A. F., & Goldhill, D. R. (2004). Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale. Anesthesia, 59(1), Meehan, W. P, 3rd., & Bachur, R.G. (2009) Sport-related concussion. Pediatrics, 123(1),

Citations (continued)
National Center for Injury Prevention and Control. (2003). Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. Atlanta, GA: Centers for Disease Control and Prevention. National Center on Shaken Baby Syndrome. Retrieved March 12, 2009, from National Research Council (2000). How people learn: brain, mind, experience, and school. Washington, DC: National Academy Press. Reed, M. J., Browning, J. G., Wilkinson, A. G., & Beattie, T. (2005). Can we abolish skull x- rays for head injury? Archives of Disease in Childhood, Electronic Publication, 90(8), Reilly, P. L., Simpson, D. A., Sprod, R., & Thomas, L. (1988). Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Child's Nervous System, 4(1), Savage, R. C., & Wolcott, G. F. (1994). Educational Dimensions of Acquired Brain Injury. Austin, Texas: Pro-Ed Inc. Sellars, C. W., Vegter, C. H., & Ellerbusch, S. S. (1997). Pediatric Brain Injury: The Special Case of the Very Young Child. Huston, Texas: HDI Publishers. Sternbach, G. L. (2000). The Glasgow coma score. Journal of Emergency Medicine, 19(1), Teasdale, G., Murray, G., Parker, L., & Jennett, B. (1979). Adding up the Glasgow Coma Score. Acta neurochirurgica. Supplementum (German), 28(1), Traumatic Brain Injury.com. Retrieved January 15, 2009, from

For More Information For other EMSC educational modules and information: Illinois EMSC website: Federal EMSC Program: Illinois EMSC is a collaborative program between the Illinois Department of Public Health and Loyola University Medical Center For more information, click on the links to the Federal and Illinois EMSC Web sites. 91 91 91 91

Appendix A: Abusive Head Trauma 92 92 92
In Appendix A, we will briefly review the condition known as Abusive Head Trauma. 92 92 92 Link to Child Maltreatment (slide 34)

Abusive Head Trauma Abusive Head Trauma results from the violent shaking (Shaken Baby Syndrome) or intentional blow to the head of an infant or small child. An impact mechanism can occur, but is not necessary to cause irreversible brain injury. What Happens: Brain rotates within the skull cavity resulting in shearing injuries to the brain and blood vessels injuring or destroying brain tissue Subarachnoid bleeding (bleeding in the area between the brain and the thin tissues that cover the brain) and subdural hemorrhages (a collection of blood on the surface of the brain) occur. Subdural hematomas are markers for shearing injury. Cerebral edema peaks at 72 hours after injury All children are immediately symptomatic Associated findings may include: Retinal hemorrhages that involve multiple layers of the retina and extend out to the periphery of the retina either in one or both eyes Skeletal injuries such as rib fractures and metaphysial injuries to the long bones National Center on Shaken Baby Syndrome 2009 While the focus of this education is on mild head injuries, it is important to continually increase the awareness of Abusive Head Trauma. Abusive Head Trauma can manifest itself in many ways. When the child sustains repeated blows to the head or violent shakes, the brain rotates within the skull causing shearing injuries that can destroy brain tissue. The symptoms of Abusive Head Trauma appear immediately. Subarachnoid bleeding and subdural hemorrhages occur. Subdural hematomas are a marker for shearing injury. Cerebral edema results and reaches its maximum level within 72 hours after injury. Healthcare providers should also be alert for signs of retinal hemorrhage as well as related skeletal injuries, such as rib fractures.

Abusive Head Trauma (cont.)
Symptoms of Abusive Head Trauma: Lethargy / decreased muscle tone / extreme irritability Decreased appetite, poor feeding or vomiting for no apparent reason No smiling or vocalization / poor sucking or swallowing Rigidity or posturing / difficulty breathing Seizures / inability to lift head Head or forehead appears larger than usual or fontanel appears to be bulging Inability of eyes to focus or track movement or unequal size of pupils NOTE: External findings are rarely found Symptoms of Abusive Head Trauma include: lethargy or extreme irritability; decreased appetite or poor feeding; vomiting for no obvious reason; no smiling or vocalization; poor sucking or swallowing; rigidity or posturing; difficulty breathing; seizures; trouble lifting the head; the head or forehead appears larger or fontanel is bulging; eyes have trouble focusing or tracking; or pupils may be unequal. Also, since this type of trauma does not necessarily result from a direct impact to the head, there may not be any external findings such as bruises, or gashes.

Abusive Head Trauma (cont.)
Work Up: To make this diagnosis, you must have a strong suspicion of Abusive Head Trauma. Brain injury is a necessary finding - eye and skeletal findings are not necessary for the diagnosis. Plan for immediate transfer if your ED is not equipped to complete the work up. If equipped: Perform a skeletal survey Have an eye exam done by a qualified ophthalmologist aware of the signs/symptoms of Abusive Head Trauma Note: All children are immediately symptomatic at the time of brain injury. There is no lucid period in children that are violently shaken. J. C. Glick (personal communication, March 19, 2009) When diagnosing Abusive Head Trauma, there must be evidence of actual brain injury, but not necessarily structural findings such as eye or skeletal injuries. If suspected, it is recommended to perform a skeletal survey and have an eye exam done by a qualified ophthalmologist who has experience looking for the ophthalmologic findings consistent with Abusive Head Trauma. Remember that symptoms of Abusive Head Trauma manifest immediately.

Information for Parents / Caregivers / Coaches
Appendix B: Information for Parents / Caregivers / Coaches In Appendix B, we will briefly review some helpful information and resources for the lay population regarding mild traumatic head injuries. 96 96 96

Signs of MTHI Consult a healthcare professional if your child experiences: Headache or “pressure” in head Nausea or vomiting Balance problems or dizziness Double or blurry vision Sensitivity to light Sensitivity to noise Feeling sluggish, hazy, foggy, or groggy Concentration or memory problems Confusion Does not “feel right” CDC Heads-Up Listed on this slide are the signs and symptoms of MTHI, also known as a concussion, which all parents, caregivers, and coaches should be made aware of. If a child shows any of these signs, you should consult a healthcare professional for a full evaluation. 97 97 97 97

What To Do If MTHI Is Suspected
Seek medical attention right away. A healthcare professional will decide how serious the injury is and when it is safe to return to normal activities. If playing a sport, keep the child out of play. Mild traumatic head injuries take time to heal. Children who return to play too soon risk a greater chance of having a second injury. Second or later injuries can be very serious. They can cause permanent brain damage, affecting your child for a lifetime. When in doubt, sit them out! If you think your child or athlete has sustained a MTHI, do not assess it yourself. Take him/her out of play and seek the advice of a healthcare professional to determine the level of severity. A child who returns to play before fully recovering has a greater chance to suffer from another head injury. Multiple head injuries, even if minor, can lead to very serious complications, including permanent brain damage. Remember the saying: “When in doubt, sit them out!” 98 98 98 98

Sports Injuries Many head injuries often occur during sports activities. This is a time to be particularly vigilant. Football is the most common cause of sports injuries in children. 74% of football related injuries are associated with MTHI. Most children who experience the symptoms of head injury do not seek help: Most do not even tell their coach! Many coaches are not trained to recognize the symptoms of serious head injury. Atabaki 2007 Many head injuries are directly related to sporting activities, especially football. This is a time to be particularly observant for signs and symptoms of MTHI. Most children experiencing symptoms of MTHI do not seek help on their own, and may not mention any problems to their coaches. As a parent, ask yourself – Is your child’s coach trained to recognize and manage suspected head injuries? As a coach, ask yourself – How capable are you at recognizing the signs and symptoms of MTHI? 99 99 99 99

Resources for Coaches: The CDC Heads Up Tool Kit
The CDC, working in partnership with noted professional medical, sport, and educational organizations, has created a tool kit called Heads Up that is designed to help coaches prevent, recognize, and manage concussion in sports. It contains: A concussion guide for coaches; A coach’s wallet card on concussion for quick reference; A coach’s clipboard sticker with concussion facts and space for emergency contacts; A fact sheet for athletes in English and Spanish; A fact sheet for parents in English and Spanish; An educational video/DVD for you to show athletes, parents, and other school staff; Posters to hang in the gym or locker room; and A CD-ROM with additional resources and references. Coaches can use tool kit materials to educate themselves, athletes, parents, and school officials about sports-related concussion and work with school officials to develop an action plan for dealing with concussion when it occurs. The Heads Up tool kit can also be ordered or downloaded free-of- charge at: To reduce the number of head injuries, the CDC has developed a tool kit for coaches entitled, Heads Up: Concussion in High School Sports. This kit contains practical, easy-to-use information including a video and DVD featuring a young athlete disabled by a MTHI, a guide, wallet card and clip board sticker for coaches, posters, fact sheets for parents and athletes in English and Spanish, and a CD-ROM with downloadable kit materials and additional concussion-related resources. The Heads Up tool kit can also be ordered or downloaded free-of-charge at the Web address listed on the slide.

For Coaches: Signs of MTHI
Suspect MTHI if the student: Appears dazed or stunned Is confused about assignment or position Forgets sports plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness (even briefly) Shows behavior or personality changes Can’t recall events prior to or after the hit or fall CDC: Heads-Up Listed on this slide are the signs and symptoms of MTHI related specifically to child athletes. Remember: “When in doubt, sit them out!” 101 101 101 101

Sport Concussion Assessment Tool 2 (SCAT2)
This tool represents a standardized method of evaluating people after concussion in sports. It is used for patient education as well as for physician assessment of sports concussion. It was developed by a group of international experts at the 3rd International Consensus Meeting on Concussion in Sport held in Zurich, Switzerland (November 2008). Pocket SCAT2 SCAT2 for Healthcare Professionals McCrory 2009 The Sport Concussion Assessment Tool2, known as the SCAT2, is a standardized method of evaluating injured athletes 10 years and older. The SCAT2 was designed for the use by healthcare professionals. The Pocket SCAT2 was designed for coaches as a quick reference to help recognize suspected MTHI. Both tools were developed by a group of international experts at the 3rd International Consensus Meeting on Concussion in Sport in November Click the icon to download the tools, which can be freely copied for distribution to individuals, teams, groups, and organizations. (213 Kb) 102 102 102 (268 Kb) 102

Summary: Sports Guidelines
Never return an injured child to active play/sports on the same day. After one MTHI, child must be symptom-free and cleared by a healthcare professional before resuming normal activities or participating in sports. When In Doubt, Sit Them Out Remember these 3 main points: Never return an injured child to active play or sports on the same day the injury occurred. After suffering a MTHI, the child must be symptom-free and medically cleared by a healthcare professional before resuming a normal level of activity, including participating in sports. - When in doubt, sit them out! 103 103 103

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