Emergency Department Evaluation of Concussion (Traumatic Brain Injury) Sylvia E Garcia, MD Assistant Professor Pediatric Emergency Medicine Icahn School of Medicine At Mount Sinai Department of Emergency Medicine

Disclosures I have no financial disclosures to report. Department of Emergency Medicine

Primary Care Office Visits Pediatric Head Trauma Deaths 7,000/yr Hospitalizations 95,000/yr 60%↑ in ED visits in last 10 years ED Visits > 500,000/yr Primary Care Office Visits Assume numerous, No data Hospital care costs alone exceed 1 billion/year - 29,000 permanent disabilities annually

Goals and Objectives Recognize the importance of obtaining a comprehensive history that identifies previous injury / concurrent medical conditions Know the importance of assessing vestibular balance Understand the role of neuroimaging in the evaluation of the concussed patient Recognize the importance of clear discharge instructions Department of Emergency Medicine

Recognition of Concussion Signs Symptoms Dazed or stunned Headache Confused / forgetful Dizziness Answers slowly Nausea / vomiting Moves clumsily Double / blurry vision Loss of consciousness Sluggish / foggy Behavior / personality changes Concentration problems Amnesia Confusion Change in sleep pattern Department of Emergency Medicine

Comprehensive history Comprehensive history should include documentation of previous Closed head injuries / concussions Depression / anxiety Sleep disturbances Learning disorders Attention deficit disorders Headaches ( migraines ) Department of Emergency Medicine

Physical Exam ABCs C-spine immobilization as needed GCS determination Neuroimaging as deemed necessary Detailed neurological evaluation Department of Emergency Medicine

Assessment Tools Acute Concussion Evaluation ( ACE ) Brain Injury Survey Questionnaire ( BISQ ) Sport Concussion Assessment Tool ( SCAT ) SCAT 3 Child SCAT 3 Department of Emergency Medicine

Assessment Tools The Brain Injury Survey Questionnaire ( BISQ ) is a screening tool that assesses for: Any unidentified previous TBI Persistent symptoms associated with a previous TBI Events and conditions other than TBI that can cause similar symptoms Parent and / or patient is given Part 1 of the BISQ Cantor J et al. Arch Phys Med Rehabil 2004;85(4 Suppl2):S54-60 Department of Emergency Medicine

Assessment Tools The Sport Concussion Assessment Tool is a standardized tool utilized in the evaluation of concussion in patients ≥ 5 yrs of age Child- SCAT3 ( ages 5 -12yrs ) SCAT3 ( age ≥ 13 yrs ) Cognitive assessment Neck examination Balance and coordination examinations Delayed recall Department of Emergency Medicine

Assessment Tools Balance exam assesses vestibular system Double leg stance Single leg stance Tandem stance Tandem gait Scored by error or deviations from proper stance Specific, not sensitive, indicator of concussion Postural deficits last ~72 hrs 3Harmon KG, Drezner JA, Gammons M, et al. Br J Sports Med 2013,47,15-26 Department of Emergency Medicine

Assessment Tools There’s an App for that Sway Balance SystemTM for iOS devices Uses the built in motion sensor for cell phone Patient is given instruction for vestibular exams Begin test button is tapped when ready and the device is held against the chest Department of Emergency Medicine

Assessment Tools Department of Emergency Medicine

Neuroimaging Conventional brain CT or MRI is usually normal in concussive injury Prevalence of an abnormal CT increases with decreasing GCS Department of Emergency Medicine

Neuroimaging Emergent Head CT Clinical deterioration or worsening symptoms Seizure ( other than impact seizure ) or prolonged seizure Pre-existing condition increasing risk for bleeding Penetrating injury GCS ≤ 14 Focal neurologic abnormalities Signs of depressed or basilar skull fracture Prolonged loss of consciousness (> 1min) , < Jeff E. Schunk, Sara A. Schutzman. Pediatric Head Injury. Pediatrics in Review, Volume 33, Number 9 (September 2012), pp. 398-411 Department of Emergency Medicine

Neuroimaging The Pediatric Emergency Care Applied Research Network ( PECARN ) study identified children at very low risk for clinically important TBI after head trauma for whom CT scan is unnecessary Kupperman et al. Lancet 2009;374:1160-70 Department of Emergency Medicine

Neuroimaging : PECARN Study Children up to age 18 yrs old were enrolled All subjects were seen within 24 hours GCS recorded was 14 – 15 Preverbal ( ≤2 yo ) and verbal ( ≥2 yo ) groups were analyzed separately Kupperman et al. Lancet 2009;374:1160-70 Department of Emergency Medicine

PECARN Imaging Guidelines > 2yo Kupperman et al. Lancet 2009;374:1160-70 Department of Emergency Medicine

Neuroimaging The prediction rule for children ≥ 2 yrs had a negative predictive value of 99.95% and sensitivity of 96.8% Normal mental status No loss of consciousness No vomiting Non-severe injury mechanism No sign of basilar skull fracture No severe headache No high-risk mechanism Kupperman et al. Lancet 2009;374:1160-70 Department of Emergency Medicine

Management Medications Tylenol or Ibuprofen for headaches Avoid drugs that can alter mental status Anti-nausea medications used with caution No medications for sleep, mood or attention disturbances Meclizine can affect cognitive function Department of Emergency Medicine

Discharge Instructions Instructions should be clear on what to expect after diagnosis of concussion Monitor for 24 – 48 hours No need for periodic awakening Majority of symptoms improve / resolve in 7 days Department of Emergency Medicine

Discharge Instructions Patients should return to the ED Worsening headaches Increased drowsiness / not able to be awoken Repeated emesis Unusual behavior or seem confused or irritable Seizures Weakness or numbness in arms / legs Unsteadiness Slurred speech Department of Emergency Medicine

Discharge and Follow-up Rest / sleep Avoiding activities requiring concentration Avoid strenuous activities No alcohol No sleeping pills No driving or play until cleared Department of Emergency Medicine

Discharge Instructions Return to learn before return to play School should be made aware of the need for reduced workload, frequent rest periods, extended time to complete tests or complicated tasks Department of Emergency Medicine

Discharge and Follow-up No one should be cleared to ‘return to play’ from the ED Excuse should be given for delayed return to school / work Department of Emergency Medicine

Summary Review past history for previous injury and conditions that may exacerbate recovery Motor domain of neurological function can be reliably assessed by vestibular balance testing CT scan is rarely necessary Discharge instructions should clearly outline expectations, and indications for follow-up Department of Emergency Medicine

Summary Patients should be reassessed by a physician in 3 to 5 days Follow-up with a specialist if no improvement or recovery noted within 5 to 7 days Department of Emergency Medicine

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