1. KIDCUSSION ASSESSMENT
Neurobehavioural Rehabilitation in Acquired Brain Injury
May 2, 2018
Dr. Eric Koelink, BMBS FRCPC Dip Sport Med
Pediatric Emergency Medicine
McMaster Children's Hospital
Pediatric Sports Medicine
David Braley Athletic Centre

2. Excluding More Serious Pathology
Outline
Case
Excluding More Serious Pathology
Making the Diagnosis
Sideline Assessment
Looking at the Numbers

3. Case

4. Case 13 year old hockey player
Gets hit with her head down and strikes head on ice, LOC x a few seconds, feels “in a fog” afterward
Dizziness
Headache
Amnesia
Presents to local pediatric ED  Normal neurologic examination, cognitive function assessment, symptoms improving
Case

5. Should we do a CT of her brain?
Does she have a concussion?
The questions:

6. Excluding More Serious Pathology

7. ER Evaluation

8. Full neurological and mental function assessment
As always, CABs
Full neurological and mental function assessment
ER Evaluation
In the Emergency Department during the initial evaluation, every child as always, should have their AIRWAY, BREATHING and CIRCULATION assessed. In addition, appropriate cervical spine precautions should be taken.
Then,
Thorough history should be completed, including any signs & symptoms the patient is experiencing or a history of previous head injuries.
Head, neck & neurologic examination (postural stability, Romberg test, tandem gait)
Assessment of cognitive function, which can be done using the Sport Concussion Assessment Tool (also known as SCAT5)

9. Concussion is a functional rather than structural brain injury
X-ray, CT, MRI are normal acutely, therefore not routinely recommended
Unless…
To image or not to image?

10. PECARN – Who does NOT need a CT?
>2 YEARS OLD
Pediatric Emergency Care Applied Research Network
Over children enrolled in prospective cohort study to produce validated prediction rules in children <2 and >/=2
ciTBI defined as death from traumatic brain injury, required neurosurgery, intubated >24 hours, admitted to hospital >/= 2 nights
Altered mental status: agitation, somnolence, repetitive questioning
Basilar skull fracture: racoon eyes, Battle’s sign, CSF oto/rhinorrhea, hemotympanum
Severe MOI: MVC with patient ejection, death of another passenger, rollover Pedestrian/cyclist hit by car, fall >3 or 5 feet, head struck by high impact object
Kupperman et al Lancet 2009

11. Why PECARN?

12. Objective/Methods
To validate 3 clinical decision rules in a large sample of children
Large, multicenter prospective observational study of 20,137 children

13. All three had negative predictive values of 99-100%
Overall, <1% of patients underwent neurosurgery and <1% passed away
PECARN had highest sensitivity and was only rule to not miss a single patient requiring neurosurgery
All three had negative predictive values of %
Negative predictive value is the probability that subjects with a negative screening test truly don't have the disease

14. Making the Diagnosis

15. Concussions

16. Sport related concussion is a traumatic brain injury induced by biomechanical forces
Definition
This is differentiated from mild traumatic brain injury (mTBI), which is defined as head injury due to contact and/or acceleration/deceleration forces with a Glasgow Coma Scale score of 13 to 15, measured at approximately 30 minutes after the injury
McCrory et al, 2017

17. Signs/Symptoms Purcell, 2012 Symptoms/Signs Headache Nausea/Vomiting
Dizziness
Visual disturbances
Photophobia
Phonophobia
LOC
Amnesia
Emotional/Behavioural
Irritability
Emotional lability
Sadness
Anxiety
Inappropriate emotions
Cognitive
Slowed reaction times
Difficulty concentrating
Difficulty remembering
Confusion
Feeling in a fog/dazed
Sleep Disturbance
Drowsiness
Trouble falling asleep
Sleeping more
Sleeping less
Signs/Symptoms
Purcell, 2012

18. Diagnosis Made
Mechanism of Injury
Signs/Symptoms
Concussion

19. Sideline Assessment
and the SCAT5

20. Assessment Priorities
Rule out more severe pathology
Eg. hemorrhage
Make concussion diagnosis
Rule out other significant injuries
Eg. c-spine injury
Is ED assessment indicated?
Initial Management including removal from match

21. Who should we send to the ED?
PECARN +
C-Spine concern including axial load, motor/sensory deficits in limbs
Post-traumatic seizure
Deterioration of patient’s condition

22. Brief neuropsych assessment of attention/memory on the field
Evaluate athletes aged 13 years and older
Child SCAT 5
Ages 5-12
Sport Concussion Assessment Tool 5:

23. On-Field Assessment

24. Off-Field Assessment Orientation, immediate memory, concentration
Including balance
(modified Balance Error Scoring System)

25. Inside the Numbers

26. Football, soccer, and hockey have shown >40% increase in rates of reported head injury from for children and youth
Among children and youth (10-18 years) who visit an ED for a sports-related head injury, 39% were diagnosed with concussions, and further 24% were possible concussions
Epidemiology - Canada
Not great data for Canada.
Nov 16, 2017

27. Epidemiology - Canada
The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) is an emergency department (ED)-based injury and poisoning surveillance system operating in 16 sites across Canada

28. Total Number of Registered Ice Hockey
Players in Canada
Epidemiology - Canada
Numbers from IIHF

29. Epidemiology - Ontario
Over 8 year span: 88,698 total or 11,087/year
Macpherson et al, 2014

30. Why the increase? Number of sports activities available
Competitiveness of youth sports
Intensity of practice and play times
AWARENESS AND REPORTING

31. Increasing media attention
The Star, National Post, Online, brought the new CPS statement to the forefront when the new CPS statement came out in January of this year

32. Objective/Methods
To assess the knowledge of paediatric concussion diagnosis and management among front-line primary care providers
E-survey sent to ED MDs, family MDs, pediatricians, sport medicine physicians, RNs, physician assistants (13,500 distributed, ~5.5% responded)

33. Results
Physicians and non-physicians equally recognized concussion (90% and 85% respectively)
Only 37% of physicians correctly applied graduated return to play guidelines
Return to learn recommendations were also insufficient: 53% neglected to recommend school absence and 40% did not recommend schoolwork accommodations
Improvement in use of guidelines may help to reduce the impact of concussion and persistent post-concussive problems in children and adolescents

34. Front Line Knowledge

35. Front Line Knowledge Main outcome Results 73/348 (21%) response rate
Relationship between awareness of concussion management and lifestyle, education background, and residency placement
Results 73/348 (21%) response rate
5.2/9 questions regarding concussion diagnosis and management answered correctly (58%)
32% of residents did not believe that every individual with a concussion should see a physician
16% believed that direct trauma to the head was required to sustain a concussion
12% reported never learning about concussion during residency training
Conclusion
Further knowledge translation efforts needed at both undergraduate and residency levels

36. Conclusion Assess for more serious injury
Confirm the diagnosis and remove from play if indicated
Sideline assessment
Continued efforts needed to improve education of healthcare providers on proper diagnosis and management
Conclusion

37. Thank You