1. 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

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

3. 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

4. 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

5. 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

6. 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

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

8. 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

11. 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

13. 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

14. 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

15. 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

16. Assessment Tools
Department of Emergency Medicine

17. 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

18. 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
Department of Emergency Medicine

19. 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:
Department of Emergency Medicine

20. 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:
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21. PECARN Imaging Guidelines > 2yo
Kupperman et al. Lancet 2009;374:
Department of Emergency Medicine

22. 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:
Department of Emergency Medicine

23. 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

24. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Play Safe
Department of Emergency Medicine