Evaluation of the Concussed Child/Adolescent

Naomi Brown

Eileen P. Storey

William P. Meehan, III

Corina Martinez

Christina L. Master

• Introduction

Concussion is a common injury among active young athletes. According to the parent-reported National Health Interview Survey conducted in 2016, 8.3% of boys and 5.6% of girls aged 3 to 17 years have experienced at least one significant head injury. Among children 15 to 17 years of age, 11.7% experienced at least one head injury.¹ A recent epidemiological study in a large-scale pediatric network reported that most pediatric concussions occur during sports, especially in children older than 5 years.² Although 30% of pediatric and adolescent concussions occur outside of sports, an increasing proportion of concussions occur during sports as children get older. Timely recognition and diagnosis of concussion is important, especially because continuing to play is associated with delay in recovery.³ It is critical for coaches, team physicians, athletic trainers, and other clinicians responsible for the care of athletes to be knowledgeable in the diagnosis, acute management, and ongoing care of the concussed child.

Each year, hundreds of thousands of children and young adults are diagnosed with concussion. According to the Centers for Disease Control and Prevention (CDC), an estimated 2.6 million children aged 19 years or younger were treated annually for sports- and recreation-related injuries. Of those, approximately 6.5% were traumatic brain injuries and 70.5% were among persons aged 10 to 19 years.⁴ The incidence of concussion is higher for contact and collision sports, particularly those male athletes playing American football, ice hockey, rugby, and lacrosse. For female athletes, soccer, lacrosse, and field hockey have the highest incidences of concussion.⁵,⁶,⁷ The most recent High School Reporting Information Online (RIO) data from the 2016 to 2017 school year found that concussions accounted for 24.8% of all injuries sustained during 1.18 million athletic exposures.⁸

A concussion, by definition, is a traumatic brain injury that affects brain function. However, concussion remains a heterogeneous injury that affects individuals in different ways. There are a wide variety of mechanisms of injury, with the most common involving a direct blow to the head, face, or neck, as often occurs in sport. An injury can also occur from forces that are transmitted to the head, such as a whiplash injury during a motor vehicle accident or a blow delivered to another part of the body.⁹

After an injury, there is a neurometabolic disturbance that can result in a variety of symptoms.¹⁰ Symptoms can be organized into four domains: physical, sleep, thinking/remembering, and mood disruption. Symptoms often worsen when the brain is required to perform more metabolically demanding activities such as physical activity or higher level cognitive processing involved with schoolwork.¹¹ However, the diagnosis and management of concussion remains challenging because symptoms are nonspecific and overlap with several other possible etiologies, including depression, lack of sleep, primary headaches, autonomic dysfunction, viral illness, dehydration, and many others. In fact, uninjured teenagers also report concussion-like symptoms even when they are healthy (Figures 10.1 and 10.2).¹²

FIGURE 10.1 Symptoms of concussion. (Image courtesy and © The Childrens’s Hospital of Philadelphia.)

• Acute On-Field Evaluation

Acute on-field evaluation is directed at excluding a more emergent injury, recognizing concussion, and removing injured athletes from play and the possibility of additional injury. In evaluating a child who has been injured on the field, one should first ensure that the child is stable and does not need
emergency resuscitation by performing a primary survey. The primary survey, ABCDE, consists of the following steps to ensure that a provider does not miss a more severe head, cervical spine, or other injury:

FIGURE 10.2 Overlapping clinical profiles of concussion. (From Harmon KG, Clugston JR, Dec K, et al. American Medical Society for Sports Medicine position statement on concussion in sport. Br J Sports Med. 2019;53:213-225: Figure 1.)

Airway assessment and protection
Breathing and ventilation assessment
Circulation assessment
Disability assessment
Exposure assessment

Airway

As part of the airway assessment, one must first determine if the child is conscious or unconscious. If the child is conscious, asking the patient a simple question, such as “what is your name?” determines if the person is conscious and able to speak, indicating that the patient is aware and able to protect the airway. For those sports that require helmets, the face mask and chin strap are designed to be removed quickly
to enable access to the athlete’s airway. It is important for anyone providing medical coverage for such sports to be familiar with the required protective equipment and to have the knowledge and the tools to be able to safely and quickly remove equipment (eg, facemask) in the setting of serious injury. In the unconscious child, the airway must be protected immediately and a mouth guard should be removed so it does not block the airway. One should also recognize the possibility that an injury to the cervical spine has occurred until proven otherwise. Maintaining cervical spine stabilization is critical, because an unconscious child may also have a cervical spine injury.¹³

Breathing

Once airway patency is assessed, the adequacy of oxygenation and ventilation should be determined and steps should be taken to ensure that adequate oxygenation is maintained by the injured party or if further support of the airway is urgently needed.

Circulation

The provider should evaluate circulation by palpating central pulses, and if needed, steps should be taken to control any hemorrhage and maintain adequate end-organ perfusion. Emergency response should be activated to call for an ambulance and an automated external defibrillator (AED). Chest compressions should be initiated, if no pulse is detected, and AED applied for defibrillation if indicated.

Disability

A general neurologic evaluation is performed, including determining the Glasgow Coma Scale (GCS) score assessing the pupillary size and reactivity, gross motor function, and sensation. During the assessment on the field, one should immediately evaluate for signs of more serious head trauma, such as a skull hematoma or a scalp defect. If there are signs of a skull fracture, such as hematoma, scalp step off or depression, crepitus, or significant soft-tissue swelling, there is increased concern for elevated intracranial pressure. Any concerning signs should prompt emergent transportation to an emergency facility for evaluation and advanced imaging (Figure 10.3).

Any athlete suspected of having a concussion should be immediately removed from play. If the athlete is conscious and it has been determined that he or she does not need immediate emergency care, sideline screening assessments for concussion, such as the SCAT5 or Child SCAT5, could be considered. These tests, however, are brief and not intended to replace a more comprehensive office clinical concussion evaluation as described below.

FIGURE 10.3 Axial CT shows the right temporal scalp hematoma with underlying subdural hematoma and parenchymal contusions. (From Castillo M. Neuroradiology Companion. 4th ed. Philadelphia, PA: Wolters Kluwer; 2011: Figures 8-27, with permission.)

FIGURE 10.4 If a neck injury is suspected in an athlete wearing shoulder pads and a helmet, the equipment should be left in place to maintain a neutral spine position. Note in this picture that the athlete’s neck is in an unsafe hyperextended position because shoulder pads are in place and helmet has been removed.

Exposure

Depending on the sport, the sideline evaluation can be difficult because of the equipment worn. Many sports have equipment that can either be easily removed or is designed to be left on during an emergency. In football, lacrosse, and ice hockey, shoulder pads, helmets, and chin strap should be left in place when possible to keep an injured neck in a neutral position (Figure 10.4). The helmet also prevents head movement, and towel rolls, foam head blocks, and/or tape can be used to stabilize the head if needed. If the helmet or the shoulder pads are to be removed, they both need to be removed (Figure 10.5). Removing just the helmet will force the neck into extension by shoulder pads. Conversely, removing just the shoulder pads would flex the neck out of a neutral position due to the helmet. If the athlete with a neck injury is wearing a helmet without shoulder pads, the helmet should be removed while maintaining the cervical spine in a neutral position in a controlled manner by an experienced clinical provider with experience in helmet removal, such as a certified athletic trainer.¹⁴ Repeated rehearsal of these procedures is highly recommended for those covering athletic events. Site-specific emergency action plans should also be reviewed to ensure efficient access to athletic venues for emergency responders.

Emergent injuries identified during the primary survey should be addressed and prompt transfer to an appropriate medical facility should be arranged. A trained professional should stabilize the athlete’s
neck in a neutral position and ensure there is no added injury when moving the patient (Figure 10.6). The log-roll maneuver is used to move a patient without flexing the spinal column. At least three, ideally more, people are required to perform the log-roll technique properly (Figure 10.7). If trained personnel are available, the six-person lift may be utilized. With the legs stretched, the head is immobilized and the
patient moved in a secure manner typically in order to examine the patient or move the athlete from the field to a stretcher. The arms should be placed palms inward, extended by the athlete’s side, unless an arm is injured. If the arm is injured, the backboard should be placed on the injured side, so the athlete rolls onto his/her uninjured side. One rescuer is placed at the head of the athlete and the other two kneeling opposite the board; one at the mid-chest and one at the upper legs. When the patient is logrolled, the posterior side of the body should be examined by an additional rescuer.¹⁵

FIGURE 10.5 Before emergency transport, the head and neck should be stabilized and the face mask removed to allow for access to the airway if emergency management is required.

FIGURE 10.6 Stabilization of neck while patient is being moved

FIGURE 10.7 Logroll method.

• Sideline Evaluation

The concussion examination and assessment may vary somewhat when performed in the emergency department, the office setting, or from the sideline. This is due, in part, to the pressures and constraints of the setting, as well as the ultimate goals of the assessment. Yet in each location, assessment of consciousness, awareness, and orientation should occur immediately. Potential intracranial pathologies should be considered if there is any alteration in loss of consciousness, presence of amnesia, seizures, weakness or paralysis, or other concerning signs or symptoms, such as severe worsening of headache or vomiting or level of consciousness.

If the general neurologic examination is normal (eg, the pupillary size and reactivity, gross motor function and sensation are normal), then the goal is to determine if there is a sports-related concussion. It is important to note that the diagnosis of a concussion remains a clinical judgment made by a medical professional. There are tests that have been created specifically for sideline use, such as the SCAT5 which includes the Maddocks questions, a cervical assessment, the Post-Concussion Symptom Scale (PCSS), Standardized Assessment of Concussion (SAC), and modified Balance Error Scoring System (BESS). Preinjury baseline tests may be helpful but are not essential for use of these tools following injury (

Video 10.1-10.9).

• SCAT5

The SCAT5 is a tool used for evaluating athletes aged 13 years and older to aid in the diagnosis of concussion, but a normal SCAT5 does not necessarily exclude the possibility of a concussion as signs and symptoms may evolve early after the injury (Appendix 10.1). While the SCAT5 is currently the mainstay for acute sideline assessment,¹¹,¹⁶,¹⁷ its utility decreases over time and does not seem to be as helpful 3 to 5 days out from injury.

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