Concussion

Concussion is a traumatic brain injury¹ resulting from acceleration/deceleration forces from a direct blow to the head, face, neck or elsewhere on the body with an ‘impulsive’ force transmitted to the head. Loss of consciousness and/or amnesia are not required to make the diagnosis.

This document is adapted from Zemek R, Reed N, Dawson J, et al. “Living Guideline for Pediatric Concussion Care.” The original resource and all tools in this document can be found at pedsconcussion.com

• Physical/somatic symptoms may include headache, nausea, vomiting, loss of balance and dizziness.
• Cognitive symptoms may include feeling in a ‘fog’, difficulty concentrating/remembering, amnesia, irritability and confusion.
• There can also be emotional (anxiety, depression) changes, behavioural issues and sleep disturbance.

HISTORY AND PHYSICAL EXAMINATION³

• Record the acute event, symptoms (initial and ongoing), past medical history (concussion, migraine, ADHD/learning disorders), medications, social history.
• Assess Glasgow Coma Scale (GCS), balance (Balance Error Scoring System), HEENT, neck, neurological exam including gait, Romberg’s testing, vestibular-ocular exam (training video for the vestibular-ocular exam).
• Use Living Guideline PedsConcussion Physical Examination resource.

DETERMINE NEED FOR NEUROIMAGING

• Order head and/or neck CT if a clinically important intracranial or cervical spine injury is suspected using PECARN (head), PECARN (cervical spine) and/or CATCH 2 rule. ^4,5,6
• Head CTs and MRIs are not used routinely as imaging results are NORMAL in concussion.

DETERMINE RISK OF PERSISTING SYMPTOMS AFTER CONCUSSION (PSAC)⁷

• Assess risk of symptoms lasting one month or longer using 5P risk score (see Table 1) to aid in counseling.
• Patients are considered low risk for persistent symptoms if their score is 0-3, moderate risk if their score is 4-8 and high risk if their score is 9-12.
• Refer those with 5P risk score ≥ 5 and those in competitive sports and/or with pre-existing mental health conditions to a medically supervised interdisciplinary concussion team for early intervention, if available. Otherwise, primary care provider should coordinate referrals (e.g., physiotherapy, occupational therapy, mental health) for ongoing rehabilitation, as required

• After assessing the need for neuroimaging, strongly consider admission or prolonged ED observation for patients with increasing or persistent confusion/irritability, worsening headache, persistent vomiting, ongoing seizures, focal neurologic symptoms/signs, prolonged altered level of consciousness, history of bleeding disorder and/or multisystem injuries.
• Discharge patients with normal mental status and improving symptoms, no risk factors indicating need for CT scan (or normal CT scan, if performed) and no indications for prolonged hospital observation/admission.

• Provide patients/caregivers with handouts outlining Return-to-School and Return-to-Activity protocols. Provide written instructions on when to return to ED/primary care provider.
• If required, use printable Medical Assessment Letter to document the injury and assessment.
• Counsel gentle activities around the house, including social interactions and light walking (if tolerated) for the first 24-48 hours post-injury and physical and cognitive relative rest (if needed). Complete rest for more than 24- 48 hours may negatively impact recovery.²
• Recommend that physical and cognitive activity be started 24-48 hours after acute concussion, increasing the intensity gradually as part of the initial treatment. Activities that pose no/low risk of reinjury should be resumed even if mild residual symptoms are present.
• Screentime should be minimized in the first 48 hours after injury. After 48 hours, screentime may be gradually resumed and increased according to symptom tolerance as the child/adolescent recovers.¹⁰
• Most children recover within 2-4 weeks, although 30% may have persistent symptoms after 1 month.⁹
• Recommend medical follow-up 1-2 weeks following the injury or earlier if symptoms worsen. Initiating clinical care early (within 8 days) is associated with improved recovery times.⁷

RETURN TO SCHOOL

• Medical clearance is not required to return to school. Gradual return to school (Return-to-School Steps) should be encouraged as soon as possible, even if symptoms are still present. Prolonging the return to school may be detrimental to recovery. Complete absence from school for more than one week is not recommended.
• Children with concussion should return to school after a short break (24-48 hours at most) and as soon as they can tolerate academic activities with adequate accommodations in place. Any school-related activity that has a risk of reinjury should be avoided until medically cleared.

RETURN TO ACTIVITY^1,2

• Resume physical activities by 24-48 hours post-injury (at most). Gradually increase the intensity of aerobic activity as part of the initial treatment for acute concussion using a step-wise Return-to-Activity protocol.
• Start with ‘light-intensity’ aerobic exercise, progressing to ‘moderate-intensity’ aerobic exercise, and continue to increase the intensity over time as symptoms are tolerated. Mild exacerbation of symptoms is common; suggest taking a break from the activity if increase in symptoms is more than mild/brief or the symptoms cannot be tolerated.^1,2
• Avoid contact sports/activities that risk reinjury until:
  1. full return to school without concussion-related academic accommodations AND
  2. medical clearance for full-contact sport and high-risk activities
• Written determination of medical clearance should be provided before unrestricted return to sport as directed by local laws and/or sporting regulations.
• Patients experiencing concussion-related symptoms after medical clearance should return to their health care provider for reassessment with a goal of full resolution of symptoms with exertion before engaging in high-risk activities.

SYMPTOMATIC TREATMENT

• Counsel regarding the importance of hydration and sleep hygiene. Melatonin can be considered for difficulty sleeping.
• Use NSAIDs and/or acetaminophen PRN for headache during the first few days post-injury.
• Recommend physiotherapy for cervicogenic headache and/or vestibular therapy for dizziness, vertigo, or visual changes.
• Counsel families and primary care provider that early Cognitive Behavioural Therapy for emotional and behavioural symptoms is important for optimal recovery.
• The use of sunglasses, ear plugs and/or noise-cancelling headphones may also be helpful as short-term aids.

Thank you to the following content experts who led the development of the Pediatric Concussion Bottom Line Recommendations:

Roger Zemek, MD Pediatric Emergency Physician, Division of Emergency Medicine, CHEO, Chair of the Pediatric Emergency Research Canada (PERC)

Jennifer Dawson, PhD, Research Associate, CHEO

Thank you to the TREKK Editorial Committee, editor Dr. Sarah Reid (CHEO), who provided editorial support and expertise in the development of this resource. Thank you as well to Mateja Carevic, TREKK Project Coordinator (University of Manitoba) who coordinated the development process, and Dr. Ariane Boutin, Pediatric Emergency Physician, CHU Sainte-Justine, for reviewing the translation.

1. Reed, N.*, Zemek, R.*, Dawson, J., Ledoux, AA., et al. (2023). Living Guideline for Pediatric Concussion Care. *these two authors contributed equally.
2. Ledoux et al 2022. Is early activity resumption after paediatric concussion safe and does it reduce symptom burden at 2 weeks post injury? The Pediatric Concussion Assessment of Rest and Exertion (PedCARE) multicentre randomised clinical trial. Br J Sports Med. 2022 Mar;56(5):271-278.
3. Osmond M, Klassen TP, Wells G.A., et al. (2018). Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department. CMAJ. 190(27), 816-822.
4. Vaughan et al 2023. Association Between Early Return to School Following Acute Concussion and Symptom Burden at 2 Weeks Postinjury. JAMA Netw Open. 2023 Jan 3;6(1):e2251839.
5. Zemek R, Barrowman N, Freedman SB, et al. (2016). Clinical risk score for persistent postconcussive symptoms among children with acute concussion in the ED. JAMA. 315(10):1014-1025.
6. Leonard, Julie C et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. The Lancet Child & Adolescent Health, Volume 8, Issue 7, 482 – 490.
7. Patricios et al. (2023). Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British Journal of Sports Medicine 2023;57:695-711.
8. Dawson et al. (2023). Returning to school following concussion: Pointers for family physicians from the Living Guideline for Pediatric Concussion Care. Can Fam Physician. 2023 Jun;69(6):382-386
9. Kontos AP, Jorgensen-Wagers K, Trbovich AM, et al. (2020). Association of time since injury to the first clinic visit with recovery following concussion. JAMA Neurol. 77(4):435–440.
10. Cairncross M, Yeates KO, Tang K, Madigan S, Beauchamp MH, Craig W, Doan Q, Zemek R, Kowalski K, Silverberg ND. Early Postinjury Screen Time and Concussion Recovery. Pediatrics. 2022 Nov 1;150(5):e2022056835. doi: 10.1542/peds.2022-056835. PMID: 36250231.

For a complete list of the evidence that informed the creation of the Concussion Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use