Ep 153 Pediatric Minor Head Injury and Concussion

We see about 750,000 pediatric patients annually with traumatic head injury in EDs across North America. That’s a lot of kids. While most of these kids will be fine regardless of what we do in the ED, even minor pediatric head injury may require neurosurgical intervention, investigating is not without serious risk, there may be long term consequences even with trivial bonks and the signs can be devilishly subtle. Recent literature suggests that pediatric patients take longer to recover from mild traumatic brain injury compared to adults and persistent post-concussive symptoms (PPCS) after 1 month occur in up to 30% of children after minor head injury. These children can and should be identified in the ED based on the PPCS clinical risk score. In this EM Cases main episode podcast “Pediatric Minor Head Injury and Concussion” Dr. Sarah Reid and Dr. Roger Zemek discuss how best to incorporate the PECARN and CRASH2 decision tools into your practice, the role of Fast MRI, how to identify children who are at risk for long term sequelae after a minor head injury and how to manage persistent concussion symptoms when a child returns to the ED after a minor head injury….

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Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Winny Li, edited by Anton Helman March, 2021

Cite this podcast as: Helman, A. Reid, S. Zemek, R. Pediatric Minor Head Injury and Concussion. Emergency Medicine Cases. March, 2021. https://emergencymedicinecases.com/pediatric-minor-head-injury-concussion. Accessed [date]

Emergency physicians should have a rock-solid approach to identify high-risk patient with minor head injury; to identify those at risk for long term sequelae, to use imaging responsibly, and to ensure ongoing appropriate care for the concussed child after they leave the ED.

Classification of pediatric head injury

The classification of pediatric head trauma is divided into minor, moderate and severe which are defined by GCS cut offs on first assessment in the ED.

GCS 14 to 15: Minor head trauma

GCS 9 to 13: Moderate head trauma

GCS ≤8: Severe head trauma

Minor head injury is defined as injury within the past 24 hours associated with one of the following:

• Witnessed loss of consciousness
• Definite amnesia
• Witnessed disorientation
• persistent vomiting (> 1 episode) or
• persistent irritability (< 2 years old)
• and a GCS score of 14–15

Fortunately, only 5% of children with minor head injury will have an intracranial abnormality and about 1% will have a clinically important outcome. It is important that we use our history and physical exam to identify the patients at high risk for a clinically important outcome.

Key features on history to identify children at risk for an intracranial lesion requiring imaging

Mechanism of injury

PECARN: severe mechanism (MVC with ejection, death another passenger, rollover, pedestrian or bicyclist w/o helmet struck by motorized vehicle, fall 0.9m or 3ft, head struck by high-impact object)

CATCH2: high risk mechanism (fall ≥3ft or 5 stairs, bicycle with no helmet), worsening headache, persistent irritability if under 2 years old)

Recurrent vomiting

Isolated vomiting in the absence of other high-risk factors is rarely associated with significant traumatic brain injury (TBI). Recurrent vomiting (≥ 4 episodes, at least 15min apart) is a significant risk factor for intracranial injury  in children after minor head injury. The addition of ≥ 4 episodes of vomiting to CATCH2 increased sensitivity to 100% for neurosurgical intervention and 99.5% for any brain abnormality.

Age and persistent irritability

Not acting normally as per parent or persistent irritability is always a worrisome sign in a head-injured child under the age of 2 years. In a nonverbal child, assess whether the child can be settled by their caregiver.

CT should be more strongly considered for children with multiple findings, worsening symptoms or signs, and for infants younger than 3 months of age – owing to their limited ability to communicate and thinner skull.

Isolated features on history not associated with an intracranial lesion requiring imaging

Children who present with the following isolated clinical features with no high risk features on history or physical have an extremely low risk of clinically important TBI and can generally be safely discharged without imaging:

• Isolated headache
• Isolated loss of consciousness (LOC)
• Impact seizure (seizure immediately following head injury)

Key physical exam findings/maneuvers to identify children at risk of intracranial injury or post-concussion symptoms

Assess the child’s general appearance, GCS (see below), mental status and whether they are agitated, somnolent, displaying repetitive questioning or are slow to respond. Look for signs of basal skull fracture including hemotympanum, Battle’s sign, raccoon eyes, and CSF rhinorrhea. Palpate to look for a skull fracture and for non-frontal boggy scalp hematoma >2cm in size, which carries a higher risk for clinically important outcomes.

Pediatric GCS

Update 2022: A secondary analysis of the NEXUS validation study with 1,018 pediatric patients including 128 notable injuries on CT found that the sensitivity and specificity of provider physical examination to detect skull fracture was 18.5% and 96.6% respectively.  The authors concluded that physical exams have a poor sensitivity for skull fractures in the pediatric population. Abstract

Vestibular and oculomotor screening (VOMS) examination for concussion

In addition to the screening neurological examination to evaluate for an intracranial lesion, evaluate for vestibular and oculomotor dysfunction, which has a high predictive value in identifying concussion and aids in prognostication for persistent concussion symptoms.

Video demonstrating modified vestibulo-ocular exam for concussion (minutes 3:13-6:03)

Pediatric head injury decision tools: PECARN and CATCH2 – which to use and when?

Pediatric head injury decision rules were developed to decrease CT utilization and radiation effects of CT. In counselling parents, comparison to background radiation dose may be helpful: in comparison to a CXR which has a similar radiation dose to ~10 days of background radiation for a child, a CT head has a similar radiation dose to ~8 months of background radiation.

PECARN

US-based study, where the baseline assumption was that everyone needed a scan, thus the rule was developed in order to determine who does not need a CT scan.

Note that regardless of age group, PECARN recommends a CT scan in any child who presents with a Glasgow Coma Scale < 15, altered mental status, signs of palpable or basilar skull fracture. It included patients with GCS of 14-15.

PECARN on MDcalc

Update 2021: Analysis of 1081 infants (< 3 months old) with minor blunt head trauma according to PECARN traumatic brain injury (TBI) low-risk criteria; this criteria accurately identified infants at low-risk of clinically important TBIs (though cautious approach required since infants remained at risk for TBIs on CT imaging). Abstract

Update 2021: Multicenter study of clinically important traumatic brain injury (ciTBI) in Australia and New Zealand of an external cohort of 15,163 children. PECARN algorithm showed ciTBI risk estimates across high-, intermediate-, and low-risk groups of 8.5%, 0.2% and 0.0% for children >2 years, and 5.7%, 0.7% and 0.0% in children <2 years old respectively. Consistent with the original study; signs of “palpable skull fracture” and “basilar skull fracture” were isolated high-risk predictors of ciTBI. Abstract

CATCH2

Canadian study, and the baseline assumption was that no one needed a scan (as to prevent radiation risk), thus rule was developed to determine who does need a scan. It included patients with GCS of 13-15.

The original CATCH study had a sensitivity of 91% for neurosurgical intervention, but the addition of “>4 episodes of vomiting” resulted in a refined 8-item rule (CATCH2) with 100% sensitivity for neurosurgical intervention and 99.5% sensitivity for brain injury.

CATCH on MDcalc (note that CATCH2 requires “>4 episodes of vomiting” in addition to CATCH)

Bottom line: Our experts recommend using PECARN in patients with GCS 14-15 in whom your gestalt is that they do not require a CT scan and using CATCH2 in patients with a GCS of 13 in whom your gestalt is that they do require a CT scan.

POCUS is accurate in diagnosing skull fractures but has limited role in ruling out ICH

POCUS has been shown to be useful and reliable at diagnosing skull fractures (sensitivity 77-100%, specificity 94-100%). Our experts recommend using a small interface surface, scanning suture lines and using the contralateral side as control, and to scan around the hematoma as fractures may not be directly underneath the hematoma. POCUS however has a limited role in identifying ICH and often still requires a CT to rule out ICH, however identifying a skull fracture on POCUS may help inform next investigative steps.

Role for Fast-MRI as an initial imaging modality in minor head injury

In one small study, Fast MRI had a sensitivity of 92.8%, missing isolated skull fractures and small subarachnoid hemorrhage that did not require neurosurgical intervention. While larger studies are required, Fast MRI has potential as a radiation-sparing imaging modality for pediatric head injury in centers with quick access to MRI and radiologist experience with the modality for this specific indication.

Observation of the child with minor head injury and concussion in the ED

Many patients who are assessed using the PECARN tool require a period of observation and reassessment to identify evolving high risk features requiring imaging. Although an optimal duration of ED observation after minor head injury remains to be determined, a large retrospective study of children <14 years of age with minor head trauma demonstrated that only 5% of children were diagnosed with ICH more than 6 hours after the time of injury. Therefore, the necessary ED observation length is likely no more than 6 hours from the time of injury and is reasonable to consider active observation at home with appropriate caregiver instruction.

Criteria for safe discharge home after minor head injury and concussion

Combined with clinical judgement, home observation may be considered safe if:

• Normal mental status with improving symptoms
• No risk factors indicating need for CT scan or normal CT scan if
  already done
• No indications for prolonged hospital observation including
  worsening symptoms, bleeding disorders, multisystem injuries or comorbid conditions

Concussion diagnosis, discharge instructions and follow up

Most children with concussion recover within 2 weeks, however persistent post-concussive symptoms (PPCS) after 1 month occur in up to 30% of children after minor head injury. Thus, in the ED, it is important to identify these children and set expectations for possible PPCS and follow-up of the above-mentioned delayed symptoms. Furthermore, there is evidence that pediatric patients take longer to recover from mild traumatic brain injury compared to adults.

Our experts recommend using the PPCS clinical risk score for predicting risk of post-concussive symptoms. The tool performed significantly better than physician judgment in predicting PPCS. Consider early referral to a multidisciplinary head injury team for children with prolonged concussion symptoms or those at high risk for having prolonged symptoms as per the PPCS  clinical risk score.

Risk score: Low (0-3), Moderate (4-8), High (9-12) 

Discharge instructions for pediatric minor head injury and concussion

Cognitive rest after minor head injury and concussion

Most children require a 24-48 hour break from school followed by gradual return to full academic/cognitive activities. Prolonged rest beyond the first 24-48 hours after a concussion is no longer recommended and may be associated with harm.

Parental advice on “screen” time: AAP recognizes that young adults are highly connected through social media and electronics. Removing them may result in feelings of anxiety and isolation. Thus hand-held devices and video games should be limited in patients with particular light sensitivity or oculomotor dysfunction, but otherwise the conservative use of electronics seems to be harmless.

Physical rest after minor head injury and concussion

An initial period of 24-48 hours of rest is recommended before starting a graduated return to physical activity. Patients may begin light physical activity even if symptoms are present as long as symptoms are tolerated.

Children and adolescents should return to a full school load, without accommodation, before they return to full-contact sport and game play.

Parachute Canada Concussion protocols (Return to school/play/work)

Sleep hygiene and adequate hydration have been suggested as important aspects of treatment after minor head injury.

 Update 2021: Randomized tertiary center trial of post-concussion screen time recommendations in 162 patients (12-25 years old) seen within 24 hours of sustaining a concussion. Participants who engaged in screen time within 48 hours post-concussion had a significantly longer recovery time of 8.0 days, compared to 3.5 days in the screen time abstinent group. Abstract

Take home points for pediatric minor head injury and concussion

• Minor head injury is defined as injury with one of the following: witnessed LOC, amnesia, disorientation, persistent vomiting (>1 episode), persistent irritability (<2years old) and GCS 14-15
• High risk features on history to help identify children at risk of intracranial injury include: severe mechanism of injury as per PECARN and CATCH2, recurrent vomiting >4 episodes, worsening headache, persistent irritability under the age of 2, and delayed post-traumatic seizure
• Isolated features on history that are not associated with clinically important TBI include: isolated headache, isolated loss of consciousness and isolated impact seizure
• On physical exam, examine for a non-frontal boggy scalp hematoma >2cm as this is a high risk feature for skull fracture and TBI requiring neurosurgical intervention
• Routinely evaluate for vestibular and oculomotor dysfunction, which may help identify concussed patients as well as prognosticate those at risk for prolonged recovery from concussion
• PECARN was developed in order to determine which patients do not require a CT scan
• CATCH was developed in order to determine which patients do require a CT scan. CATCH2 included “>4 episodes of vomiting” with 100% sensitivity for neurosurgical intervention and 99.5% sensitivity for brain injury
• POCUS can be useful in the ED to assist in diagnosing skull fractures and inform next investigative steps
• Consider Fast MRI if available in your ED as an alternative to CT for high risk minor head injury patients in which there is a concern for radiation exposure, understanding that it may miss skull fractures and small subarachnoid hemorrhages
• If observation in the ED is required as per the PECARN tool, the necessary observation length has not been definitely defined, however it is likely no more than 6 hours from the time of injury
• Children take longer to recover from TBI compared to adults, and 30% have persistent symptoms at 1-month
• Use the Persistent Post-Concussive Symptoms (PPCS) Risk score to identify those at high risk and consider early referral to multidisciplinary services
• The mainstay of concussion treatment is a short period of physical and cognitive rest (24-48hrs) followed by gradual return to activities

Learn more on this topic at:

Episode 3 Pediatric Head Injury

BEEM Cases- Pediatric Minor Head Injury

Additional resources

Ontario Neurotrauma foundation (ONF): https://onf.org/knowledge-mobilization/acquired-brain-injury/guidelines-for-concussion-and-moderate-to-severe-traumatic-brain-injury/

Brain Injury Guidelines: http://braininjuryguidelines.org/

5P Calculator: http://www.5pconcussion.com/en/scorecalculator

CATT – concussion assessment training tool: https://cattonline.com/

Parachute Canada Concussion protocols (Return to school/play/work): https://parachute.ca/en/professional-resource/concussion-collection/concussion-protocol-resources-for-schools/

References

Drs. Helman and Reid have no conflicts of interest to declare. Dr. Zemek was the author of the PPCS risk score discussed in this podcast.