Introduction
Some head injuries require more than rest. Learn the signs that a head injury needs immediate attention. Visit choa.org/concussion for more information.
Video
Some head injuries require more than rest.
There are red flags that signal something more severe has occurred.
It is very important while we do the initial assessment to see if there are any red flags that may prompt further evaluation after the injury has occurred, you know, the concussions are the most common neurologic injury in sports is not the only one.
You know, kids have suffered traumatic brain injuries whether it's on the football field, or in some other venue, they can they can definitely suffer other problems in the brain.
They can have bleeding in the brain.
They can have skull fractures.
They can have just swelling in the brain it's important for the pediatricians or the clinicians to know what the signs of symptoms are that maybe some other some other problem could be going on in the brain.
Then a child who has a head injury.
If they exhibit certain red flags need to be evaluated in the emergency department.
Immediately some of these red flags include things like an alteration in the level of consciousness that would be indicated by a Glasgow Coma score of less than 15 an abnormality in the neurologic exam, such as focal deficits or suspicion of a skull fracture, especially a basilar skull fracture that would be indicated by symptoms, such as clear drainage of fluid from the nose or ears or ecchymosis behind the ears or the eyes or concern that this may this head injury may be from something the symptoms may be from something different than the head injury.
If a patient has any of the following, you should refer to the emergency department.
Immediately altered mental status concerned for intracranial process concern that symptoms may not be related to the recent minor head injury, abnormal neurological exam, evidence or strong suspicion of skull, fracture consider obtaining a CT scan for the following non frontal hematoma multiple and or worsening symptoms, especially on a younger child, severe headache and or recurrent vomiting severe mechanism.
This algorithm shows the protocols used at Children's to determine if a patient should be observed in the emergency department, or if additional testing or transfers to other specialists are required the guidelines also helped deliver standardized care and discharge instructions for patients.
Head injuries are one of the most common in today's scene and children.
And with the increasing prevalence of sports.
Now, both at high school and middle school level and fairly aggressive levels of sports participation.
Head injuries are becoming very common a nationwide as well as in atlanta.
And in the emergency department, we do see a lot of children with head injuries and a lot of them that concussions and the attempt with these guidelines.
As is the case with any other guideline is to see not only standardized how we evaluate children.
But in this case, in particular, there was a very recent article in The Lancelet that talked about when head CT scans are required in a minor injury, and when they can be withheld safely, and we use that Lancelet article to guide our a pathway or guideline as to when as to how to manage these children when they require a head CT scan.
And when it can be safely withheld, a concussion is a brain injury that is not seen on a head CT scan.
However, a negative head CT scan is not required to make the diagnosis of a concussion in the past doctors would order head CT scans or a lot of children even with minor head injury.
And once they were negative, they would perhaps call it a concussion, but we all know the risk of radiation now with CT scans.
So we are much more careful in when we order them and recognizing that that you don't have to have a negative head CT.
A concussion is a diagnosis that can be made on based on clinical symptoms alone.
A CT scan may be indicated in some other situations, even if the child does not require emergency evaluation in the emergency department, some of those include things like severe symptoms or worsening symptoms or multiple symptoms, such as a severe headache and persistent emesis or concern in a child who has a pre-existing medical history, where such as a bleeding disorder would be indications for a head CT with or without an ER evaluation.
Many of the things we worry most about with head injury are not necessarily independently predictive of a serious brain injury.
In other words, a child is at a head injury.
Who's vomited vomiting by itself is not independently predictive of head injury.
That child does not necessarily need a CT scan, although they made an observation, a child has had loss of consciousness.
If its brief does not necessarily need a CT scan.
So many times community physicians very concerned about the child children that they're seeing may send a child to the emergency department and give the parents, the expectation that you're going to get a head CT.
But our job is to make that evaluation when we see the patient and many of these children, meet the criteria for a concussion, but not the criteria for a head CT.
As we've defined the algorithm.
The algorithm is is is intended to guide our treatment, but it's, very useful I.
Think for community physicians to understand what can we expect when the child goes to the emergency departments? And so it takes a child who's had a head injury.
Who is what we call it GCS of 14 or 15, which means they are mildly affected, and they are basically normal-appearing if they're not then.
This is not the algorithm for this patient.
If they are head injured and mildly affected, meaning, they may have a headache and may have vomited.
They might have had a loss of consciousness, but they're otherwise unaffected.
They are responding appropriately to commands and questions.
They have a mild head injury, which may suggest a more serious condition and that's.
Why they're coming in to see us the algorithm takes us from the patient who presents with these symptoms and helps us decide who should get an immediate CT scan, and who we can watch the children who need immediate CT scan include those who are definitely not normal in their baseline they're, not answering questions, they're altered.
They have a focal neurological abnormalities on examination.
We don't need to worry about washing them.
We need to get a CT scan and see what's going on the other patients who seem otherwise normal whose neurological exam is normal and may have an upset.
Stomach might have a headache may have passed out, but otherwise seemed fine can be safely watched depending on the severity of their symptoms.
The more severity, the more frequent substance symptoms that they have if they have more than one or two raises the risk.
And we have to make a judgment call, then after watching them and seeing them improve it's safe to send them home, but only if they're improving, and if their symptoms are easily controlled with oral medication, if they're not some of these children spend the night with us, our hope is not to do a CT scanner in every head injured patient.
There are mounting concerns about the effects of radiation on children and head injury is very frequent.
Most of these children do not require a head CT.
What they require is a careful history and physical examination by someone who sees this for a living and I think most patients do very well with Adam, most parents understand it.
But sometimes it takes a little while of a little bit of a discussion to help work them through the difference between a neurosurgical emergency and the injury that you have from concussion, which is not something you can see on CT scan.
One thing I have found is that talking to them about a concussion telling them what it is and why it does not necessarily require a head CT can.
And of course, when you mention the risk of radiation, parents are much more willing to accept not getting a head CT scan done many questions are asked, not only about a CT scan, but about an MRI scan CT scan is primarily the gold standard right now for a child with a concussion if you're going to do any imaging procedure, that's, the one that is recommended, but not every child needs a CT scan.
Recently, there's been questioned about exposure to levels of radiation with CT scans, particularly if you're doing it's eerily, the things to know for the PCP so that we have one of the lowest radiation doses per scan for cts in the country.
So that reduces a lot of the risk that we're worried about in getting a CT.
It remains very important for pediatricians coaches, parents, all to remember the importance of prompt recognition of concussions.
If they are promptly recognize the importance.
The significance would be that the child would not be allowed to return to play too rapidly and have the risk of second impact syndrome.
Sometimes knowing that you don't have to be seen in the ED.
They may feel well, this is not an important injury and it's.
Okay to go right back to play.
No that is not the case.
And the other important point to emphasize is the significance of appropriate management and particularity of follow-up until all symptoms have resolved.
