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
Disclosures
I have no financial disclosures to report.
Department of Emergency Medicine
Pediatric Head Trauma
Deaths
7,000/yr
Hospitalizations
95,000/yr
ED Visits
60%↑ in ED visits
in last 10 years
> 500,000/yr
Primary Care Office Visits
Assume numerous, No data
- Hospital care costs alone exceed 1 billion/year
- 29,000 permanent disabilities annually
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
Recognition of Concussion
 Signs
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Dazed or stunned
Confused / forgetful
Answers slowly
Moves clumsily
Loss of consciousness
Behavior / personality
changes
Amnesia
Department of Emergency Medicine
 Symptoms
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Headache
Dizziness
Nausea / vomiting
Double / blurry vision
Sluggish / foggy
Concentration
problems
• Confusion
• Change in sleep pattern
Comprehensive history
 Comprehensive history should include
documentation of previous
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Closed head injuries / concussions
Depression / anxiety
Sleep disturbances
Learning disorders
Attention deficit disorders
Headaches ( migraines )
Department of Emergency Medicine
Physical Exam
ABCs
C-spine immobilization as needed
GCS determination
Neuroimaging as deemed necessary
Detailed neurological evaluation
Department of Emergency Medicine
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
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
Department of Emergency Medicine
Cantor J et al. Arch Phys Med Rehabil 2004;85(4 Suppl2):S54-60
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 )
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Cognitive assessment
Neck examination
Balance and coordination examinations
Delayed recall
Department of Emergency Medicine
Assessment Tools
 Balance exam assesses vestibular system
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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
Department of Emergency Medicine
KG, Drezner JA, Gammons M, et al. Br J Sports Med 2013,47,15-26
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
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Assessment Tools
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Neuroimaging
Conventional brain CT or MRI is usually
normal in concussive injury
Prevalence of an abnormal CT increases
with decreasing GCS
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Neuroimaging
Emergent Head CT
• Penetrating injury
• GCS ≤ 14
• Focal neurologic
abnormalities
• Signs of depressed or
basilar skull fracture
• Prolonged loss of
consciousness (> 1min)
,<
Department of Emergency Medicine
• Clinical deterioration or
worsening symptoms
• Seizure ( other than
impact seizure ) or
prolonged seizure
• Pre-existing condition
increasing risk for
bleeding
Jeff E. Schunk, Sara A. Schutzman. Pediatric Head Injury. Pediatrics in
Review, Volume 33, Number 9 (September 2012), pp. 398-411
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;374:1160-70
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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;374:1160-70
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PECARN Imaging Guidelines > 2yo
Kupperman et al. Lancet 2009;374:1160-70
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Neuroimaging
 The prediction rule for children ≥ 2 yrs had a
negative predictive value of 99.95% and
sensitivity of 96.8%
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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;374:1160-70
Department of Emergency Medicine
Management
 Medications
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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
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
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Discharge Instructions
 Patients should return to the ED
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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
Discharge and Follow-up
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Rest / sleep
Avoiding activities requiring concentration
Avoid strenuous activities
No alcohol
No sleeping pills
No driving or play until cleared
Department of Emergency Medicine
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
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
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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
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
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