Introduction: spinal injuries. These sorts of diagnoses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Introduction:

 

A concussion can occur with any sort of
trauma to the head or anything that causes forceful acceleration of the brain
within the skull, causing brain injury and temporary neurologic dysfunction
(Armsby, C.). Concussions are more prevalent in children who play contact
sports, but they can occur with falls, collisions with moving and non-moving
objects or persons, and even rapid acceleration or deceleration. A lot of times
children who play contact sports such as hockey and football are required to
wear helmets, which can help aid in the deterrence of concussions. Sports where
helmets are not a part of the uniform such as soccer or basketball also have
risk of concussion with out the added barrier for protection. In any sort of
environment where there is a falling risk from a moving object, like dirt
biking or horse back riding, children should be strongly advised to wear
helmets. There are risks for concussion in truly anything a child does, even
when they are not in a sport, which makes concussions very difficult and
hazardous.

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            Though each of these activities are
different in the mechanism of injury for a concussion, the general idea
clinicians need to be concerned with is both recognizing and treating a child
with a concussion. Although unconsciousness may transpire, it is not required
for a child to be diagnosed with a concussion. Any child that has a concussion
needs to be treated in a very serious manner, because no concussion can be
taken lightly. Children with a concussion need to be assessed by a doctor
before they return to playing any sports (Bloom, J.). There has not been any
research to quantify how many concussions cause irreversible and serious damage
to a child’s brain. Therefore prevention, recognition, and treatment are key.

Presentation and Scope:

            Patients suffering from a concussion
typically present with confusion, mild memory impairment, a headache, and
occasionally unconsciousness succeeding the concussion event. Some children may
suffer from difficulty walking, disjointed speech, poor concentration, vertigo,
and vomiting (Meehan, W.). Concussions alone are serious, but other dangerous
conditions also need to be ruled out after any sort of trauma such as possible
brain hemorrhage, fractures, or spinal injuries. These sorts of diagnoses
require emergency department assessment for pathology.

For injuries involving contact sports,
clinician’s or designated health personnel are able to assess patients without
imaging, either on the side-lines of a field immediately after incidents, or in
a clinical setting. It is helpful to establish a neurologic function baseline
in each child that will be participating in contact sports, to better assist in
the comparison if injury does occur (Meehan, W.). If a baseline for the
specific child has not been established, then the clinician must gauge the
patients performance on an age related basis. In a sports setting, helpful
tools for assessment of concussion are as follows; by asking the child to place
their hands on their iliac crests, close their eyes, and perform a single leg
stance, double leg stance, and tandem stance. By testing if the child becomes
unsteady, has to open their eyes, or take their hands off of the iliac crest in
order to maintain balance, you can assess if there is in issue with their
stability, which can reflect underlying brain injury (Bloom, J.). . “The American Academy of Neurology has identified the Post
Concussion Symptom Scale and Graded Symptom Checklist as tools that can
accurately capture concussion symptoms” as stated by Pamela Mapstone, DNP. This
scale helps to set a scoring system to assess symptoms and their severity to
provide accurate and rapid management of pediatric concussions in a nonclinical
setting such as sporting events or in school offices (Mapstone, P.). Any child suspected to have a concussion
should be removed from the sport or activity immediately and should not return
until thoroughly and properly assessed by a healthcare provider.

As a clinician performing an examination
to diagnose or rule out the occurrence of concussion, there are certain aspects
of the history and physical that should be the primary focus. For the history,
pertinent information involves recollection of mechanism of injury, the timing
in which the event occurred, the onset of symptoms relative to the incident,
the symptoms following the incident, and if the patient has had any concussions
prior (Meehan, W.). The criterion in place for diagnosing a concussion is in
the form of a scale known as, the Post Concussion symptom scale, or PCSS
(Howell, D.). This scale lists 22 symptoms which asks the patient to rate the
severity on a scale from 0, being unaffected, to 6, being very severe (Howell,
D.). This scale is very subjective, but has proven reliable in aiding a
clinician to establish a diagnosis of concussion based off of symptom involvement
and severity. It is pertinent to emphasize focus on neurologic symptoms,
temporary paralysis, paresthesia, and numbness, to name a few. These symptoms
may indicate possible spinal cord injury, which would need immediate attention.

Another important entity to rule out
involves injury to the neck. Any pain in this area would require measures to be
taken for C-spine immobilization and visualization with X-ray to make sure
there is no pathology. With trauma to the brain or head it is always important
to rule out hemorrhage manifesting as a subdural or epidural hematoma, for
example. These can be life threatening and need to be excluded via imaging
modalities.

 A
neurologic examination of the patient should be performed thoroughly,
encompassing assessment of the cranial nerves, mental status with cognitive
function, cerebellar function of gait and balance, and sensory and motor
testing. In the majority of patients with a concussion the findings of the
neurologic exam will be within normal limits; however, if anything tested is
abnormal, immediate assessment of brain or spinal cord injury needs to ensue
(Meehan, W.). After complete evaluation to exclude injury to the brain or
cervical spine, and thorough neurologic testing, patients should be advised
that they do not return to play any sports until all symptoms have resolved and
there is solid evidence of recovery. Immediately after incidents of concussion,
the brain is at a higher risk for increased injury, which is why precautions
need to be taken very seriously in such children.

Etiology and Prevalence:

            As aforementioned, concussions can
arise from anything causing a gyratory force to the brain within the skull. Studies
on the mechanism and symptoms of concussion have been mainly carried out
through the study of animals, thus the injury to the brain is the same, but
variations of severity in trauma and magnitude of symptoms can differ between
species (Mapstone, P.). The most common etiology of pediatric concussions is
trauma within contact sports. Trauma inflicted does not have to be directly to
the head for a concussion to occur. Contact sports such as basketball, football,
lacrosse, soccer, and rugby have higher occurrence rates for concussion, and
thus children who partake in these activities have a higher incidence rates. But
concussions are not exclusive to sports, which involve contact. Horse back
riding, dirt biking, skate boarding, and anything involving moving objects also
carry a risk due to prospect of falling. Children playing outside, whom happen
to run into something, fall from heights, or even just tripping and falling to
the ground, all have a risk of experiencing concussion. A child, who was
involved in a car accident, could have a concussion concomitant with whiplash,
due to the sudden deceleration. There are many mechanisms of injury that can
cause the brain to move within the skull, which all encompass the possibility
of resulting in minor brain trauma and neurologic disruption.

Prevention, Treatments,
and Recommendations:

            Children partaking in an organized
activity of any kind, where concussion is a risk, should have their baseline
cognitive and neurologic status assessed and recorded. By doing so it allows
the clinician to evaluate if injury has occurred and if so, how bad the injury
is. A step to help aid in concussion prevention is the use of helmets. Multiple
contact sports have helmets as a part of their uniform, as it is recognized how
important it is to protect the head. It should also be stressed for a child to
wear a helmet whenever they are riding on a moving object, whether it is a
bike, scooter, or even skates. Helmets do not stop the brain from experiencing
an injurious rotational force, but they do help to lessen the impact with
traumatic contact and also protect the skull.

            Rest is the corner stone of therapy
when treating concussions. Children with concussions are advised to take a
24-48 hour period of rest (Meehan, W.). After this time period children may
ease slowly into physical activity that does not involve contact. Children who
resume sports or physical activity too soon have amplified chance of
intensification of symptoms and risk for more damage (Howell, D.). Once
symptoms have completely resolved the child may see a clinician to be cleared
to return to sports. Children that have symptoms of concussion should be warned
that these symptoms might persist and even worsen after the initial event.
Anything that exacerbates these concussion symptoms should be avoided. Some
children may lie about the symptoms they are experiencing or not admit to such
symptoms due to the want to return to playing a sport and fearing that telling
the truth will deter them from being able to do so. Children may also not
recognize that they are experiencing symptoms of concussion (Howell, D.). It is
key to emphasize to both the child and the parent how important it is to take
precaution, and that it will help them to return sooner if they do not compound
the concussion with further injury. Repeat episodes can be detrimental to a
child, especially when they closely follow a previous event (Howell, D.). It is
also important that in sports settings, if there is any event during play that
provides a mechanism where concussion can occur, that the child be removed and
evaluated. Headache, vomiting, sleep disturbances and dizziness all can be
treated symptomatically and with rest. NSAIDs or Tylenol can be used to aid in
the treatment of headache, and ondansetron can aid with vomiting (Meehan, W.).
If any of these symptoms persist or worsen after an extended period of time, or
past 10 days, the child should be urgently reevaluated by a clinician and
referred to a specialist if necessary.

 With injury to the brain, great steps need to
be made by parents and clinicians to treat and prevent harm. The mainstay of
treatment is rest, which includes rest cognitively and physically. It is
advised that children ease back into their curriculum and that the school is
informed about the concussion and the precautions to be taken post event (Meehan,
W.). Physical and cognitive rest allows the brain’s neurophysiologic function
to normalize, and decreases chance for exacerbation of injury. By making the
public more aware of concussions and the serious threats they pose to one’s
health, we can help to take steps to prevent them and better recognize when
they do, to allow more rapid and efficient treatment.

Summary

            It seems that recently concussions
have been taken much more seriously. This is prevalent in not only the world of
sports, but within the home too. The public acknowledges the danger of
concussions and has taken steps to promote prevention and awareness. Parents
more often place helmets on their children when riding a moving object. Rules
have been put into place for contact sports in attempt to deter injury to the
head. Parents and authority figures have been educated on concussion
recognition, assessment, and the immediate steps to take after such an event.
Emphasis has been placed on “When in doubt, sit them out” in order to prevent
further injury, as established by the motto from, The American Academy of
Pediatrics in regards to concussions. As stated prior, there is no evidence that
allows us to assign a number to the amount of concussions that will result in
permanent brain damage. With that being said all of these steps listed above
that have been taken to educate the public, and even clinicians on concussions
and their gravity, help to alleviate potential damage and raise awareness.