Pediatric Concussions in United States Emergency Departments: The Tip of the Iceberg
2010; Elsevier BV; Volume: 157; Issue: 6 Linguagem: Inglês
10.1016/j.jpeds.2010.08.039
ISSN1097-6833
Autores Tópico(s)Cardiac Arrest and Resuscitation
ResumoSee related articles, p 889 and p 894Approximately 700 000 children and adolescents aged 0 to 19 years are seen in emergency departments, hospitalized, or die each year because of traumatic brain injury (TBI) in the United States.1Faul M. Xu L. Wald M.W. Coronado V.G. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002-2006. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta2010Crossref Google Scholar More than 90% of these children and adolescents will be discharged from the emergency department. Children with concussions account for a large number of those discharged. In a 2003 report to the US Congress, the National Center for Injury Prevention and Control referred to mild TBI as a "serious public health problem" and a "silent epidemic."2National Center for Injury Prevention and ControlReport to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Centers for Disease Control and Prevention, Atlanta2003Google Scholar Since then, progress has been made in the recognition, assessment, and management of concussions in children and adolescents, but there remains much to be done. See related articles, p 889 and p 894 In this issue of The Journal, Meehan and Mannix, with National Hospital Medical Care Survey, data estimate the incidence of concussions in children who come to emergency departments and describe the rates of neuroimaging and follow-up instructions provided.3Meehan III, W.P. Mannix R. Pediatric concussions in United States emergency departments in the years 2002-2006.J Pediatr. 2010; 157: 889-893Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar A question that the authors address in their introduction is what should we call these injuries? Concussion and mild TBI are often used interchangeably. This is not optimal, but both terms have their advantages. Concussion is defined as "…a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces."4McCrory P. Meeusisse W. Johnston K. Dvorak J. Aubry M. Molloy M. Cantu R. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.Br J Sports Med. 2009; 43: i76-i84Crossref PubMed Scopus (480) Google Scholar However, neither the public nor health care professionals have a good understanding of what this means. This is important for the patients who sustain these injuries, their families, and the healthcare providers who care for them. As Meehan and Mannix point out, "…signs, symptoms, and duration of concussive brain injury are often not considered 'mild' by the patients experiencing them…."3Meehan III, W.P. Mannix R. Pediatric concussions in United States emergency departments in the years 2002-2006.J Pediatr. 2010; 157: 889-893Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Therefore, the authors use the term "concussion." However, although most healthcare providers view concussions as a brain injury, the public may not appreciate this. In a study looking at public knowledge and perceptions, 80% of primary care pediatricians felt they were the most appropriate source of medical follow-up for children with concussions, but 10 patients with symptoms of concussion in the previous 6 months, and more than 50% said they had not participated in any continuing medical education activities related to this subject.9Kaye A.J. Gallagher R. Callahan J.M. Nance M.L. Mild traumatic brain injury in the pediatric population: the role of the pediatrician in routine follow-up.J Trauma. 2010; 68: 1396-1400Crossref PubMed Scopus (27) Google Scholar A lack of consensus and clear understanding also makes defining populations for research studies difficult. Meehan and Mannix used a conservative definition which relied on the precise use of an International Classification of Diseases, Ninth Revision code for concussion. As they point out, this most likely underestimates the number of pediatric patients treated in emergency departments. Confusion about nomenclature, lack of knowledge on the part of providers of the definition of a concussion, and simple coding errors may all contribute to this. Even with this limitation, concussions accounted for almost 0.5% of all emergency department visits in this age group. As pointed out by the authors, certain aspects of care provided are more worrisome. Approximately 70% of patients in whom a concussion is diagnosed underwent neuroimaging.3Meehan III, W.P. Mannix R. Pediatric concussions in United States emergency departments in the years 2002-2006.J Pediatr. 2010; 157: 889-893Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Without individual charts to review, it is impossible to comment whether these studies were indicated. However, there is an increasing trend in the use of computed tomography (CT) scans in emergency departments for the evaluation of children with seemingly mild head injuries,10Blackwell C.D. Gorelick M. Holmes J.F. Bandyopadhyay S. Kuppermann N. Pediatric head trauma: changes in the use of computed tomography in emergency departments in the United States over time.Ann Emerg Med. 2007; 49: 320-324Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar despite 80% will have a resolution of symptoms and normalization of neuropsychological abnormalities within 4 weeks).14Collins M.W. Lovell M.R. Iverson G.L. Ide T. Maroon J. et al.Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study.Neurosurgery. 2006; 58: 275-286Crossref PubMed Scopus (189) Google Scholar Not arranging for or at least recommending follow-up visits, at which reassessment for progression of symptoms and discussion of the resumption of normal activities including school attendance, driving (in the case of adolescents), and sports participation takes place, may put patients at risk of re-injury before symptom resolution. This has been associated with prolonged symptoms, worse school performance, and rarely catastrophic outcomes of second injuries.15McCrory P. Does second impact syndrome exist?.Clin J Sport Med. 2001; 11: 144-149Crossref PubMed Scopus (151) Google Scholar In some communities, it is not always clear who should provide or who is willing to provide follow-up. As aforementioned, general pediatricians felt they were the appropriate source of this follow-up, although they were less likely to be comfortable when there had been a loss of consciousness or especially when there were persistent symptoms.9Kaye A.J. Gallagher R. Callahan J.M. Nance M.L. Mild traumatic brain injury in the pediatric population: the role of the pediatrician in routine follow-up.J Trauma. 2010; 68: 1396-1400Crossref PubMed Scopus (27) Google Scholar Most general pediatricians would refer patients to a neurologist. The sheer volume of patients with concussions in this age group means that primary care physicians will have to provide follow-up. These physicians should have a plan for when and to whom to refer these patients to when their recovery is complicated. In different communities, consultations may involve sports medicine physicians, neurologists, neurosurgeons, neuropsychologists, pediatric trauma surgeons, psychologists, athletic trainers, and/or rehabilitation medicine specialists. Post-concussive symptoms vary widely, and for patients with complicated courses, multidisciplinary teams may provide the best outcomes. Despite these challenges, much progress has been made in the recognition, assessment, and management of concussion in children and adolescents. The Centers for Disease Control and Prevention has promoted awareness in both the public and health care professionals with a program entitled "Head's Up." These initiatives have been aimed at physicians (including new materials specifically targeted at emergency physicians), those involved in high school athletics and youth sports, and school administrators and personnel. Materials can be found at http://www.cdc.gov/TraumaticBrainInjury/index.html.16Centers for Disease Control and Prevention. Injury prevention and control: traumatic brain injury. Available at http://www.cdc.gov/TraumaticBrainInjury/index.html. Accessed Aug 12, 2010.Google Scholar Neuropsychological testing has allowed more accurate diagnosis of post-concussive symptoms and, when used as a tool in addition to good medical follow-up and care, may allow for safer return to play for athletes.4McCrory P. Meeusisse W. Johnston K. Dvorak J. Aubry M. Molloy M. Cantu R. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.Br J Sports Med. 2009; 43: i76-i84Crossref PubMed Scopus (480) Google Scholar Multidisciplinary treatment programs, including medication use for patients with complicated recoveries, offer hope for the rare individuals who have unusually severe or prolonged post-concussive symptoms. Yet, there is much more to be done. Research avenues that need to be explored include making it easier for those in charge of youth and adolescents involved in sports to recognize concussions by developing assessment tools that can be used with minimal training. Being better able to predict which patients will have prolonged or complicated recoveries at or shortly after the time of an acute injury would be useful for patients and professionals alike. Exploring the role that genetic predisposition and premorbid symptoms play in the susceptibility to concussions and the development and persistence of post-concussive symptoms may play a major role in such efforts. Further understanding of the basic science of brain injuries is also important. Also in this issue of The Journal, Kaulfers et al examine endocrine dysfunction in children with moderate and severe brain injuries.17Kaulfers A. Backeljauw P.F. Reifschneider K. Blum S. Michaud L. Weiss M. Rose S.R. Endocrine dysfunction following traumatic brain injury in children.J Pediatr. 2010; 157: 894-899Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar Are similar abnormalities present to a lesser degree in children with mild brain injuries, and can these or other metabolic causes be identified to explain some of their symptoms? Developing ways to prevent concussions through improved technology and education related to avoidance of preventable injuries is also important. Education of the public and health professionals needs to be stressed. One point often forgotten is that although sports injuries are the most common cause of concussions in this age group, more than two-thirds of concussions are related to other causes.3Meehan III, W.P. Mannix R. Pediatric concussions in United States emergency departments in the years 2002-2006.J Pediatr. 2010; 157: 889-893Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar The mechanisms of injury in these cases may be more severe. Recognition of these injuries and attention to the assessment and treatment of these patients should also be emphasized. In May 2009, the Zackery Lystedt Law was signed, and the State of Washington became the first state to require that any youth athlete suspected of sustaining a concussion be removed from play and not be allowed to return without written clearance from a licensed health care provider. The law also instituted educational and administrative requirements for schools and youth sports organizations, including requiring parental informed consent before youth participation. Several other states have passed or are developing similar legislation. Meehan and Mannix have provided us with an estimate of the number of pediatric patients with concussions coming to emergency departments.3Meehan III, W.P. Mannix R. Pediatric concussions in United States emergency departments in the years 2002-2006.J Pediatr. 2010; 157: 889-893Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Their estimate is but the tip of an iceberg, both for the numbers of injuries each year and the work needed to be done. Pediatric Concussions in United States Emergency Departments in the Years 2002 to 2006The Journal of PediatricsVol. 157Issue 6PreviewTo estimate the incidence and demographics of concussions in children coming to emergency departments (EDs) in the United States and describe the rates of neuroimaging and follow-up instructions in these patients. Full-Text PDF Endocrine Dysfunction following Traumatic Brain Injury in ChildrenThe Journal of PediatricsVol. 157Issue 6PreviewTo identify the incidence of endocrine dysfunction in children following traumatic brain injury (TBI). Full-Text PDF
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