Mild traumatic brain injury (mTBI) and concussion, a subtype of mTBI, commonly present to the emergency department (ED)and may present with symptoms identical to those associated with more severe TBI. The development and use of clinical decision rules, increased awareness of the risk of radiation associated with head computed tomography, and the potential for patient observation has allowed emergency clinicians to make well-informed decisions regarding the need for imaging for patients who present with mTBI. For patients who present to the ED with concussion, appropriate diagnosis, management, and education are critical for optimal recovery. This issue reviews the most recent literature on concussion and mTBI and provides recommendations for the evaluation, diagnosis, and treatment of mTBI and concussion in the acute setting.
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Following are the most informative references cited in this paper, as determined by the authors.
2. * Lumba-Brown A, Yeates KO, Sarmiento K, et al. Diagnosis and management of mild traumatic brain injury in children: a systematic review. JAMA Pediatr. 2018;172(11):e182847. (Systematic literature review and clinical guideline) DOI: 10.1001/jamapediatrics.2018.2847
3. National Center for Injury Prevention and Control. Report to congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Accessed May 15, 2021. (Literature review and recommendations from the CDC mTBI group)
8. * Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort; 42,412 children) DOI: 10.1016/S0140-6736(09)61558-0
9. * Halstead ME, Walter KD, Moffatt K, et al. Sport-related concussion in children and adolescents. Pediatrics. 2018;142(6). (Guideline) DOI: 10.1542/peds.2018-3074
21. * Committee on Sports-Related Concussions in Youth, Board on Children, Youth, and Families, Institute of Medicine, National Research Council. Sports-related concussions in youth: improving the science, changing the culture. Washington DC: National Academies Press (US). 2014. (Consensus study report) DOI: 10.17226/18377
37. * Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010;182(4):341-348. (Prospective cohort; 3866 children) DOI: 10.1503/cmaj.091421
38. * Dunning J, Daly JP, Lomas JP, et al. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006;91(11):885-891. (Prospective cohort; 22,772 children) DOI: 10.1136/adc.2005.083980
39. * Lyttle MD, Crowe L, Oakley E, et al. Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries. Emerg Med J. 2012;29(10):785-794. (Review) DOI: 10.1136/emermed-2011-200225
40. * Easter JS, Bakes K, Dhaliwal J, et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014;64(2):145-152, 152.e141-145. (Prospective cohort; 1009 children) DOI: 10.1016/j.annemergmed.2014.01.030
45. * Nigrovic LE, Lee LK, Hoyle J, et al. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Arch Pediatr Adolesc Med. 2012;166(4):356-361. (Secondary analysis of a prospective observational cohort study; 42,412 patients) DOI: 10.1001/archpediatrics.2011.1156
54. * Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003;42(4):492-506. (Prospective cohort; 22,772 children) DOI: 10.1067/s0196-0644(03)00425-6
57. * Dayan PS, Holmes JF, Schutzman S, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med. 2014;64(2):153-162. (Secondary analysis of a prospective multicenter cohort study; 10,659 children) DOI: 10.1016/j.annemergmed.2014.02.003
92. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Accessed May 15, 2021. (Clinical descriptions and diagnostic guidelines)
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Keywords: mild traumatic brain injury, mTBI, clinically important traumatic brain injury, clinically important TBI, ciTBI, concussion, sports-related concussion, sport-related concussion, symptoms of concussion, clinical decision rules, Pediatric Emergency Care Applied Research Network, PECARN, Canadian Assessment of Tomography for Childhood Head Injury, CATCH, Children’s Head Injury Algorithm for the Prediction of Important Clinical Events, CHALICE, Glasgow Coma Scale, GCS, Pediatric Glasgow Coma Scale, pGCS, Sideline Concussion Assessment Tool, SCAT, SCAT5, Maddocks questions, Balance Error Scoring System, BESS, mBESS, tandem gait evaluation, Standardized Assessment of Concussion, Post–Concussion Symptom Scale, Vestibular Ocular Motor Screening, VOMS, King Devick Test, cognitive assessment, balance assessment, vestibular-ocular assessment, computed tomography, magnetic resonance imaging, neuroimaging, post–concussion syndrome, posttraumatic headache, second-impact syndrome, SIS, ImPACT, sideline assessment, sideline care, evaluation for concussion, nonaccidental trauma, return-to-sports recommendations, return-to-school recommendations
The CATCH Rule predicts clinically significant head injuries in children.
The Canadian Assessment of Tomography for Childhood Head Injury (CATCH) rule is for use in pediatric patients aged ≤16 years who have minor head injury. The rule identifies high-risk patients with specific signs and symptoms. The original study for the CATCH rule included detailed sensitivity analysis for combinations of risk factors, resulting in a more nuanced approach to the decision to obtain a computed tomography (CT) scan. Generalizability of the CATCH rule is limited, as it uses numerous strict inclusion and exclusion criteria. The rule is less sensitive than the Pediatric Emergency Care Applied Research Network (PECARN) pediatric head injury algorithm, which is more widely validated.
Diana Fleisher, MD
The original study by Osmond et al (2012) enrolled 3866 patients aged 0 to 16 years. Eligibility was determined by an initial Glasgow Coma Scale (GCS) score ≥13 (by physician determination), injury within 24 hours of presentation, and at least 1 of the following criteria:
The exclusion criteria were:
The study defined brain injury as pneumocephalus or any acute intracranial finding on CT scan; nondepressed skull fractures and basilar skull fractures were excluded from the definition. Patients who did not receive CT scans on initial presentation were contacted 14 days later to assess for brain injury and recalled for a CT scan if they reported any of the following criteria: headache (unless mild), seizure or focal motor findings, or inability to return to usual daily activities.
Only 277 of the 3866 patients in the study were aged <2 years. Patients in that age group are often considered to be higher risk, but the study authors did not perform a separate subgroup analysis. The rule missed 3 patients with conditions that did not require intervention: an occipital skull fracture with pneumocephalus, mild brain edema, and a small extra-axial hemorrhage with a small cerebral contusion. Fifty-three percent of the patients in the study received a CT scan. Intoxicated patients were not excluded from the study, so the GCS score estimations may have been unreliable.
The CATCH rule uses 7 risk factors, which are stratified as high risk or medium risk. Sensitivity and specificity of the risk factors was analyzed, with the following results:
A need for neurologic intervention was defined as the occurrence of any of the following events within 7 days of presentation:
A study by Lyttle et al (2013) compared 3 clinical decisions rules (CDRs) for pediatric head injury: the CATCH rule, the Children's Head injury Algorithm for the prediction of Important Clinical Events (CHALICE) rule, and the PECARN pediatric head injury algorithm. To determine the proportion of patients with head injury to whom each CDR would apply, 949 patients were evaluated. The study found that no single CDR was applicable to all patients. CHALICE was the most applicable (97% of patients; 95% CI, 96%-98%) and CATCH was the least applicable (26% of patients; 95% CI, 24%-29%).
Lyttle et al (2012) performed a systematic review and assessment of the CATCH rule using the Quality Assessment of Diagnostic Accuracy Studies Tool. The authors noted that CATCH was distinctive from CHALICE and PECARN for several reasons: CATCH was the only CDR to perform with 100% sensitivity for identifying the primary outcome; it defined intracranial findings on CT as a secondary (not primary) outcome, and unlike the other CDRs, it did not include hospital admission as an outcome. It also collected the fewest predictor variables in its derivation (26 variables, compared to 30 for CHALICE and 40 for PECARN). Kappa values for assessment of clinical variables for all 3 studies were >0.5. The derivation for CATCH was unique in the use of bootstrapping to evaluate the alternative combinations of risk factors, though all 3 CDRs used recursive partitioning in multivariate analysis.
A single center prospective observational study by Easter et al (2014) compared physician estimation (gestalt prediction of <1% risk of traumatic brain injury [TBI]) and practice (actual CT ordering practice) with the CATCH, CHALICE, and PECARN CDRs for children aged <18 years who presented within 24 hours of blunt head injury and had a GCS score ≥13. The primary outcome was clinically important TBI (ciTBI), which was defined as TBI that resulted in death, a need for neurosurgery, intubation for >24 hours, or hospital admission for >2 nights. This definition matches the PECARN definition of ciTBI. The sensitivities and specificities found by the study were as follows:
While this was not an external validation study per se, the authors demonstrated that both PECARN and physician practice identified all ciTBIs.
Martin H. Osmond, MD
The PECARN pediatric head injury prediction rule is a well-validated clinical decision aid that allows clinicians to safely rule out the presence of clinically important traumatic brain injuries.
The Pediatric Emergency Care Applied Research Network (PECARN) pediatric head injury prediction rule is a well-validated clinical decision rule that allows clinicians to safely rule out the presence of clinically important traumatic brain injuries (ciTBIs) without the need for computed tomography (CT) imaging, including injuries that would require neurosurgical intervention among pediatric head injury patients who meet the PECARN criteria.
Unlike in the adult population, CT imaging of the head in pediatric patients is believed to be associated with an increased risk of lethal malignancy over the life of the patient, with the risk decreasing with age. The estimated lifetime risk of lethal malignancy from a head CT for a 1-year-old patient is 1 in 1000 to 1500; this risk decreases to 1 in 5000 in a 10-year-old patient. In the United States, there are more than 600,000 emergency department (ED) visits annually for head trauma among patients aged ≤18 years. Applying the PECARN rule would allow clinicians to determine which pediatric patients can be safely discharged without undergoing a head CT.
In patients with suspected or radiologically confirmed traumatic brain injury (TBI), first assess the patient’s airway, breathing, and circulation, and consider neurosurgical or intensive care unit consultation and/or local policies for fluid management, seizure prophylaxis, administration of hypertonic saline or mannitol, and disposition. Consider observation for 4 to 6 hours for patients who do not have imaging, in order to assess for changes in clinical status. Reassurance, education, and strict return precautions are warranted for patients discharged without imaging, including direction to follow up with a primary care provider or neurologist, and anticipatory guidance on return to play/school if concussion is suspected.
Daniel Runde, MD
Joshua Beiner, MD
The original PECARN rule trial included 42,412 children aged <18 years presenting to one of the 25 PECARN-affiliated EDs in North America (Kupperman et al 2009). There were 33,785 patients in the derivation cohort (8502 of whom were aged <2 years) and 8627 patients in the validation cohort (2216 of whom were aged <2 years). CT scans were performed at the physician’s discretion in 35.3% of patients, while medical records, telephone surveys, and county morgue records were used to assess for cases of missed ciTBI in patients discharged without imaging. TBI occurred in 5.2% of patients and 9% percent of patients were admitted to the hospital. ciTBI occurred in 0.9% of patients, neurosurgery was performed in 0.1% of patients, and no patients died. In patients aged <2 years who were negative for any PECARN risk factor, the rule was 100% sensitive (95% confidence interval [CI], 86.3%-100%) with a negative predictive value (NPV) of 100% (95% CI, 99.7%-100%) for ruling out ciTBI in the validation cohort. In patients aged ≥2 years who were negative for any PECARN risk factor, the rule was 96.8% sensitive (95% CI, 89.0%-99.6%) with a 99.95% NPV (95% CI, 99.8%-99.99%) for ruling out ciTBI in the validation cohort. The potential for CT reduction was likely underestimated, given that CT utilization in this study (35.3%) was significantly lower than the estimated average for North American EDs (50%).
The algorithm has reasonable specificity (53%-60%), considering its extremely high sensitivity. Sixty of 376 patients (15.9%) with ciTBI underwent neurosurgery, 8 patients (2.1%) with ciTBI were intubated for >24 hours, and no patients died. As a result of the infrequency of ciTBI, the lower bounds of the CIs of sensitivity started at 86% and 89%, respectively, for the cohorts aged <2 years and ≥2 years. The NPV CIs very closely approximated 100%.
The PECARN rule has now been externally validated in 2 separate studies. One trial of 2439 children in North American and Italian centers found the PECARN rule to be 100% sensitive for ruling out ciTBI in both age cohorts (Schonfeld et al 2014). The rates of 0.8% (19 of 2439) of patients with ciTBI and 0.08% (2 of 2439) of patients requiring neurosurgery were similar to the rates in the original PECARN study. A second trial at a single United States ED of 1009 patients aged <18 years prospectively compared the PECARN rule to 2 other pediatric head CT decision rules, the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) and the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), as well as to physician estimates and physician practice (Easter et al 2014). In this sample, 2% of patients (21 of 1009) had ciTBI and 0.4% of patients (4 of 1009) needed neurosurgery. Again, the PECARN rule was found to be 100% sensitive for identifying ciTBI. The PECARN rule outperformed both the CHALICE and CATCH rules, which were 91% and 84% sensitive for ciTBI, respectively. Although the goal was to rule out patients with very low risk for ciTBI, the PECARN rule also performed well to rule out TBI on head CT. In patients aged <2 years, sensitivity and NPV were 100% for TBI on CT, with narrow CIs. In patients aged ≥2 years, sensitivity was 98.4% and NPV was 94% for TBI on CT, with relatively narrow CIs.
Two PECARN rule subgroup analyses attempted to further risk stratify patients with single predictors (eg, isolated scalp hematoma in patients aged <2 years). In one study, ciTBI was too uncommon to apply age, hematoma size, or hematoma location predictors (Dayan, Holmes, Schutzman, et al 2014). There were several non–statistically significant trends for higher rates of TBI on head CT that may affect imaging tendencies (eg, age <3 months, nonfrontal hematoma, and large hematoma size). Another subanalysis of patients with isolated vomiting and no other PECARN predictors reiterated the parent study results (Dayan, Holmes, Atabaki, et al 2014). In the cohort of patients aged ≥2 years, there was a low rate of TBI on head CT (3.2%, 26 of 806 patients) and an even lower rate of ciTBI (0.7%, 10 of 1501 patients), so observation rather than emergent imaging is indicated in the majority of these patients. The number and timing of vomiting episodes were not helpful in predicting ciTBI or TBI on head CT, as there was a non–statistically significant counterintuitive trend towards less ciTBI or TBI on CT with more vomiting episodes.
The PECARN rule applies only to children with Glasgow Coma Scale scores ≥14.
Nathan Kupperman, MD, MPH
The Glasgow Coma Scale estimates coma severity based on eye, verbal, and motor criteria.
The Glasgow Coma Scale (GCS) is an adopted standard for assessment of impaired consciousness and coma in acutely ill trauma and nontrauma patients, and assists with predictions of neurological outcomes (ie, complications, impaired recovery) and mortality. It is designed for use in serial assessments of patients with coma from either medical or surgical causes and is widely applicable. The GCS is commonly used in the prehospital and acute care settings, as well as during the course of a patient’s hospital stay, to evaluate for mental status assessment in both traumatic and nontraumatic presentations. In the care of an individual patient, the scoring for each of the 3 components of the GCS (eye, verbal, motor) should be assessed, monitored, reported, and communicated separately. The combined GCS score is an index of the net severity of impairment and is useful as a summary of a patient’s condition, in classifying groups of different severity, for triage, and in research. A GCS score should not be calculated if 1 or more of the components cannot be assessed.
Correlation of the GCS score with outcome and severity is most accurate when applied to an individual patient over time; the patient’s trend is important. A GCS score of 8 should not be used in isolation to decide whether to intubate a patient, but it does suggest a level of obtundation that should be evaluated carefully.
The GCS score can be indicative of the severity of critical illness. A trauma patient presenting with a GCS score <15 warrants close attention and reassessment. A declining GCS score is concerning in any setting and should prompt assessment of the airway and possible intervention. Conversely, a GCS score of 15 should not be taken as an indication that a patient (trauma or medical) is not critically ill. Decisions about the aggressiveness of the management and treatment plans should be made based on clinical presentation and context, and not in any way overridden by the GCS score.
The GCS allows clinicians in multiple settings and with varied levels of training to communicate succinctly about a patient’s mental status. The score has been shown to have statistical correlation with a broad array of adverse neurologic outcomes, including brain injury, need for neurosurgery, and mortality. The GCS score has been incorporated into numerous guidelines and assessment scores (eg, ACLS, ATLS®, APACHE I-III, TRISS, and the WNS SAH Grading Scale).
In some patients, it may be impossible to assess 1 or more of the 3 components of the GCS. The reasons include, but are not limited to, intubation, sedation, paralysis, local injury to the eye, and eye edema. If a component is untestable, a score of 1 should not be assigned (Teasdale et al 2014), and summation of the findings into a total GCS score is invalid. The 3 components of the GCS are charted independently, and a component can be recorded as NT (not testable), with an option of indicating the reason (eg, C for eye closure or T for intubation).
Daniel Runde, MD
The modified GCS (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14-point original GCS) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale and Jennett 1974).
The evidence presented in 53 published reports on the reproducibility of the GCS was synthesized in a systematic review by Reith et al in 2016. Eighty-five percent of the findings in the studies identified as high quality showed substantial reliability of the GCS as judged by the standard criterion of a kappa statistic >0.6. Reproducibility of the total GCS score was also high, with kappa >0.6 in 77% of the observations. Education and training on the usage of the GCS resulted in a clear beneficial effect on reliability.
In its most common usage, the 3 components of the GCS are combined to provide a summary of severity. The original authors themselves have explicitly objected to the GCS being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality. A GCS score of 4 predicts a mortality rate of 48% if calculated as 1 + 1 + 2 for eye, verbal, and motor components, respectively, and a mortality rate of 27% if calculated as 1 + 2 + 1, but a mortality rate of only 19% if calculated as 2 + 1 + 1 (Healey et al 2014). The modified GCS provides a method of assessing patients with acute brain damage that is almost universally accepted, but summation of its components into a single overall score loses information and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the motor component of the scale (as in the Simplified Motor Score) can perform as well as the GCS and is less complicated. However, contracted scores may be less informative in patients with less severe injuries.
Sir Graham Teasdale, MBBS, FRCP and Bryan Jennett, MD
The Pediatric Glasgow Coma Scale (pGCS) assesses impaired consciousness and coma in pediatric patients.
The Pediatric Glasgow Coma Scale (pGCS) can be used in initial and serial assessments for patients aged ≤2 years who have head trauma, altered mental status, or neurologic abnormalities, in order to obtain, track, and communicate the mental status and level of consciousness in preverbal children. It is a variation of the standard Glasgow Coma Scale (GCS) with age-appropriate modifications to the motor and verbal components.
The pGCS allows for calculation of the GCS score in preverbal children, for whom some of the components in the standard GCS are not able to be measured. The standard GCS is a component of several prognostic and clinical decision-making tools such as the PECARN Pediatric Head Injury/Trauma Algorithm, the Revised Trauma Score, the Age-Specific Pediatric Trauma Score, and the Canadian CT Head Injury/Trauma Rule. The pGCS score should be reported as a sum but should include the scores of each of the individual components (eye, verbal, and motor) because of the difference in prognostic value and variations of the individual components (eg, “Total pGCS of 12 = E3 + V4 + M5”) (Healey et al 2003). The pCGS is as accurate for identifying clinically important traumatic brain injury (ciTBI) in preverbal children as the GCS is for verbal children.
The pGCS score should be obtained prior to the administration of analgesics or other interventions that could alter the score. It is somewhat less accurate in identifying patients with any traumatic brain injury (TBI) on computed tomography (CT) as compared with the GCS in older children (Borgialli et al 2016). The distinction between normal and abnormal flexion for the pGCS may be challenging, especially for nonspecialist clinicians (Reilly et al 1988). In intubated patients for whom the verbal score may not be obtained, clinicians should consider using the Full Outline of Unresponsiveness (FOUR) score, which is a validated, expanded scoring system (Wijdicks et al 2005) (Sadaka et al 2012).
Common applications of the pGCS include the need to consider intubation and/or definitive airway management in patients with a GCS score <8. However, the entire clinical picture must be considered. Due in part to the value in identifying patients with ciTBIs, any patient with an abnormal pGCS score should be assessed and closely monitored. All patients with a pGCS score <15 need appropriate monitoring.
Joyce Brown, DO, CHSE
Matthew Meigh, DO
The pGCS was evaluated in a subanalysis of a large, prospective observational multicenter cohort study of children with blunt head trauma, to compare the accuracy of the pGCS in preverbal children (defined as aged ≤2 years) to the standard GCS score in older children (aged >2 years) for identifying patients with TBIs after blunt head trauma (Borgialli et al 2016). The study demonstrated statistically similar test performance for the pGCS and the standard GCS in identifying patients with ciTBIs. The pGCS had slightly lower accuracy than the standard GCS in identifying patients with TBIs visible on CT. The area under the receiver operating characteristic curve for the association between GCS score and TBI visible on CT was 0.61 for the pGCS cohort and 0.71 for the standard GCS cohort. With a 95% confidence interval, the area under the receiver operating characteristic curve for the association between GCS score and ciTBI was 0.77 for the pGCS cohort and 0.81 for the standard GCS cohort. Interobserver agreement in each cohort for the total score and all individual score components met the criteria for at least moderate interobserver agreement (kappa 95%, lower confidence limit >0.4). Limitations of the study included an age threshold of ≤2 years to define the preverbal pediatric population and the fact that only 36% of the study population underwent cranial CT imaging, so it is possible that some of the children who did not undergo imaging might have had traumatic findings on CT.
The pGCS is only intended for use in children aged ≤2 years. For older children, use the standard GCS. Clinicians should be aware of the difference between the Glasgow Coma Scale score (total score, applicable when all 3 components are testable) and the Glasgow Coma Scale (component scores, applicable if any of 3 components is not testable).
Sir Graham Teasdale, MBBS, FRCP
Madeline Joseph, MD, FACEP, FAAP; Audrey Paul, MD, PhD
Susan B. Kirelik, MD, FAAP; Todd W. Lyons, MD, MPH
June 2, 2021
July 1, 2024
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