First-Ever Pediatric Concussion Guidelines: Real-Life Cases

Assessing Risk for More Severe Head Injury

Twelve hours later, he was experiencing photophobia, nausea, vomiting, and headache. His mother took him to a nearby hospital. A repeat CT scan was ordered, which showed a slightly larger contusion without subdural or epidural hematoma, mass effect, or edema. He was admitted to the hospital for observation.

The patient was observed for 24 hours and received a neurosurgery consultation. His neurologic condition had returned to normal and he was discharged, with a recommendation for the following follow-up exams:

Brain MRI;
Neuropsychological testing; and
Neurologic exam at 1 week and 3 months.

Head CT can help determine which patients are at risk for intracranial injury (ICI) but should not be routinely used to diagnose mTBI. Use validated clinical decision rules to identify children with mTBI at low risk for ICI, in whom head CT is not indicated, as well as children who may be at higher risk for clinically important ICI. These validated tools, such as the PECARN decision rule, serve to avoid unnecessary exposure to radiation while also ensuring that children with increased risk for ICI receive the needed imaging and interventions.

Any suspicion of neurologic deterioration or persistent focal neurologic deficit should prompt emergency evaluation. Neuroimaging with CT or MRI to rule out intracranial bleeding or other structural pathology should be performed on the basis of validated imaging decision tools. Existing decision rules describe a variety of factors that, when assessed together, indicate the need for neuroimaging to rule out more serious ICI:

Age < 2 years old;
Vomiting;
Loss of consciousness;
Severe mechanism of injury;
Severe or worsening headache;
Amnesia;
Non-frontal scalp hematoma;
Glasgow coma score < 15; and
Clinical suspicion for skull fracture.

The need to admit a child for hospitalization following an mTBI may not always be clear. Clinician experience and judgment are key factors in making this decision. These common indications may prompt admission:

Any signs of intracranial injury that require monitoring and repeat neurologic exams;
Fluctuating or deteriorating neurologic, cognitive, or symptom evaluation;
The safety of the patient is better served by careful neurologic observation than by home observation;
Concern about whether the patient can be adequately observed for signs of deteriorating neurologic function if sent home or to an unsupervised situation; and
Severe symptoms that render the patient unable to tolerate oral intake or ambulate safely.

Patients should be carefully observed following a head injury during the first 24-48 hours and should be transported for immediate medical attention if they have any indication of cervical spine injury, focal neurologic deficit, decreasing level of consciousness, or severe or worsening symptoms.