PEDIATRICS/EXPERT CLINICAL MANAGEMENT
Managing Pediatric Concussion in the Emergency
Department
Rebekah Mannix, MD, MPH*; Jeffrey J. Bazarian, MD, MPH
*Corresponding Author. E-mail: rebekah.mannix@childrens.harvard.edu, Twitter: @rebekah_mannix.
0196-0644/$-see front matter
Copyright © 2019 by the American College of Emergency Physicians.
https://doi.org/10.1016/j.annemergmed.2019.12.025
[Ann Emerg Med. 2020;-:1-5.]
INTRODUCTION
Pediatric concussion can present a diagnostic challenge
to emergency medicine providers because the symptoms of
concussion are often vague and subject to developmental
differences in reporting, and may change over time.1,2
Indeed, as many as 60% of children who ultimately meet
consensus criteria for a diagnosis of concussion may not
receive such a diagnosis in the emergency department
(ED).3 Objective measures such as neuroimaging or
laboratory testing do not usually contribute to concussion
diagnosis and management. Despite these challenges, an
accurate and timely ED diagnosis of concussion in children
is vital to initiate best practices, including risk reduction,
guided rest, and longitudinal symptom-based treatments.
The ED clinician plays an important role in counseling in
regard to the risk of reinjury within the vulnerable window
during which reinjury could result in prolonged
postconcussive symptoms or, in rare instances, catastrophic
brain swelling, often referred to as second impact
syndrome.4 In addition, emergency physicians play a vital
role in anticipatory guidance. Several studies have
demonstrated that patients recover more rapidly when
concussion education and such guidance are delivered.5,6
Here, we review the ED diagnosis and management of
concussion in children, with an emphasis on the emergency
clinician’s role in recognition, risk stratification, provision
of concussion education (including anticipated signs,
symptoms, and recovery course), outpatient referral, and
information on preventing reinjury. This review will
specifically target school-aged children because little is
known about concussion symptomatology or outcomes in
infants and toddlers. This article assumes that the patient
has had a proper evaluation for clinically important
traumatic brain injury and that the clinician has now either
excluded this from further consideration or has a plan in
place (eg, observation) to address it.
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DEFINITIONS
The term concussion is often used in the medical
literature interchangeably with mild traumatic brain injury,
although concussion more specifically describes a
pathophysiologic state that results in a characteristic set of
signs and symptoms. Many experts believe that concussion
represents a distinct spectrum of mild traumatic brain
injury; specifically, without findings on conventional
neuroimaging sequences. The 2017 Concussion in Sport
Group consensus statement offers a useful framework for
the diagnosis of concussion,7 depicted in Figure 1.
HISTORY AND PHYSICAL EXAMINATION
The manifestations of concussion can be obvious or
subtle. In addition, many pediatric patients are unaware of
the symptoms of concussion or may disguise or hide their
symptoms from clinicians. Figure 2 depicts a general
diagnostic approach suitable for older children. Concussion
in younger children may be especially challenging to
diagnose, and there is scant literature to guide their
diagnostic approach. For younger children, clinicians
should rely on a parent’s or guardian’s reports of behavior
change such as increased crying or emotionality, changes in
feeding or sleeping habits, changes in communication
patterns, or a loss of interest in people or objects.8
The Acute Concussion Evaluation ED tool, which
provides a checklist approach for concussion assessment,
may improve completeness of evaluation but does not fully
address the need for a comprehensive trauma assessment.9
Medical history should focus on conditions that increase
the risk of complicated recovery (such as previous head
injuries or migraine headaches).10 Previous concussion
history should also be noted and may be relevant to
recovery course after injury.
The signs and symptoms of concussion range from overt
loss of consciousness to more subtle complaints such as
fatigue. The presence of prolonged loss of consciousness,
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Managing Pediatric Concussion
Figure 1. Diagnostic criteria for concussion.
posttraumatic seizure, persistent vomiting, or severe
headache should raise suspicion for an intracranial
hemorrhage or more significant structural injury.11,12
Headache, nausea, dizziness, fatigue, imbalance, difficulty
concentrating, and confusion or disorientation are reported
frequently across several case series.2,13 Nausea and
vomiting can cause significant distress and may require
therapeutic intervention with antiemetics and intravenous
fluids. Photophobia, phonophobia, blurred vision,
diplopia, and emotional lability may also be present. A
structured postconcussion symptom checklist is provided in
Figure 2.
The physical examination should pay special attention
to the head, neck, and neurologic examination result,
including mental status, gait, balance, and evidence of
associated extracranial injury. Focal neurologic deficits
Figure 2. A general diagnostic approach for concussion diagnosis in school-aged children. TBI, traumatic brain injury.
2 Annals of Emergency Medicine
Mannix & Bazarian
such as vision loss or sensory changes are rare and
warrant reconsideration of the diagnosis of concussion.
The most common abnormal physical examination
finding with concussion is imbalance, including gait
instability,7 often assessed by tandem gait. However, in
many cases, the physical examination result is normal.
Vestibular ocular examination may enhance a routine
balance assessment in the ED setting.14 We therefore
recommend a screening ocular examination in children
who can cooperate with the examination, including
evaluation of the eyes in 8 positions, nystagmus,
saccades, smooth pursuits, and near point of
convergence/accommodation.
Outside of the Acute Concussion Evaluation ED tool,
which was specifically designed to be implemented in an
ED setting, standardized assessment tools (eg, Standardized
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Mannix & Bazarian
Assessment of Concussion, Balance Error Scoring System,
the Sport Concussion Assessment Tools version 5) and
computerized assessment tools (eg, Immediate Post-
Concussion Assessment and Cognitive Test) have an
unclear role in the ED. Generally, the test performance of
these instruments has not been evaluated in the ED setting
or has not shown sufficient sensitivity or specificity to be
incorporated into routine ED care.15,16 The tests have not,
in some cases, been validated in young children. Emerging
technologies such as eye tracking, pupillometry, and
electroencephalogram are of great interest but not ready to
deploy in most EDs.
IMAGING
Consensus statements agree that computed tomography
(CT) or magnetic resonance imaging (MRI) is not
indicated to either diagnose or manage acute concussion.7
Although CT is currently the modality of choice to evaluate
for acute intracranial hemorrhage, care should be taken to
avoid unnecessary exposure to ionizing radiation in the
developing brain. However, many of the symptoms of
concussion (eg, headache, vomiting, mental status changes)
overlap with those of gross structural injury, intracranial
hemorrhage, or both, and decisions in regard to when to
use advanced imaging can be challenging. The use of a
validated decision rule, such as the Pediatric Emergency
Care Applied Research Network traumatic brain injury
rule,12 in conjunction with imaging-sparing management
practices such as observation, can reduce the use of
advanced neuroimaging significantly.17
Although MRI is increasingly being investigated in the
research setting as a diagnostic tool, current MRI
modalities have virtually no role in acute concussion
diagnosis or management. Recently, rapid MRI with
ultrafast T2 sequences has been suggested as a radiation-
sparing technique to detect intracranial hemorrhage18;
however, whether these sequences have adequate sensitivity
to replace CT for the detection of acute intracranial
hemorrhage remains unclear.19 In addition, most
conventional MRI sequences do not reveal clinically
actionable findings obtained for patients with concussion.20
LABORATORY TESTING
There are no validated fluid markers to diagnose
pediatric concussion. The Food and Drug Administration
recently approved 2 serum biomarkers of traumatic brain
injury, glial fibrillary acidic protein and ubiquitin C-
terminal hydrolase-L1. Although these markers perform
well in detecting intracranial lesions visible on CT, it is not
clear whether they have adequate performance to diagnose
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Managing Pediatric Concussion
concussion, nor are these markers approved for children.
Similar limitations apply to other promising fluid-based
biomarkers of injury, including neuron-specific enolase,
S100B, tau, and neurofilament light chain.
DIFFERENTIAL DIAGNOSIS
In patients with a witnessed head trauma, the primary
differential diagnosis should be serious intracranial injury.
In instances in which a definite trauma is not witnessed,
even in the context of high-risk activities such as collision
sports, other causes of symptomatology should be
considered. For example, children with heat-related illness
may present with many of the nonspecific symptoms of
concussion, including headache, vomiting, and confusion.
Similarly, hypoglycemia may cause headache and
confusion. Loss of consciousness may be the result of head
trauma but can also be caused by cardiogenic syncope or
atonic seizure. Eyewitness or patient accounts of the events
immediately before and after the onset of symptoms, in
conjunction with a detailed physical examination, should
help distinguish whether the presenting symptoms are the
result of head trauma. However, in some cases malingering
or psychiatric overlay may make a clear diagnosis a
challenge.
DISPOSITION
The majority of children treated in the ED for
concussion can be discharged home after the initial history
and examination. A subset of children may warrant an
observation period both for symptom management and to
ensure that no clinical deterioration occurs that suggests
intracranial injury requiring imaging or intervention.
Intractable nausea or vomiting, headache, or dizziness often
requires admission for symptomatic management, although
children with ongoing amnesia, minor balance disturbance,
or minor visual complaints can often be safely discharged
home. Other factors that may necessitate admission for
children with concussion include drug or alcohol
intoxication, other injuries, suspected nonaccidental injury,
or inadequate support structures for safe discharge and for
subsequent care (eg, competent supervision at home).
The mainstay of discharge planning is expectant
management.4 Although most children recover within 2
weeks of injury,2 a recent large, multicenter study
demonstrated that as many as 30% of children treated in
the ED will have symptoms that persist for more than 1
month after injury.10 Factors associated with prolonged
recovery include older age, female sex, previous concussion
with symptom duration of longer than 1 week, physician-
diagnosed migraine history, headache, sensitivity to noise,
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Managing Pediatric Concussion
Figure 3. Discharge instructions.
fatigue, answering questions slowly, and abnormal tandem
stance.10 A history of preinjury mood disorder may also be
associated with prolonged recovery.21 ED clinicians should
advise high-risk patients to proactively manage concussion
recovery with their outpatient providers.
DISCHARGE INSTRUCTIONS
Anticipatory guidance is a vital part of the ED
management of concussion. Recommendations for
discharge instructions are summarized in Figure 3 and
should include a thorough review of symptoms that would
necessitate return to the ED. Children do not need to be
awakened through the night, which may exacerbate
concussion symptoms. A brief (24- to 48-hour) period of
cognitive and physical rest should be advised, although the
optimal duration of rest has not been determined. Recent
evidence suggests that return to physical activity within 7
days of the injury may improve recovery.22 However, the
ED clinician should not be managing return to activity
decisions beyond the immediate postdischarge period.
No medications have been proved to speed recovery
from concussion or prevent long-term effects from injury.
ED recommendations for symptom management should be
targeted to preventing exacerbations of symptoms and
managing specific symptoms such as headache and nausea.
Patients should be advised to avoid specific triggers for
symptoms, such as bright lights, which may induce
headaches. Brief courses of over-the-counter analgesics such
as ibuprofen or acetaminophen are appropriate for acute
symptom management, but should be limited after the first
few days after injury because their prolonged use may
worsen symptoms.23 Opiates are not appropriate in the
treatment of concussion. Antiemetics may alleviate nausea,
and their use alone is unlikely to mask significant
intracranial injury.24 Therapeutic interventions targeting
more complex symptoms such as dizziness, persistent visual
4 Annals of Emergency Medicine
Mannix & Bazarian
disturbance, or cognitive slowing probably require
multidisciplinary outpatient management.
Many patients and their families inquire about the need for
subspecialty referral for concussion management. Most
concussion patients should be referred to their primary care
physician when further referral to subspecialty care can be
made at follow-up assessment. The ED clinician should
recognize that some children may benefit from subspecialty
referral to a neurologist, sports medicine physician, or other
concussion specialist in addition to follow-up with primary
care. Indications for referral in the outpatient setting include
prolonged symptoms (>10 to 14 days), a history of multiple
concussions or difficult recovery from previous concussions,
known risk factors for prolonged recovery (eg, attention
deficit/hyperactivity disorder, migraine history, learning
disability, mood disorder), prominent or severe vestibular or
visual symptomatology, or uncertain diagnosis.25
Supervising editor: Steven M. Green, MD. Specific detailed
information about possible conflict of interest for individual editors
is available at https://www.annemergmed.com/editors.
Author affiliations: From the Division of Emergency Medicine,
Boston Children’s Hospital, and Harvard Medical School, Boston,
MA (Mannix); and the Department of Emergency Medicine,
University of Rochester School of Medicine and Dentistry,
Rochester, NY (Bazarian).
Authorship: All authors attest to meeting the four ICMJE.org
authorship criteria: (1) Substantial contributions to the conception
or design of the work; or the acquisition, analysis, or interpretation
of data for the work; AND (2) Drafting the work or revising it
critically for important intellectual content; AND (3) Final approval
of the version to be published; AND (4) Agreement to be
accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships
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Mannix & Bazarian
in any way related to the subject of this article as per ICMJE conflict
of interest guidelines (see www.icmje.org). Dr. Mannix is funded in
part by philanthropic support from the National Hockey League
Alumni Association through the Corey C. Griffin Pro-Am
Tournament. Dr. Bazarian is a member of the scientific advisor
boards of Abbott and Q30 Innovations and receives research
support from BrainScope LLC.
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