Caring for Kids With Concussions

My first lesson about concussions started with a baseball bat in a Boston backyard. My friend Jeffrey—the only kid on the block who liked golf—decided to channel his inner Arnold Palmer by teeing up with my Louisville Slugger as if it were a 4-iron. I was 7 years old and knew plenty about baseball, but not enough about backswings—until Jeffrey’s caught me right above my eyebrows. 

I didn’t black out or even fall. I just felt dizzy. I sort of remember Jeffrey getting scared and running to find my mother. When she saw the knot on my forehead, she brought me home and told me to lie down until the doctor came. Yes, they did that in 1960.

The diagnosis? Concussion. The prescription? Rest and avoid backswings. No ambulance, no ED, no CT scan. None of those, as we know them, had been invented yet. (By way of context, we’d just gotten our first dial phone.)

In spite of superficial assessments by my Eisenhower-era caregivers, I recovered. But that concussion, combined with several others, left me with questions, as a patient and a paramedic, about managing childhood head injuries.

What should EMS providers know about pediatric concussions? How are cases like mine handled today? And what can happen to kids after supposedly minor head trauma?

Prehospital Priorities

Concussions are injuries that temporarily disrupt normal brain function.¹ They’re usually caused by a blow to the head but can result from impacts elsewhere. Common signs and symptoms include headache, nausea, dizziness, visual disturbances, and memory loss,² although patients may present with more subtle complaints—tingling sensations and sadness, for example—or be asymptomatic.

Concussions and other forms of traumatic brain injuries are hot topics among pediatric specialists, perhaps because a third of all TBI-related ED visits involve children.³ Responders should weigh mechanisms of injury and remember that serious brain insults may begin with just a “bump on the head.”

“The pediatric population is more difficult to assess because everything’s smaller and young children are often nonverbal,” says pediatric surgeon Catherine Musemeche, author of Hurt (2016) and Small: Life and Death on the Front Lines of Pediatric Surgery (2014). “You have to find someone who can give you a reliable history—an adult who can confirm loss of consciousness (an important sign) or tell you, ‘No, he was never knocked out. He fell and cried the whole time.’ If you can’t get that, it’s better to err on the side of caution and get that kid to a hospital with surgical capabilities.”

Trauma centers are preferred not only because of their in-house staffs but also for their superior imaging. A 2017 Oklahoma study revealed that 44% of the CT scans done and read outside of trauma centers miss clinically significant injuries⁴—more likely when peds are asymptomatic or MOIs are unknown.

En route to definitive care, Musemeche urges EMTs and paramedics to follow their ABCs and recognize dangerous complications such as hypotension and hypoxia. “They’re both bad after brain trauma,” the Orange, Tex. native says. Her concern is supported by the University of Arizona’s EPIC study, which suggests maintaining SpO₂ and systolic blood pressure at or above 90.⁵ 

“The injured brain, like any other body part, is subject to swelling,” Musemeche adds. “If that happens and cerebral perfusion pressure [mean arterial pressure minus intracranial pressure] gets too low, secondary damage may occur.”

Musemeche also recommends spinal immobilization whenever a patient with a possible head injury is unconscious. “I realize [EMS doesn’t] backboard trauma victims routinely anymore, but if you’re treating someone who can’t communicate, you have to be concerned about whether a blow to the head was transmitted to the neck.”

The opposite can be true too: “I had a friend who was thrown from his bicycle and temporarily paralyzed,” says Musemeche. “All the focus was on his spine, but he also had a concussion.” The bottom line for prehospital providers is to get the patient to a hospital where physicians can figure out the damage.

Post-Concussion Recovery

Even after definitive care, patients with head trauma may experience ongoing symptoms known as post-concussion syndrome. Headaches, dizziness, fatigue, anxiety, and other complaints can linger for weeks or months after the initial injury. Researchers aren’t sure why some concussion sufferers develop the syndrome and others don’t, but risk factors include a history of depression, anxiety, PTSD, and other everyday stressors.⁶

A less common but more serious consequence of concussions in kids is second impact syndrome, whereby the initial head injury is followed by another insult within several weeks. Sudden diffuse cerebral swelling and brain herniation can lead to death within minutes.⁷

Among children, 80%–90% of concussions will heal on their own within a month.⁸ Limiting rest to 2–3 days is actually more beneficial than restricting cognitive and physical activity for longer periods.⁹

Getting Your ‘Bell Rung’

Not long after my childhood confrontation with a baseball bat, Musemeche suffered a sports-related concussion of her own.

“I was about 10 and playing football with my older brother,” she recalls. “I was the offense; he was the defense. He gave me one last play to run the ball to the sidewalk—our goal line. So I made like Walt Garrison [a Dallas Cowboys running back] and got flipped into the air by my brother. I landed headfirst on the cement.

“I don’t remember what happened after that. I’m told I was acting strange. I didn’t know who anyone was. My brother said something about me getting my bell rung, so my mother called the doctor. He told her to keep an eye on me and let him know if my pupils changed. That was it, even with complete amnesia.”

Musemeche knows she’d be assessed much more thoroughly today, but after two more childhood concussions, she shares my concern about adult-onset disabilities.

“We do know kids can have lasting effects from severe head injuries,” she says. “Repeated concussions that would be considered mild individually can lead to chronic traumatic encephalopathy as early as high school.”

Best known for its high-profile sufferers among professional athletes, CTE involves clumps of protein that form throughout the brain, killing neurons. Victims encounter memory loss, confusion, impaired judgment, and progressive dementia.¹⁰ 

Unfortunately, CTE is confirmed postmortem only, through microscopic analysis of brain tissue. That hardly clarifies the future for concussed juveniles like Musemeche and me, but the doc thinks we’re both at least a few hits to the head short of permanent damage.

“The science still isn’t conclusive,” she says. “We think you need more frequent, ongoing insults to a young brain, perhaps due to many years of child abuse or playing collision sports, before you have to be concerned about long-term irreversible effects.

“However, we’ve seen cognitive disabilities present after so-called mild head trauma. We’re trying to be more vigilant about those cases, especially with peds, by doing psychometric testing and in-depth follow-up—not just ‘Do you know where you are?’ but assessing how the patient is functioning cognitively.”

Memo to my wife: The next time I forget to take out the trash, go easy on me. 

References

1. American Academy of Pediatrics. Care of the Young Athlete Patient Education Handouts: Concussion, www.aap.org/en-us/pubserv/coya/Documents/Concussions_FINAL_secured.pdf.

2. Thorne A. Concussion in the Pediatric Population. Academy of Pediatric Physical Therapy, https://pediatricapta.org/includes/fact-sheets/pdfs/17%20Concussion%20in%20Pediatric%20Population.pdf?v=1.

3. Centers for Disease Control and Prevention Traumatic Brain Injury & Concussion: TBI-related Emergency Department Visits, Hospitalizations, and Deaths (EDHDs), www.cdc.gov/traumaticbraininjury/data/tbi-edhd.html.

4. Bonds M, Hersperger S, Garwe T, et al. Adequacy and accuracy of nontrauma center computed tomography: What are we missing? J Trauma Acute Care Surg, 2017 July; 83(1): 30–5.

5. Spaite DW, Bobrow BJ, Keim SM, et al. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines with Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg, 2019 May; 8: e191152.

6. Mayo Clinic. Post-concussion syndrome, www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/symptoms-causes/syc-20353352. 

7. Bey T, Ostick B. Second Impact Syndrome. West J Emerg Med, 2009 Feb; 10(1): 6–9.

8. Op. cit., Thorne.

9. Frellick M. CDC Issues First Pediatric Concussion Treatment Guidelines. Medscape, www.medscape.com/viewarticle/901517.

10. Concussion Legacy Foundation. CTE Resources: What Is CTE?, https://concussionfoundation.org/CTE-resources/what-is-CTE.

Mike Rubin is a paramedic in Nashville and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.