Monday, October 5, 2015

Concussions…Ding ding…Not as simple as getting “your bell rung” anymore?

By Ann L. Contrucci, M.D.

Concussions – what to do? In “the good ol’ days”, children or adolescents with concussions or “getting your bell rung” were back in the game very quickly, often within minutes. Follow up or objective neuropsychological testing was also rarely performed. As more and more research is done, diagnostic and treatment options including follow up of head trauma has become more involved. This issue confronts primary care and ER doctors on a daily basis making care for patients with concussions confusing and complex. To complicate things further, giving the proper amount of time needed to care for the patient can also be taxing on an already stressed staff.

This article is the first in a three-part series dealing with the pathophysiology and statistics of this common injury. The second article will focus on the clinical picture and diagnosis, and the last on treatments, complications and follow up recommendations. The series will spotlight concussions in children and adolescents as they exhibit certain unique characteristics.

Some of the statistics surrounding concussions in children and adolescents illustrate that this type of injury is extremely prevalent within this age group. During the 2008-2009 school year, 400,000 concussions occurred in high school athletes nationwide. From 1997-2007, ED visits for concussions doubled within the 8-13 year old age group and almost tripled for older children. A 2011 study of high schools with one or more athletic trainers on staff found that concussions were responsible for almost 15% of all reported sports injuries. Traumatic brain injuries in kids are associated with sports and recreational activities 21% of the time. Female high school athletes suffer more concussions than males: 40% more in soccer, and 240% more in basketball. Additionally, once a high school athlete has sustained a concussion, he or she is three times more likely to have another in the same season.

The definition of concussion is, interestingly enough, not universally accepted. A conglomeration of sports medicine groups define it as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Notably, this definition designates concussions as a functional injury, not a structural injury. This is why imaging studies do not show any abnormalities. The neurometabolic cascade involved occurs after some kind of traumatic force triggers neuronal dysfunction. In turn, this results in axonal dysfunction. Besides the aforementioned trauma-induced disruption of brain function, concussion characteristics must include at least one of the following as well as a Glasgow Coma Score of 13-15: an alteration in mental status at the time of injury, amnesia less than 24-hours before or after the event, loss of consciousness, or focal neurological deficits that may be transient.

With a still developing brain children and adolescents are even more susceptible to concussions. Why? The tissue is unable to recover as quickly as adult tissue because it is more vulnerable to neurochemical and metabolic changes. The axons themselves are not as myelinated or insulated as the adult brain, increasing the likelihood of injury. Secondly, younger athletes’ muscles are less developed and therefore insufficient at absorbing traumatic forces, i.e. cervical and shoulder musculature is not as able to withstand the shock of a blow to the head. Not using the proper technique in defending against a hit in sports also increases their risk.

No two concussions are alike, even with similar mechanisms of injury. Sometimes a mild traumatic brain injury can have long lasting impact and complications including sleep disturbances, cognitive impairments, and more. A recent trend has moved away from the traditional “grading” system used in diagnosing and treating concussions and towards an individualized assessment of symptoms to determine best course of treatment and follow up. This will be covered in detail in the second part of this series. Stay tuned!

Ann L. Contrucci, M.D., Director, Risk and Patient Safety at MagMutual Patient Safety Institute. Dr. Contrucci continues to practice pediatrics in a tertiary care children’s Emergency Department as well as in primary care offices.

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