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Provincial Clinical Knowledge Topic Concussion, Pediatric – Emergency

Version 1

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Revision History

Version Date of Revision Description of Revision Revised By

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Important Information Before you Begin The recommendations contained in this clinical knowledge topic have been provincially adjudicated and are based on best practice and available evidence. Clinicians applying these recommendations should, in consultation with the patient, use independent medical judgment in the context of individual clinical circumstances to direct care. This knowledge topic will be reviewed periodically and updated as evidence and best practice change.

The information in this topic strives to adhere to Institute for Safe Medication Practices (ISMP) safety standards and align with Quality and Safety initiatives and accreditation requirements such as the Required Organizational Practices. Some examples of these initiatives or groups are: Health Quality Council Alberta (HQCA), Choosing Wisely campaign, Safer Healthcare Now campaign etc.

This topic is based on the following guideline(s):

• Guidelines for Diagnosing and Managing Pediatric Concussion, Recommendations for Health Professionals(Ontario Neurotrauma Foundation, 2014)

• Position Statement: Sport-related concussion: evaluation and management (Canadian Pediatric Society, 2014)

• Joint Position statement - The Role of Family Physicians and physicians with Added Competencies in Sportand Exercise Medicine in a Public Health Approach to Concussions (August 2017)

• Consensus statement on concussion in sport—the 5th International Conference on Concussion in Sport held inBerlin (October 2016)

• Report from the Pediatric Mild Traumatic Brain Injury Guideline Workgroup: Systematic review and clinicalrecommendations for healthcare providers on the diagnosis and management of mild traumatic brain injuryamong children: Report to the Board of Scientific Counselors, National Center for Injury Prevention andControl, Centers for Disease Control and Prevention (2016)

• Parachute. Canadian guideline on concussion in sport. Toronto: Parachute (2017)

For questions or feedback related to this knowledge topic please contact Clinical Knowledge Topics by emailing clinicalknowledgetopics@ahs.ca

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Rationale Pediatric concussion is a prevalent and common presentation in Alberta primary care offices and emergency departments. The numbers of children and families seeking care for concussion is on the rise. Year over year concussion reporting in Alberta reveals an increase in diagnosis of concussion in primary care and emergency department settings.

Post-concussive symptoms are most severe acutely but can persist for days to several weeks (or even months) and result in functional disability and decline in quality of life. Clinics advertising concussion investigation often at high expense without a proven positive effect is increasing in popularity. However, the majority of children with a concussion can be managed by their primary care provider and do not require treatment at a specialty clinic or expensive investigations. Only a small proportion of children with a concussion will require a referral to specialized concussion resources for management of persistent and/or complicated presentations. Front line providers involved in concussion diagnosis and management should be empowered, educated and supported to gain the skills in recognizing concussion and comfort in making appropriate clinical decisions to optimize patient care and patient recovery.

This document will outline the diagnosis and management of pediatric concussion. Pediatric concussion is defined here as concussion injury in children and adolescents ages 5-17 years old. This document has been developed in consultation with various pediatric concussion experts in Alberta. This document outlines the first steps which will apply to the management of most children with concussions and will assist providers to identify the minority of patients who may require more specialized care.

While concussions may occur in the presence of other injuries, this guidance applies to the management of concussion only. Clinical judgement and discretion must be applied to triage the patient (in the case of complicated injury or polytrauma), evaluate and treat the patient according to injury severity.

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Decision Making Figure 1. Clinical algorithm for the initial acute evaluation of a suspected head injury, concussion, mild traumatic brain injury and/or neck injury for pediatric patients (Age 5-17 years old)

Presentation to ED with suspected head injury/concussion within 3 days of injury

Concussion Symptom Checklist

Assess for risk / modifying factors for concussion

Concussion Assessment:

Complete initial physical/neurological examination.

Complete balance or postural stability testing.

Complete and document remainder of assessment tools if not already completed to establish injury baseline.

If additional considerationsrequired, provide supportive interventions as indicated.

Manage persistent symptoms greater than 2 to 3 weeksInitial symptom management

Discharge

Initial Assessment & Rule Out

Severe Head Injury

ConcussionAssessment/Evaluation

Concussion Management

Establish follow up plan with pediatrician and plan a referral to neurology, headache clinic or concussion clinic

• GCS < 15• Signs of skull fracture, cervical spine

and other orthopedic injuries • Altered Mental Status (agitation,

somnolence, slow response, repetitive questions)

• Vomiting (4 or more episodes)• Scalp Hematoma (excluding frontal)• History of Loss of Consciousness• Severe Headache (not acting normal

per parent)• Severe Mechanism of Injury (fall > 5

feet, MVA with ejection/rollover/fatality, bike/ped vs vehicle without a helmet, high impact injury to head)

Consider diagnostic imaging (transfer to alternate site if

imaging not available)

Determine if results are within normal limits; treat positive

findings accordingly and consult neurosurgery.

Establish a follow up plan with pediatrician, family medicine, sports medicine or physiotherapy

Provide teaching and handout

Re-assessment of symptoms or late

presentation

No

Yes to any

No

Review mechanism and

other injury characteristicsYes to any

Positive Findings?

Consider Admission

Yes

No

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Refer to the following links for more information regarding: ☑ Aids for recognition and management of concussions (Appendix A)☑ Detailed symptom management guidance (Appendix B)☑ Patient Handout (Appendix H)☑ Disposition planning - criteria for safe discharge, criteria for hospital admission, planned follow up (Disposition

Planning and Follow Up)☑ Clinical questions and recommendations (evidence summaries) (Appendix K)

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Definitions The following definitions are being described and used for the purpose of this document only. However there is no current evidence based consensus on terms related to post concussion symptomology.

• Concussion: Acquired traumatic injury to the brain that results in rapid onset of impairment of neurologicalfunction that is usually short-lived.

o This can result from a blow to the part(s) or region(s) of the head, face, neck or elsewhere on thebody with an ‘impulsive’ force transmitted to the head. Although concussions are generally sports - and recreation-related injuries, they can occur

in relation to other activities such as falls, motor vehicle collisions, and assault.

• Concussive Event: The event causing the injury

• Acute Concussion Symptoms: Symptoms that begin at the day of injury up to 0 to 27 days after aconcussive event

• Persistent Concussion Symptoms: Symptoms continuing more than 28 days to 3 months after a concussiveevent in children / adolescents. (Please note this time-frame is 10-14 days for adults.) These symptoms arepost-traumatic, non-specific and require a comprehensive assessment to identify relevant factors, pathologiesor dysfunctions that may be present.

• Chronic Concussion Symptoms: Describes symptoms persisting longer than 3 months. These symptomsare post-traumatic, non-specific and require a comprehensive assessment to identify relevant factors,pathologies or dysfunctions that may be present.

• Complicated/Modified Mild Traumatic Brain Injury (TBI): Glasgow Coma Scale (GCS) 13 to 15 with intracranial pathology

• Moderate TBI: GCS 9 to 12

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Key Recommendations for Clinicians

History and Physical Examination • Document the mechanism of injury.

o A blow to the head, face, neck or elsewhere on the body with an ‘impulsive’ force transmitted to thehead may cause a concussion. Although concussions are generally sports-related, they can occur inrelation to other activities such as falls, motor vehicle collisions, and assault.

• Document the symptomso A post-concussion checklist or inventory of symptoms such as may be used:

PCSI-C PCSI-Y PCSI-P Health and Behaviour Inventory (HBI) (Appendix I)

o The symptoms usually appear minutes to hours after the injury and usually resolve on their own within27 days.

• A general physical examination and neurological examination should be performed with a focus on level ofconsciousness and behavior, the skull, the neck, focal neurological signs, and balance in addition to athorough assessment for presence of other injuries.

• Tools helpful for documentation of concussion include:o ACE-ED for any concussiono SCAT5 / ChildSCAT5 for sport-related concussions.

These abbreviated tools highlight the key required points for assessing concussion. A detailed neurological examination to rule out other injury is required.

• A head CT is not useful in the diagnosis of concussion but may be warranted to rule-out other importantintracranial injuries.

• Healthcare providers should use validated clinical decision rules (like PECARN, CATCH (CanadianAssessment of Tomography for Childhood Head Injury) rule, or Canadian CT Head Rule for children over 16years of age) to identify children at risk for intracranial injury.

• Any persistent abnormality in level of consciousness / GCS, suspected open or depressed skullfracture, worsening headache, or irritability on examination warrants a CT to rule important intracranialinjury like an intracranial bleed.

• Signs of a basal skull fracture, large boggy hematoma, or a dangerous mechanism (e.g. motor vehiclecollision, fall from bicycle with no helmet, or fall from a height of 3 feet or 5 stairs) may warrant a CT.

Clinical Diagnosis • History of an observed injury mechanism• Minimum of 1 symptom from a post-concussion checklist or inventory of symptoms (PCSI-C, PCSI-Y and

PSCI-P, ACE-ED or SCAT5 or Child SCAT5) (with increasing clinical suspicion if more symptoms are present),Health and Behavior Inventory (HBI) (Appendix I)

o Without symptoms or signs of a more severe injury or alternative diagnosis• Glasgow Coma Scale (GCS) rating of 13 to 15.• A loss of consciousness and/or amnesia is not required for confirming a diagnosis of concussion. When there

is a loss of consciousness, it is usually brief.

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o In our experience, if the loss of consciousness is longer than 5 minutes and / or the attainedhistory details do not fit within these clinical parameters, a more severe traumatic brain injury oralternative diagnosis (Appendix F) should be considered.

• Concussion does not show any brain injury on routine imaging tests like x-rays, CT or MRI scans.• A CT may be considered to rule out intracranial injury (i.e. intracranial bleed) in the presence of:

o Persistent abnormality in level of consciousness or GCS,o Suspicion of an open or depressed skull fracture,o Worsening headache,o Irritability on examination,o Signs of a basal skull fracture,o Large boggy hematoma,o A dangerous mechanism (e.g. motor vehicle collision, fall from bicycle while not wearing a helmet,

or fall from a height of 3 feet or 5 stairs)

There is no added value to grading the severity of a concussion itself as it will not change the treatment recommendations outlined in this document.

The following table outlines possible symptoms of concussion:

Table 1. Possible Concussion Symptoms Balance problems Blurred/doubled vision Confusion/disoriented Difficulty concentrating Difficulty remembering Dizziness Drowsiness Fatigue Headache/pressure in head Irritability Light sensitivity Mentally foggy Moving in a clumsy manner Nausea Neck pain Nervousness Noise sensitivity Sadness Slow to respond Slowed down Trouble falling asleep Vomiting

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Figure 2. Acute Concussion Evaluation in Emergency Department Setting – Sample

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Disposition Planning/Follow Up The following advice in this section pertains to information that should be highlighted with the patient and their family/immediate caregiver.

Clinicians should take the time to discuss anticipated symptoms, expected duration (even the possibility of a delayed recovery) and strategies for managing concussive symptoms at home are key components in normalizing symptoms and expected outcomes to aid recovery. The majority of children return to pre-injury functioning within 27 days post injury.

Laboratory Investigations and Diagnostic Imaging Blood work, CT, MRIs, and neuropsychology assessment are not part of routine care in the recovery from concussion.

Considerations for admission to hospital Indications for prolonged hospital observation including worsening symptoms, bleeding disorders, multisystem injuries, comorbid symptoms, or social factors influencing ability to monitor child at home

Considerations for discharge from Emergency Department With clinical judgment, it is safe to have the child/adolescent observed at home when the following conditions are evident:

i. Normal level of consciousness with improving symptoms.ii. No risk factors indicating need for CT scan or normal CT scan if already done.iii. No indications for prolonged hospital observation including worsening symptoms, persistent clinical symptoms

(nausea, headaches etc.), bleeding disorders, multisystem injuries or comorbid symptoms.

Follow Up

• Follow-up with primary care provider 7-10 days after the initial injury is recommended to monitor the progressof recovery after initial visit to the ED.

• Risk factors for protracted recovery (Appendix E) and the Pediatric Clinical Risk Score for Persistent PostConcussion Symptoms (Appendix G) may assist in early identification of those at risk for Persistent Symptoms.

o A moderate or high score is rationale for an appropriate referral to a concussion clinic or pediatricneurologist for follow up care.

• For persistent symptoms (Table 1. Possible Concussion Symptoms) lasting more than 27 days post-injury, theprimary care provider should strongly consider referral to a concussion clinic or pediatric neurologist for followup care.

• Often symptoms of ADHD and/or learning difficulties will increase for a short period of time. We recommendcontinuing all treatments and medications when children return to school. We also recommend re-contactingyour child’s school and physician/psychologist who was helping your child with these difficulties.

If the child/adolescent is currently seeing a specialist/HCP for mood and anxiety relatedsymptoms pre-injury, encourage a follow-up visit with them to keep the lines of communicationopen.

• Clinical evaluation for endocrinopathies is recommended one-year post injury if the child/adolescent reportsfatigue, cold intolerance, poor growth, altered puberty, mood disturbances or altered appetite control.

• Follow up is strongly recommended for sports-related injury even if symptoms improve.o For elite athletes, follow-up with a sports medicine physician can be recommended

• For worrisome symptoms, medical red flags, etc, child should return to ED/urgent care center.

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Discharge Instructions:

• Provide patient and family handouts (Appendix H) to go home with and to take to primary care provider

Cognitive Rest and Return to School with Return to Activity and Sport

Different activities may make symptoms worse for different people. Discuss with patient and family the child / adolescent’s regular activities and determine an individualized approach to returning to those activities.

• Rest for 24 to 48 hours post injury at home. Physical and cognitive activity should be minimized in the initial 24-48hours following a concussion. Gradual reintroduction of activities of daily living that do not provoke/increasesymptoms (including walking) can be introduced following this initial period of relative rest. Currently there is noevidence to support keeping a child / adolescent in a dark room and restricting then from all activity until symptom-free. If this is done it may cause chronic fatigue, pain and other related psychiatric/ neurological impairments.

o A gradual return to physical activity is encouraged along side gradual return to cognitive activity. This is astep-wise process and may take one or more weeks as each step is separated by at least 24 hours.Children / adolescents are strongly encouraged not to return to competitive (contact or collision) sport untilmedical clearance is obtained to avoid re-injury.

o Cognitive rest is encouraged to avoid exacerbation of symptoms for the first 24 to 48 hours after injury. Assymptoms begin to diminish, slowly increase activity to improve concentration, memory, and sensitizationto light/noise. Include the use of electronics and reading as tolerated, that is in a way or amount that doesnot exacerbate symptoms. Social interactions are encouraged.

o It is alright for a child to engage in watching television (at a reasonable distance from the screen), for ashort period of time. There is no evidence prohibiting this activity. However, child/adolescent shouldbe advised to the potential presence of phonophobia and/or photophobia. Therefore they should beadvised NOT to watch television in a dark room and/or with surround sound

o It is common for a child/adolescent to feel restless or agitated by the lack of activity.

• Step 1 - By the 2nd/3rd day post injury, the child should, if not already engaged, begin with gentle activities likemoderate reading (i.e. short periods of homework) and screen time with personal electronic devices (e.g.cellphones, tablets, and computers) for 15 to 20 minutes, followed by a break of equal length. A short and easywalk of about 15-20 minutes is also encouraged daily. If these activities are already taking place, increase timespent.

o The intention of this is to start increasing cognitive load and the associated stressors. This mayinclude homework completed at home with breaks for symptom management.

• Step 2 - If the child/adolescent is able to tolerate these activities well, try reintroducing the child/adolescentinto the school environment. Well tolerated physical aerobic activity may be progressed to include individualsport specific activity such as skating, dribbling, throwing and catching.

o Have the child/adolescent attend for half days (preferably the morning hours and stay over the lunchbreak) and also attend their less stressful classes. The main intention of this step is to have themsocializing with their peers rather than completing the school work at this time.

o They are encouraged to go to bed at regular times each night (including over weekends and holidaysand are to limit naps instead taking breaks throughout their day, if needed.

o Schooling accommodations can be used to reduce symptom burden for the first 2 weeks. (no exams,

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sitting at the front of the class, decreasing activities that require more effort, having a quiet space to work/relax, and no homework)

o Physical activity in this phase is meant to add movement. School based physical education meetingthe criteria may be engaged in (individual and skill based), however the child / adolescent isencouraged to sit out of more complex drills and situations.

• Step 3 - If they are able to tolerate the above mentioned activities well, they can attempt full days of schooland begin homework/attending exams. If symptoms are fully resolved and school work is being completed infull, the child / adolescent may re-integrate into non-contact sport/team practices including physical educationat school.

o All missed work and exams should be caught up and academic performance at pre-injury levels ofachievement.

o The physical activity goal is to increase exercise, coordination and add cognitive load to physicalactivities.

o Drills that are cooperative in nature are acceptable. These drills do not involve “challenge forpossession” or include high risk skills such as blocking in volleyball, football and rugby or aerials ingymnastics, cheer and skateboarding.

o Resistance training may be included at this stage.o Situations or drills involving scrimmages, games and opportunity for body and head contact are

restricted until medical clearance is obtained.

• Step 4 – Full return to learning is complete and symptoms should be fully resolved at this stage. Medicalclearance for return to sport may be obtained by the child / adolescent to initiate contact practices in thedesired sport.

o The goal for the child / adolescent is to regain confidence. Full practice speed, training and drills withappropriate learning progressions are expected.

• Step 5 – Full return to sport / activity and game play

Return to Learn and Return to Play can be performed simultaneously, however a full and complete return to school should occur prior to return to competitive (contact and collision) sport environments and include medical clearance for this activity.

Table 2. Return to School Strategy Step 1 Aim Start at home activities

Goal Gradual return to typical activity Activity Usual activities such as reading, texting, screen time, home work. Begin with 5-15

minutes and increase gradually Step 2 Aim Start going back to school

Goal Initial gradual return to school Activity Start going to school for half days, work up to full days

Consider school supports to foster return Step 3 Aim Return to near-normal routine

Goal Back to school full days all or most days of the week Activity Go to all classes, take transportation, limit naps

Step 4 Aim Return to school full time Goal Return to full academic activity

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Activity Full-time attendance with a normal, full workload, including exams.

Table 3. Return to Sport Strategy Step 1 Aim Start at home activities

Goal Gradual return to typical activities Activity Usual activities , including light walking at an easy pace for 15-20 minutes and

well-paced household chores Step 2 Aim Light aerobic activity

Goal Increase heart rate, limit deconditioning Activity DO - Walking, swimming, cycling at a light pace

AVOID - Resistance training or weight lifting AVOID - Activity with a risk of re-injury DO - Up to 10-15 minutes, 2x/day

Step 3 Aim Sport-related training and exercise Goal Add movement Activity DO - Individual skills such as stickhandling, jumping/leaping, volleying, juggling,

shooting, dribbling, throwing and catching DO - Up to 20-30 minutes 2x per day AVOID – Activities that would involve collisions or risk impact to the head

Step 4 Aim Non-contact training drills Goal Increased exercise, coordination, and thinking Activity DO - Cooperative training drills with team-mates

DO - Full physical conditioning and exertion including resistance training AVOID - Body or head contact. This includes heading drills (soccer), diving/blocking (volleyball), aerials (gymnastics/cheer) AVOID - Drills that have an offense vs defense component (due to the risk of contact and/or re-injury)

Full Return to Learn Complete Medical Clearance BEFORE a full return to sport

Step 5 Aim Full contact practice Goal Restore confidence in the athlete and coach

Assess functional skill Activity DO - Participate in full practice and normal training activity

Step 6 Aim Return to Sport Goal Normal Game Play, starting with scrimmages with teammates and working up to

regular competitive games.

Referrals Level 1: Routine Follow Up with Primary Care Providers If they have not returned to pre-injury status (i.e. if they have concussion-related symptoms) after 7 to 10 days, we strongly suggest they follow-up with their primary care provider.

• General Practitioner (GP), Family Medicine (FM), Pediatrician and/or Sport Medicine (SM) doctor (forcompetitive athletes)

o At least within the first 7 to 10 days’ post-injuryo Follow-up assessment before returning to contact sports

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o Medical clearance should be sought out before returning to contact play. Clearance should be providedby GP/FM/Pediatricians/SM experienced with concussion care.

If not experienced/confident in providing clearance, primary care physicians should referthe patient to concussion clinic/multidisciplinary rehabilitation centre/SM.

• If patient doesn’t progress through return to play within 27 days after injury, the patient should beencouraged to return for follow up care

Level 2: Follow Up for Persistent Symptoms For persistent symptoms 28 days or more post injury, the child/adolescent needs to be sent to a SM specialized clinic, headache clinic or multidisciplinary rehabilitation centre with providers and/or specialists with expertise in managing concussion, SM, Pediatrician, Pediatric Neurologist, Physiotherapist

• Referrals should be made to a health care provider experienced with concussion recovery management or to ahealth care provider who knows the patient’s previous medical history

o When the recovery pattern is atypical: i.e. headaches not diminishing in severity or frequency, or lastinglonger than 2 weeks, see family physician/pediatrician to provide pharmacologic intervention andpossible referral to a pediatrician or headache specialist (e.g. pediatric neurologist) for management.

o If stuck within a recovery step for more than a week or persistent symptoms > 28 days, warrantsreferral to clinics with experience in treating concussions for further management.

Level 3: Follow Up Referral to Sub-Specialties For specific symptoms, referral to other subspecialties (i.e. complex concussion clinic, sleep clinic, occupational therapy, physiotherapy, psychiatry, psychology, endocrinology, neuropsychology, educational psych. (via school services), etc.)

• Dizziness - Vestibular and cervical rehabilitation may be of benefit in decreasing persistent symptoms ofdizziness and improving function. These therapies have been shown to benefit recovery when initiated within10-14 days of injury. This form of rehabilitation should be performed by physiotherapists or other HCPs withexpertise in this area as it relates to concussion.

• Neck pain - Cervical therapies may be of benefit in decreasing persistent symptoms of neck pain andheadache of a cervical nature. These therapies have been shown to benefit recovery when initiated within 10-14 days of injury. This form of rehabilitation should be performed by physiotherapists or other HCPs withexpertise in this area as it relates to concussion.

• Headaches - Headaches lasting longer than two weeks. Encourage the child / adolescent to see familyphysician/pediatrician to provide pharmacologic intervention and possible referral to a pediatrician or headachespecialist (e.g. pediatric neurologist) for management.

• Sleep disturbance – Any sleep concerns/disturbances should be referred to the primary carephysician/pediatrician. Referral to sleep clinic may be indicated.

• Cognitive complaints - Evaluation by neuropsychology/educational psych may assist in determining cause andmanagement plan for persistent cognitive difficulties > 3 months’ post injury. Management may involvesymptom control or more formal adjustments to school programming.

• Mood concerns - Children may have elevated anxiety after injury but not long term. Mood disorders persistingfor 3 months should be evaluated as any other mood disorder. Those reporting 6 months after injury, may havea new onset of disorder (i.e. anxiety disorder).

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Patient education/Discharge Instructions

Pamphlets

• “Kids – Concussions & Head Injuries” and “Concussion in Children – Returning to School and Sport” (AppendixH)

Web Links

https://myhealth.alberta.ca/Alberta/Pages/Concussions-in-Children-Care-Instructions.aspx https://myhealth.alberta.ca/Alberta/Pages/Returning-to-School-and-Sport.aspx HEAL Health Education and Learning: Head Injury MyHealth.Alberta.Ca: Stress in Children and Teenagers MyHealth.Alberta.Ca: Stress and Youth

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Name of Order Set: Minor Head Injury/Concussion ED/UCC Pediatric Order Set Requirements: Age, Weight Order Set Keywords: Head Injury, Concussion, Loss of Consciousness Blood work, CT, MRIs and neuropsychology assessments are not routinely ordered in the diagnosis of concussion. The majority of patients with minor head injuries do not require ANY imaging. If considering imaging please refer to the clinical decision rules linked below and under the Computed Tomography header. Consider diagnostic imaging if: - Glasgow Coma Scale (GCS) less than 15 - Signs of skull fracture, cervical spine and other orthopedic injuries - Altered mental status (agitation, somnolence, slow response, repetitive questions) - Vomiting (4 or more episodes) - Scalp hematoma (excluding frontal) - History of loss of consciousness - Severe headache (not acting normal per parent) - Severe mechanism of injury (fall more than 3 feet or 5 stairs, motor vehicle accident with ejection/rollover/fatality, bike/pediatric patient vs vehicle without a helmet, high impact injury to head)

Referrals to specialists are not required for most children with concussion. SCAT for Sports Related Injury: https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf

5P rule: www.5Pconcussion.com/en/scorecalculator to triage higher likelihood of requiring Specialist follow up.

Diet and Nutrition

o NPO • Frequency: Effective Now • NPO Except:

Ice Chips Sips with meds Sips of clear fluids Other (specify)

• Diet Comments: o Pediatric Diet Options (configuration note: age range of patient defaults in each order item)

Pediatric Diet – Regular Diet Pediatric Diet – Clear Fluids Pediatric Diet – Full Fluids Pediatric Diet – Balanced Fluids Pediatric Diet – Diabetic Diet Pediatric Diet – Metabolic Diet Pediatric Diet – Ketogenic Diet

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Patient Care

Precautions and Safety Spinal Motion Precautions

Type (Full, Cervical, Lumbar, Thoracic):______________ Log Roll Do Not Turn

Vital Signs **************************************************************************************************** ~Start of ED Vital Signs Order Panel

Vital Signs: These orders need to be re-evaluated when the patient stabilizes or by two hours,

whichever occurs first. frequency as per Assessment and Reassessment of Patient Practice Support Document every ______ hourly every ______ minute(s) Continuous cardiac monitoring

Neurological Vital Signs: Notify physician if Glasgow Coma Scale drops 2 or more points below the

baseline score frequency as per Assessment and Reassessment of Patient Practice Support Document every ______ hourly every ______ minute(s)

~End of ED Vital Signs Order Panel **************************************************************************************************** Notify Notify physician if:

• Glasgow Coma Scale (GCS) decreases by 2 points, • irritability • severe or worsening headache • vomiting • change in focal neurologic signs

Blood work, CT, MRIs and neuropsychology assessments are not routinely ordered in the diagnosis of concussion

Laboratory Investigations Stat Coagulation For any patient with known bleeding disorder PT INR PTT Urine Tests

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For patients greater than 12 years old, if considering imaging and patient is unable to give history of last normal menstrual period (LNMP). Pregnancy Test, Urine - POCT

Diagnostic Imaging If a pediatric patient requires a CT head, skull radiographs are unnecessary. If you are considering a skull radiograph, consultation with a pediatric centre is recommended to avoid unnecessary radiation exposure.

General Radiology GR Cervical Spine, Reason for exam: Suspected cervical injury

Computed Tomography

The Canadian Assessment of Tomography for Childhood Head Injury 2 (CATCH2) Rule CT of the head is required for children with minor head injury* and any 1 of the following findings: - Glasgow Coma Scale (GCS) score less than 15 at 2 hours after injury - Suspected open or depressed skull fracture - History of worsening headache - Irritability on examination - Any sign of basal skull fracture* - Large, boggy hematoma of the scalp - Dangerous mechanism of injury* - Greater than or equal to: 4 episodes of vomiting * Minor head injury is defined as injury within the past 24 hours associated with witnessed loss of consciousness, definite amnesia, witnessed disorientation, persistent vomiting (greater than 1 episode) or persistent irritability (in a child aged less than 2 years) in a patient with a GCS score of 13–15. * Signs of basal skull fracture include hemotympanum, raccoon eyes, otorrhea or rhinorrhea of the cerebrospinal fluid, and Battle sign. * Dangerous mechanism is a motor vehicle crash, a fall from elevation greater than or equal to 3 ft (greater than or equal to 91 cm) or 5 stairs, or a fall from a bicycle with no helmet. Our bootstrap analysis (1000 replications) for the CATCH2 rule using the derivation data6 had a sensitivity of 100% (95% CI 100%–100%) and a specificity of 35.6% (95% CI 34.0%–37.1%) for neurosurgical intervention, whereas the sensitivity for brain injury on CT was 99.4% (95% CI 97.9%–100%) and the specificity was 36.9% (95% CI 35.2%–38.4%). The potential impact of the rule was assessed by comparing the CT rate according to the CATCH rule to the actual clinical practice of the physicians at the 9 sites. For the 4060 enrolled patients, the CT rate according to the CATCH rule was 43% and the CT ordering rate by the physicians was 35%. Using the CATCH2 rule, the CT ordering rate would be 55%. One case of brain injury would have been missed using the CATCH2 rule. This was an adolescent whose occiput struck the ground after a tackle. The patient had loss of consciousness for 2 minutes. Osmand, M., Klassen, T., Wells, G., Davidson, J., Correll R., Boutis, K., Joubert, G., Gouin, S., Khangura, S., Turner, T., Belanger, F., Silver, N., Taylor, B., Curran, J., & Stiell, I. (2018). Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department. Canadian Medical Association Journal, 190 (27) E816-E822; DOI:https://doi.org/10.1503/cmaj.170406 Pediatric NEXUS is less widely validated than PECARN.

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PECARN: Pediatric Head Injury/Trauma Algorithm: https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm

CATCH 2 study: https://www.cmaj.ca/content/190/27/E816 Canadian CT Head Rule: https://www.mdcalc.com/canadian-ct-head-injury-trauma-rule

Pediatric NEXUS 2 Head CT Decision Instrument for Blunt Trauma: https://www.mdcalc.com/pediatric-nexus-ii-head-ct-decision-instrument-blunt-trauma

CT Head, Reason for exam: for suspected intracranial injury CT Cervical Spine, Reason for exam: for suspected spinal injury

Magnetic Resonance MR Brain, Reason for exam: for suspected intracranial lesion or spinal injury

Other Tests

Cardiology Electrocardiogram – 12 Lead

Medications

Analgesics and Antipyretics **************************************************************************************************** ~Start of Pediatric Fever/ Mild Pain Smart Group acetaminophen

o acetaminophen (infants) acetaminophen liquid (15 mg/kg/dose) _____ mg PO q4 for mild pain. Max 75 mg/kg/day, 1000mg/dose and 4 grams/day Max 5 doses in 24 hours OR (linked order)

acetaminophen suppository (20 mg/kg/dose) _____ mg PO q4 for mild pain. Max 75 mg/kg/day, 1000mg/dose and 4 grams/day Max 5 doses in 24 hours

o acetaminophen (children)

acetaminophen liquid (15 mg/kg/dose) _____ mg PO q4 for mild pain. Max 75 mg/kg/day, 1000mg/dose and 4 grams/day Max 5 doses in 24 hours OR (linked order)

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acetaminophen chew tab (15 mg/kg/dose) _____ mg PO q4 for mild pain. Max 75 mg/kg/day, 1000mg/dose and 4 grams/day Max 5 doses in 24 hours

OR (linked order) acetaminophen tab (15 mg/kg/dose) _____ mg PO q4 for mild pain. Max 75 mg/kg/day, 1000mg/dose and 4 grams/day Max 5 doses in 24 hours OR (linked order) acetaminophen suppository (20 mg/kg/dose) _____ mg PO q4 for mild pain. Max 75 mg/kg/day, 1000mg/dose and 4 grams/day Max 5 doses in 24 hours

ibuprofen Use caution in infants < 4 months. (Considered off-label use) and children with dehydration (as limited safety data are available for this group) Usual max dose 400 mg per dose, with a daily maximum of 40 mg/kg/day or 2400 mg/day, whichever is less.

o ibuprofen (infants greater than 4 months)

ibuprofen liquid (10 mg/kg/dose)_____ mg every 6 hours as needed for mild pain, temperature greater than 37.5

o ibuprofen (children)

ibuprofen liquid (10 mg/kg/dose)_____ mg every 6 hours as needed for mild pain, temperature greater than 37.5 OR (linked order) ibuprofen tablet (10 mg/kg/dose)_____ mg every 6 hours as needed for mild pain, temperature greater than 37.5

~End of Pediatric Fever/ Mild Pain Smart Group ********************************************************************************************

Concussion, Pediatric – Emergency V 1 Page 22 of 75

Antiemetics

Ondansetron should be used as a single dose in most situations. Multiple doses, especially IV, can lead to QT prolongation.

Ondansetron dose guidance: 8-15 kg: 2 mg/dose Greater than 15-30 kg: 4 mg/dose Greater than 30 kg: 8 mg/dose

ondansetron 0.8 mg/ml liquid oral (recommended dose 0.1 mg/kg/dose) ______ mg PO every 8 hours PRN for

nausea/vomiting ondansetron tablet (recommended dose 0.1 mg/kg/dose) ______ mg PO every 8 hours PRN for

nausea/vomiting ondansetron DISINTEGRATING tablet (recommended dose 2 mg)____mg PO every 8 hours PRN for

nausea/vomiting ondansetron oral disintegrating tablet (recommended dose 2 mg/dose) ______ mg PO every 8 hours PRN for

nausea/vomiting

Consults/Referrals Recommendation for return to play is to be seen by a physician or provider who can exam and provide clearance.

Immediate Consults Pediatric Inpatient Services/Hospitalist Neurosurgery

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Analytics

Analytics – Outcome Measure #1 Name of Measure Provision of Concussion and Head Injuries Patient and Family

Information Pamphlet at time of discharge.

Definition Of the total number of patients presenting to the ED for concussion management, how many were provided the Concussion and Head Injuries Patient and Family Information Pamphlet at time of discharge.

Rationale The Concussion and Head Injuries Patient and Family Information Pamphlet supports the teaching provided by the healthcare team and is a resource for patients diagnosed with concussion.

Notes for Interpretation

Patient Health Record to provide option for healthcare provider to document provision of information pamphlet.

Analytics – Outcome Measure #2 Name of Measure Concussion repeated presentation to ED

Definition Of the total number of patients presenting to the ED for concussion management, how many presented to the ED again for concussion management.

Rationale Does availability of a provincial concussion clinical guidance tool kit decrease re-admissions and resource utilization?

Notes for Interpretation

Variation in complexity of patients, site capacity limitations. As well, access to primary care options (urgent care centers, family physicians, walk-in clinics) in a community vary and can contribute to significant variation in outpatient management and subsequent presentation to the ED, ultimately resulting in inpatient admissions.

Cited References See knowledge topic reference list

Analytics – Outcome Measure #3 Name of Measure Referrals for Concussion Management from the ED

Definition Of the total number of patients presenting to the ED for concussion, how many patients were assessed using the Pediatric Concussion Risk Score and further followed by primary care or subspecialty provider.

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Rationale To ensure that every child meeting the moderate to high risk category from the Pediatric Concussion Risk Score Assessment is ensured a referral.

Notes for Interpretation

The usage of the AHS Concussion Assessment Evaluation tool for pediatrics will have documented Pediatric Concussion Risk Scores and recommendations for follow up.

Cited References See knowledge topic reference list

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Appendix A: Symptom Recognition Grading Concussion Severity There continues to be considerable debate about the stratification of concussion severity, and differentiating between the terms “concussion” and “mild traumatic brain injury” (mTBI / mild TBI). As a result, there are several grading systems that use loss of consciousness and amnesia as their primary determinants of the severity of the concussion or mild TBI. To aid in diagnosis and management for clinicians and other healthcare providers, this document considers all non-sports- and non-recreation- related concussions as a part of the mild traumatic brain injury (mTBI) spectrum, but on the milder end. Whereas, sports- and recreation- related concussions are placed slightly higher on this spectrum because of the risk of repeated concussion and sub-clinical concussive events, which are largely explored in scientific literature. However, there is no added value to grading the severity of a concussion / mild TBI itself (mild, moderate or severe; Level 1, 2 or 3; Grade I, II, III a or III b; AAN Grade 1, 2 or 3; ACRM & DSM-IV Type 1, 2 or 3), and grading will not change the treatment recommendations outlined in this document. As such, the broad term of ‘concussion’ to describe the assessment and management of this type of injury.

Concussion Symptom Reporting The impaired neurological function observed is usually of rapid onset. However; in some cases signs and symptoms may evolve over a number of minutes to hours, creating considerable debate about the minimum number of symptoms required to satisfy criteria for neurological impairment, and also around delayed onset of symptoms (Table 1. Possible Concussion Symptoms). Self-reporting of symptoms is an appropriate assessment tool if such history is consistent with the injury event and / or subsequent alternations in neurological status. It is also reasonable in clinical practice to assume onset of symptoms within two or three days post injury, and that symptoms are likely expected to resolve on their own in the next week or two. Retrospective reports with symptom checklists / inventories (PSCI- C, PSCI-Y, PSCI-P or HBI) are useful in monitoring acute concussion symptom resolution in comparison to the pre-injury condition and functioning of the child / adolescent, and may also be useful in reducing parental concern. Discussing anticipated symptoms and the duration (even the possibility of a delayed recovery) is a key component in normalizing symptoms and expected outcomes as the majority of children return to pre-injury functioning within 27 days post injury.

Goals of Post-Concussive Assessment The primary goals of acute post-concussive evaluations are to rule out complicated / modified mild or moderate traumatic brain injury, and to determine if there are changes in a child’s functioning compared with their pre-injury functioning. Assessment with children must be framed within the context of differences in neural development, physical, cognitive, behavioral and emotional maturation and influences of home, school and community supports and demands on the child. The collection of this information facilitates individualization of current recovery guidelines.

Concussion Assessment and Evaluation Within the initial minutes to hours after an injury, the history and examination is focused on immediate resuscitation and thorough evaluation followed by performing focused neurological assessment emphasizing on neurological deficits, cervical spine status, and mental status. In some instances, a person with a concussion may look very unwell initially. Higher energy injuries, children with loss of consciousness, recurrent vomiting, high number and severity of acute symptoms, seizures, focal neurological and / or atypical features should be seen in the Emergency Department. Regardless of the apparent initial condition (even precautionary visits), once the injured patient has been stabilized, a history and physical examination focusing on neurologic abnormalities should be obtained. A description of the injury including cause and severity provides information about its nature and potential complications requiring prompt interventions. Clear documentation of the mechanism of injury, reporting of symptoms, and pre-injury functioning will guide clinicians in ruling out more severe injuries / mimickers of concussion, as well as directing ongoing and future recommendations for the child / adolescent.

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Red Flags and Danger/Warning Signs Red flags and concussion danger/warning signs include

• Complaints of neck pain, • Increasing confusion or irritability, • Repeated vomiting (>3 episodes), • Seizure or convulsion, • Weakness or tingling (paresthesia), • Decreased coordination, • Deteriorating conscious state (including fainting, drowsiness, significant decline in alertness, inability to waken

from sleep, any prolonged loss of consciousness), • Severe or increasing headache not subsiding with rest or medication, • Unusual behavior change, • Double vision, • Incoherent speech (slurred), • Discharge of clear, colorless, serous-like fluid from the nose or ear,s • Bloody discharge from the ears, • Unequal pupil size

For Toddlers/Infants - any of the above signs or symptoms, plus

• persistent crying and cannot be consoled • not nursing or eating

Risk / Modifying Factors The presence of pre-existing medical conditions and / or particular post-injury signs and symptoms are associated with more complex concussion management and can influence the clinical interpretation, intended investigations and subsequent management. These risks and modifying factors (Appendix E) may predict the potential for prolonged or persistent symptoms and should be considered in detail during evaluation. Also, it is important to consider factors that might make the evaluation more difficult including:

• Alcohol and / or illicit drug use may mask the symptoms of concussion. • Athletes and players may not report concussive symptoms as they often feel the injury itself is not serious

enough to warrant reporting. o As well, athletes are motivated to return to play so they may downplay symptom reporting (despite

actually experiencing symptoms).

• Children with intracranial injuries do not always display signs or symptoms, making physical and neurological examination alone inadequate predictors of injury.

• Pre-existing learning difficulties and attention disorders may make acute evaluation difficult and influence outcome.

• Presence of more overt physical injury (i.e. orthopedic or spinal cord injuries), may mask the initial symptoms of a concussion.

• Young, scared or children in pain may not be fully aware or able to articulate their symptoms clearly

General Examination A general physical examination and neurological examination are recommended with a focus on level of consciousness and behavior, the skull, the neck, focal neurological signs, and balance. The presence of neurological signs and symptoms (i.e. persistent abnormality in level of consciousness or GCS, suspicion of an open or

Concussion, Pediatric – Emergency V 1 Page 27 of 75

depressed/basal skull fracture, worsening headache, irritability, large boggy hematoma, or a dangerous mechanism of injury) are risk factors for a more serious injury and may warrant further investigations with CT or MRI. Healthcare providers should use validated clinical decision rules (like PECARN, CATCH (Canadian Assessment of Tomography for Childhood Head Injury) rule, or Canadian CT Head Rule for children over 16 years of age) to identify children at risk for intracranial injury.

Existing decision rules combine a variety of risk factors: • Age less than 2 years old, • Repeated vomiting, • Length of LOC, • Severe mechanism of injury, • Severe / worsening headache, • Amnesia, • Non-frontal scalp hematoma, • GCS <15 or , • Clinical suspicion for skull fracture

In instances where CT or MRI imaging modalities are not available, validated clinical decision rules are useful in determining to transfer to more equipped facilities / centers. Likewise, neck injury may be concurrent with a concussion, specific evaluation for a significant neck injury may also be performed, including C-spine evaluation and x-rays of the neck.

Aids for Recognition and Management

Indications for Use The scoring attained from a single / various concussion recognition tools and / or symptom checklists should not be used as a stand-alone decision about a child / adolescents’ readiness to return to school or competitive play after a concussion. As signs and symptoms may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion and recommend follow-up visit with the primary healthcare provider within 7-10 days after the injury. Medical clearance to return to full physical activity and competitive play (with risk of head/body contact) is required from a healthcare provider experienced in concussion management and only after the child/adolescent has returned to full schooling activities. Tools Depending on the setting of the evaluation, the following tools are useful to aid in clinical gestalt and suspicion of concussion by medical professionals:

• Use validated clinical decision rules (like PECARN, CATCH (Canadian Assessment of Tomography for Childhood Head Injury) rule, or Canadian CT Head Rule for children over 16 years of age) to identify children at risk for intracranial injury

• Child Sports Concussion assessment tool for children aged 5-12 (ChildSCAT5), Sport Concussion Assessment Tool for Athletes aged 13+ (SCAT5), Pocket Concussion Recognition Tool and/or Acute Concussion Evaluation (ACE-ED) or ACE-Office (in primary care office) tools may be used for assessment on the day of injury or the following day

• Post-concussion symptoms inventory (PSCI-C, PSCI-Y, PSCI-P), or Health and Behaviour Inventory (HBI) (Appendix I) can be used to assess pre- and post- injury functioning with post-concussive symptoms and be used to monitor the recovery process

• Balance Error Scoring System may be used as an objective measure to assess the effects of concussion on static postural stability and can be performed in nearly any environment. The information obtained from this

Concussion, Pediatric – Emergency V 1 Page 28 of 75

clinical balance tool can be used to assist a clinician’s decisions about return to activities when compared to previous assessments (at baseline, time of injury, etc). Should be used with a standardized symptom checklist/inventory.

• Concussion clinical prediction rule can assist with assessing the risk of prolonged or persistent symptoms with concussion

• Screening questions) for cognitive and visual problems o Routine use of computerized cognitive testing is not recommended for baseline or diagnostic testing

purposes. In select cases, referrals can be made for cognitive testing and further management if needed.

• Routine laboratory investigations have little role in confirmation of the clinical diagnosis. However, any patient who is receiving anticoagulation therapy should undergo the appropriate tests to determine the level of anticoagulant effect.

o Patients with a supra-therapeutic INR may develop a delayed CNS bleed despite an initially normal cranial CT.

Cervical Spine Assessment and Management Risk factors for cervical spine injury: Reason for immobilization and radiographic evaluation

• Unconscious patient, • Mechanism of injury suggestive of possible cervical spine injury:

o High-speed motor vehicle crash, o Fall greater than body height, o Bicycle or driving collision, o Forced hyperextension injury, o Acceleration-deceleration injury involving the head,

• Neck pain, • Focal neck tenderness or inability to assess neck pain secondary to a distracting injury, • Abnormal neurologic examination findings (motor, sensory, reflex examination), • History of transient neurologic symptoms suggestive of spinal cord injury without radiographic abnormality (i.e.

weakness, paresthesia, or lightening / burning sensation down the spine / extremity or related to neck movement),

• Physical signs of neck trauma (i.e. ecchymosis, abrasion, deformity, swelling, tenderness), • Unreliable examination secondary to substance abuse, • Significant trauma to head or face, • Inconsolable child.

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Appendix B: Symptom Management

Symptom Management

• Discussing anticipated symptoms, expected duration (even the possibility of a delayed recovery) and strategies for managing concussive symptoms at home are key components in normalizing symptoms and expected outcomes. A large number of children return to pre-injury functioning within 7-10 days and the majority within 27 days post injury.

Refer to Table 1. Possible Concussion Symptoms

Cervical Spine Involvement/ Neck Pain6

• The cervical spine may be injured secondary to trauma and is widely cited as a source of neck pain and headache in the whiplash literature. The upper three cervical segments have been reported as a source of cervicogenic headache. Many of the muscles in the cervical region also refer to the head and may be a cause of headaches and neck pain. A combination of manual therapy and exercise (specific exercises focusing on neuromotor control) has been shown to be more effective than passive modalities for individuals with neck pain.

• In the area of concussion, limited evidence is available that evaluates isolated cervical spine treatments. However, in a study of adolescents and young adults with symptoms of dizziness, neck pain and/or headaches for more than 10 days following concussion, treatment involving a combination of individualized multimodal physiotherapy (including vestibular rehabilitation and cervical spine treatment) showed improvement and was superior to routine care. Treatment components include a combination of individually selected treatments focused on head/eye/neck movement control including sensorimotor and neuromotor control in conjunction with manual therapy and soft tissue techniques as indicated.

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Figure 3. Headache Management Algorithm for Acute Concussion Symptoms and Persistent Concussion Symptoms for use within Acute Care or Community Settings

Complaint of Headache

Post-Traumatic Headache

Treat headache No historyof trauma

History of trauma

Ibuprofen or Acetaminophen

Self-management

headache advice

Decrease Ibuprofen or Acetaminophen to 3 x per

week or less

Are headachespersisting?

Discontinue Ibuprofen / AcetaminophenNo

Determine Headache typeand possible

triggers

Cervicogenicheadache

MigraineOther post-traumatic headaches

Treat cervicogenic

headache

Return to family physician for re-

assessment (ED if no family

physician)

Yes

Pharmacologic Treatment:

Naproxen or Ketorolac +/-

Metoclopramide up to 3 times per week or less after the first two weeks

Self-management with graduated

aerobic activities

Referral to neurology, headache

specialist, or concussion clinic

Referral to family physician or pediatrician

If headaches persist

Acute Post-Traumatic Headache

(Less than 2 weeks post-injury)

Persistent Post-Traumatic Headache

(More than 3 weeks post-injury)

Treat migraine

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Headaches Headaches can occur within minutes of a concussive event and up to 7 days after the event, and/or be aggravated by activity. A pre-injury history of headache (such as migraine) may or may not be present.

Pre-existing headaches often become worse after a concussion. Further, headaches with different characteristics from the pre-injury headaches can also occur.

The overarching approach to headaches after a concussion is to endorse the practice of good headache hygiene behavior. This includes regular sleep habits, healthy meals, hydration, and the management of stress. (Appendix D)

Medical management of post-traumatic headaches is determined by: • Pre-injury headache diagnosis, • Characteristics of the new headaches, • Severity of the headaches, • Length of the headache disorder, • Management of comorbidities, especially anxiety and mood changes

Acute post-traumatic headaches (up to 27 days post injury)

• Usually Over-the-Counter analgesics such as ibuprofen or acetaminophen can be used to manage these headaches. In children it is important to ensure that analgesics are used with sufficient and correct dosing, and attention to daily maximums

o ibuprofen (10 mg/kg/dose; Maximum 400 mg/dose) or o acetaminophen (15 mg/kg; Maximum 75 mg/kg/day, 1000 mg/dose AND 4 g per day whichever is

less) • Consider trial of analgesics with attention to not overuse analgesia over time

o After 2 to 4 weeks, analgesics should be limited to 3 times or less per week to avoid medication overuse associated headache

o For acute severe post traumatic headaches, ED treatment may include initiation of intravenous therapy of ketorolac alone, ketorolac/naproxen and metoclopramide combination, or ondansetron only

o Sometimes, a short course of steroids may be tried although there is no evidence to support this treatment. It is recommended that these cases be discussed with a neurologist or headache specialist

o The safety of triptans in the first week after a concussion has not been determined and are not recommended at this time There have been no studies exploring these agents for the treatment of acute headache related to concussion in the ED (studies have examined their use and efficacy in children presenting with an acute exacerbation of a primary headache only)

• Optimize medical management of any pre-injury headaches (especially migraine)

Persistent Post-traumatic headaches (28 days or more post injury)

Most acute post-traumatic headaches settle by 4 weeks. However a significant number of children with concussion can have persistent headaches. These are frequently accompanied by other post concussive symptoms (Appendix G) and the presence of comorbidities such as anxiety and mood problems.

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As with all headache disorders, management includes self-management strategies, avoidance of medication overuse and use of medical treatment (pharmaceutical and non-pharmaceutical).

The following are useful suggestions to help management:

• Identification of headache type o Cervicogenic headaches should initially be treated with physiotherapy and/or occipital nerve blocks o Recognise medication overuse associated headache and decrease analgesic use

• Identification of headache triggers o Exercise and weight-lifting exercises are known to exacerbate headaches. A gradual increase in

aerobic activity as tolerated is recommended. Avoid weight-lifting where possible until back to full aerobic exercise.

o Stress is a common trigger. Self-management tips on managing stress in youth are available through MyHealth.Alberta.ca. Referral to a school or mental health counsellor for further support may be needed.

• Optimizing pre-injury headache management, especially migraine management • Goals of treatment should include improving function, reducing headache frequency, reducing the progression

to chronic daily headaches and lessening associated comorbidities • Referral to a headache specialist or pediatrician is often required

Preventative treatments

• Useful for children/adolescents with a history of headaches and/or migraine. The main goal is to break the pain cycle with acute pain medications and provide a referral to a specialist (i.e. pediatric neurologist) for follow-up care.

• Possible medications that could be used include TCAs (amitriptyline and nortriptyline), beta-blockers (propranolol), melatonin and magnesium, antiepileptic (topiramate, valproic acid, gabapentin and zonisamide). Prescribing of these medications should be done in consultation with a pediatrician, pediatric neurologist and/or headache specialist

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Dizziness/Balance

Figure 4. Dizziness/Balance Symptom Management for Acute Concussion Symptoms and Persistent Concussion Symptoms. For Use in Acute Care and Community Settings

Dizziness Identified

Identify cause of dizziness and

possible triggers

Orthostatic related Migraine related Vestibular

related

Increase water and salt intake

in the diet

See treatment for migraines/post traumatic

headache algorithms

Epley or similar manoeuvres

Vestibular rehabilitation

(physiotherapy)

Other

Dizziness is a commonly reported symptom following concussion. What children mean by dizziness is variable. For some it may mean lightheadedness, nausea, spinning, disequilibrium or even blurred vision. Therefore, it is important to determine what is meant by dizziness and treat as appropriate. Balance alterations as measured by static balance tests may occur in a significant number of children, but often will get better without specific intervention over the first 10 days. Recently, longer lasting balance disturbance has been reported as measured through dynamic balance, gait and dual task methods.

• It is not recommended to avoid movement or mild aerobic activity because of dizziness or balance problems. • Orthostatic symptoms of light-headedness or dizziness may respond to increased fluid and salt intake and light

activity.

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• Vertigo that is exacerbated by a change in head position is commonly seen in vestibular hypofunction and benign paroxysmal positional vertigo and often responds to appropriate vestibular rehabilitation and or specific maneuvers.

• Nausea and vertiginous dizziness often co-occur with migraine like headache. • Dizziness or balance problems associated with neck pain may respond to treatment with specialized

physiotherapy (see Cervical spine involvement/ neck pain).

If symptoms persist beyond 4 weeks, clinical investigation for vestibular dysfunction may be warranted.

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Cognitive Symptoms

Figure 5. Concentration and Attention Symptoms for Acute Concussion Symptoms and Persistent Concussion Symptoms. For Use in Acute Care and Community Settings

Complaints of difficulties with attention, memory, learning,

reduced response speeds and/ or executive function identified

Rest for 1-2 days

Begin light cognitive activities; follw steps outlined in the “Return

to Learn” activity guidance

Are the symptomspersisting?

Start introducing light aerobic exercises and follow the steps outlined in the

“Return to Play” guidance

See family physician or pediatrician; consider implementing a “temporary” individualized education plan to assist

the child in returning to full days at school

+/- Psychological support

+/- Referral to concussion specialist (if stuck in a single recovery step of the “Return to Learn”

guidance for greater than 1 weeek)

Are the symptomspersisting?

Start introducing light aerobic exercises and follow the steps outlined in the “Return to Play”

guidance

See family physician or pediatrician; consider treating headaches, sleep and mood

disturbances as these can contribute to the cognitive difficulties

Mood disturbances: Determine underlying cause (e.g. anxiety,

depression, personality change disorders,

PTSD, ADHD, substance abuse)

Persistent Post-Traumatic Headache:

Follow the management algorithm

Sleep disturbances:

Encourage good sleep hygiene

practices

+/- Referral to psychiatrist

+/- Behavioural modification (e.g.

cognitive behavioral therapy)

Selective serotonin reuptake inhibitor

+/- Sleep aid (e.g. melatonin, amitryptiline, or short-term non-benzodiazepine sedative)

+/- Behavioural modification (e.g. cognitive behavioral therapy)

(1 to 3 weeks post-injury)

NO

YES

YES NO

Encourage open communication between child and parent. Have the family notify teachers, child’s

school and coaches of the injury

(Greater than 4 weeks post-injury)

+/- Referral to a concussion specialist (e.g. brain injury rehabilitation clinic, educational psychology, or neuropsychology)

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Acute Treatment (< 27 days post injury)

• Supporting the child/adolescent as they return to schooling activities is key. • Families and their children should be encouraged to talk to the school before the child returns. • “Return to School” guidelines. • Individualized Support Plan (ISP) is appropriate if the child is struggling to return to school as a full time

student. • The ISP provides temporary learning accommodations/modifications if child is struggling with complaints of

attention, memory and learning difficulties, slower response speed and aspects of executive function • When possible, exemptions can be made so that the student doesn’t have to “catch up” on all assignments or

work missed, instead prioritize key areas or projects to work on (such as in-school work and assignments). • Open communication between children/adolescent and their caregivers (parent, teachers and coaches) is

encouraged, as many fear about failing at school and feeling left out. • Sometime psychological support is necessary to aid in helping cope with these emotional difficulties.

Persistent Cognitive Difficulties (Symptoms greater than 3 months post injury)

• Persistence of neuropsychological impairment (difficulties with attention, memory and learning, response speed and aspects of executive function) after concussion is still debated,

• There is little evidence that the disruption in cognitive processes is related to the pathology of concussion injury.

• WHEN cognitive difficulties are suspected, sleep, headaches and mood disturbances should be addressed first, as these can all influence cognitive performance.

• If cognitive difficulties appear related to symptoms, like headache, fatigue, poor sleep – treatment should be directed towards specific complaints:

o Headache reduction; o Sleep disturbance – may benefit from corrected sleep hygiene +/- use of temporary sleep aids

(melatonin/ amitriptyline/ short term non-benzodiazepine sedatives;) o Psychological support may be necessary in helping the child/adolescent cope with these emotional

difficulties. • Recommend a gradual return to activities similar to the ones used during the acute and sub-acute recovery

periods • Extra time in examinations is not recommended for concussion except in an examination that takes place

within a month of injury. Cognitive studies show cognitive functioning returns to baseline levels within 1 to 2 weeks post injury.

• Sometimes accommodation in examinations are warranted if anxiety or mood disorders are present. • Occasionally, neuropsychological/educational psychology evaluations can assist in determining causation and

management plans but is not routinely available. Educational psychology evaluations are performed through the school systems but do not always appropriately assess or determine objective negative sequelae of concussion. Neuropsychology evaluations are available privately in the community. Limited resources for neuropsychological evaluations through the hospital services are performed on a case by case basis through brain injury rehabilitation clinics.

Visual Symptoms

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Concussion related visual complaints include blurred/double vision, eye fatigue, the appearance of words moving on the page, loss of place when reading, and difficulty sustaining attention on a visual task. Identification of visual problems is important because approximately 50% of the brain’s circuits are dedicated to vision5 as well as the visual demands of children/adolescents engaged in full-time school (due to widespread use of electronic interfaces)1.

• Common problems may be present before the concussive injury such as accommodative disorders and convergence insufficiency. Less commonly retinal or optic nerve injury, saccadic dysfunction, and vestibulo-ocular dysfunction may be seen.

• Eye examination and optometric examination is warranted • Treatments: • Treat any visual acuity deficits with spectacles

o Convergence insufficiency may respond to short term interventions guided by appropriate professionals (e.g., vestibular physiotherapists, optometrists, ophthalmologists) experienced and knowledgeable in concussion management.)

o The value of oculomotor retraining (including use of prisms) in concussion has not be proven and is not recommended for routine use except under guidance from ophthalmology or neurology.

o Specific school-based accommodations are usually not required for typically recovering children. In some children, short term accommodation such as frequent visual breaks, and preprinted notes and material may be useful. Accommodations such as oral teaching, audio-books, large-font printed material (vs. small font electronically displayed material) are usually not required unless with guidance from an ophthalmologist, pediatrician or neurologist1

• Often a referral to a concussion specialist or eye-care professional is needed for a comprehensive visual and oculomotor evaluation beyond visual acuity testing, and for possible treatment of accommodation, binocular vision, and eye movements.

o Accommodative complaints – spectacle correction for near-sighted, oculomotor training (short-term).

o Convergence insufficiency – base in prism, near convergence exercises with in-office/home based programs, oculomotor training.

Mood Symptoms

• Mood changes and anxiety can be common during recovery from a concussion. Many children worry about failing at school, not being active, or feeling left out. These feelings may make symptoms worse (especially headaches and attention and concentration) and prolong recovery.

• Best practice recommendations emphasize the importance of providing social support to improve quality of life and reduce effects of stressors on a child / adolescent’s health. Such supports include:

o Emotional guidance (empathy, love, trust, and caring) by caregivers (from parents/guardians, teachers, coaches, friends),

• Informational guidance and appraisal (constructive feedback and positive affirmations), and provision of tangible aids/services directly assisting needs of the child/adolescent

o School accommodation letters o Counselling services

• Social isolation has been identified as a risk of poor recovery and should be avoided during the recovery process. To avoid this situation, early return to scholastic pursuits is recommended. Post injury return to school guidelines can guide this process and should include return to half days of schooling (ideally the morning half and stay over the lunch hour). They can participate in school work during this time, and interaction with friends and peers should be encouraged.

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• If the child/adolescent is currently seeing a specialist/healthcare provider for mood and anxiety related symptoms pre-injury, encourage a follow-up visit with them to keep the lines of communication open.

• Be aware of avoidant behaviors (feeling socially inept, reluctance to being involved with people, unwilling to try because the task may prove to be embarrassing), these are often associated with anxiety and should not be encouraged. Where there is avoidant behavior, it is helpful to have a psychologist or counsellor involved in the care.

Other Symptoms

The following symptoms may occur but are not commonly seen in children with concussions:

Tinnitus (Evidence Summary)

Endocrinopathies (Evidence Summary)

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Appendix C: Role of Diagnostic Imaging CT or MRI of the Head Neuroimaging is not warranted unless indicated by “red flag” symptoms and clinically suggestive focal neurological findings. Routine CT or MRI scans contribute little to concussion evaluation and should be employed only when an intra-cerebral or structural lesion is suspected or in presence of red flags. A CT may be considered to rule out intracranial injury (i.e. intracranial bleed) in the presence of:

• Persistent abnormality in level of consciousness or GCS less than 15, • Suspicion of an open or depressed skull fracture, • Worsening headache, • Irritability on examination, • Signs of a basal skull fracture, • Large boggy hematoma, • A dangerous mechanism (e.g. motor vehicle collision, fall from bicycle while not wearing a helmet, or fall from a

height of 3 feet or 5 stairs)

Health care providers should use validated clinical decision rules to identify children at low risk for intra-cranial injury, in whom head CT is not indicated, as well as children who may be at a higher risk for clinically important intra-cranial injury, and therefore may warrant head CT. Existing decision rules combine a variety of risk factors, including:

• Age less than 2 years old, • Repeated vomiting, • Loss of consciousness, • Severe mechanism of injury, • Severe or worsening headache, • Amnesia, • Non-frontal scalp hematoma, • GCS less than 15, • Clinical suspicion for skull fracture

In the instance where CT is not available, validated clinical decision rules are better than skull x-rays when screening patients with increased risk for intra-cranial injury and determining to transfer to other facilities.4 X-Ray of the Skull Skull x-rays should not be used in the diagnosis of pediatric concussion or in the screening of intra-cranial injuries. Neuroimaging modalities, such a head CT, better detects intracranial injuries, thus making it the more appropriate diagnostic imaging choice when imaging is clinically indicated to assess for acute TBI. 5

Imaging Techniques in Development

Neuroimaging Studies for Acute and Persistent Concussive Symptoms Recent neuroimaging studies have shown the use of special sequences like susceptibility weighted imaging, functional magnetic resonance imaging, and diffusion tensor imaging to detect abnormalities. However, current standard of care does not support the use in routine clinical practice of specialized MRI imaging sequences (i.e. fMRI, DTI) that have shown promise in research settings.4

Single-photon Emission Computed Tomography (SPECT) Not used commonly in a clinical setting as it may require sedation and is costly.

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Appendix D: Headache Control Table 2. Headache Control Tips for Patients and Families. Keep a headache diary Identify headache triggers and the course of each headache

Get regular sleep Go to bed and wake up at regular times each day Do not sleep excessively on weekends and too little on weekdays

Eat nutritional, regularly spaced meals Low blood sugar can trigger a headache Eat regular meals three times a day including protein, fruits, vegetables and carbohydrates Too much sugar may lead to a rapid increase in blood sugar followed by a rapid decline in blood sugar which can trigger a headache

Get moderate amounts of routine exercise Moderate exercise will help reduce stress and keep you physically fit Too much exercise or inconsistent patterns of exercise may trigger headache

Drink plenty of water Dehydration may cause headaches

Limit caffeine, alcohol and other drugs Caffeine is a stimulant. Caffeine withdrawal may cause headaches when blood levels of caffeine taper Alcohol may be a trigger for headaches

Reduce stress Stress may lead to an increase in headache Relaxation and stress management may help reduce headaches Regularly set aside time for personal relaxation and stress reduction

Manage chronic headaches Treat acute attacks of migraine early and aggressively Avoid overuse of symptomatic medication If you require prevention/suppression therapy, give the specific therapy time to be effective If you suffer from a migraine “co-morbidity,” such as chronic insomnia, anxiety, depression, or other medical problems, seek treatment for that condition

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Appendix E: Risk/ Modifying Factors The following “Risk/ modifying factors” can influence the clinical interpretation, intended investigations and management of a case of concussion/ mild traumatic brain injury. In some instances, these factors may predict the potential for prolonged or persistent symptoms and should be considered in detail during evaluation.

Table 3. Risk/Modifying Factors for Concussions8 Category Risk/ Modifying Factor Pre-existing conditions Anxiety

Attention Deficit Hyperactivity Disorder (ADHD) Depression Learning difficulties (especially in early school years)

Past medical history Migraine and exercise induced headache Previous concussions especially with delayed recovery

Psychosocial history Change of school Loss of a family member/friend or pet Previous stressful life events Recent stressors and the child’s reactions to these (i.e. conflicts)

Injury factors Assault (associated with delayed recovery) Litigation Mechanism (i.e. high energy) Severity of acute symptoms

Medication use Alternative therapies Analgesic use and/or overuse Use of marijuana or illicit substances

Family history Anxiety Attention Deficit Hyperactivity Disorder (ADHD), learning disorder in 1st degree family may support pre-existing diagnosis in child Depression Migraines, hemiplegic migraine

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Appendix F: Differential Diagnosis of Concussion Diagnosing concussions is based on clinical suspicion, acute injury characteristics and presenting signs and symptoms. However, to move towards an optimal, effective and individualized treatment plan, clinicians must use subjective reporting from the patient (and/or witnesses who saw the injury occur) and objective findings from their clinical examination. This is necessary to rule out other plausible underlying mechanisms which can have similar clinical presentations, such conditions include:

• Blunt neck trauma, • Child abuse, • Contusion of cerebrum, • Delirium, • Diffuse brain injury, • Disturbance of consciousness, • Encephalopathy, • Epidural hematoma, • Hypertensive encephalopathy, • Hypoglycemia, • Hypoxic-ischemic brain injury, • Infectious disease of central nervous system, • Intoxication, • Intra-cerebellar and posterior fossa hemorrhage, • Intra-parenchymal hematoma of brain, • Neoplasm of brain, • Poisoning by drug and/or medicinal substance, • Post-concussion syndrome, • Seizure, • Skull fracture, • Subarachnoid hemorrhage, • Subdural hematoma, • Syncope, • Thromboembolic stroke

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Appendix G: Pediatric Clinical Risk Score for Persistent Post Concussion Symptoms8

• Use within 48 hours of concussion incident • Complete an ACE Assessment or SCAT5 • Use the following chart to create a Pediatric Clinical Risk Score • Before this score is adopted in clinical practice, further research is needed for external validation, assessment

of accuracy in an office setting, and determination of clinical utility.

Pediatric Clinical Risk Score for Persistent Post Concussion Symptoms8 Predictor Description Points Score Age group *

5 – 7 8 – 12 13 – 17

0 1 2

Gender Female 2

Prior concussion and symptom duration

Prior concussion AND Symptoms lasting ≥ 1 week 1

Physician-diagnosed migraine history

Yes 1

Answering questions slowly Yes 1

Balance Error Scoring System Tandem stance only

≥ 4 errors OR Physically unable to test 1

Headache Yes 1 Sensitivity to noise Yes 1 Fatigue Yes 2 Total Score 12 * not applicable for children less than 5 years of age Anticipate recovery in 10 days < 3 Follow up with primary health care provider or pediatrician 4 – 8

Provide family with referral to neurology and/ or concussion specialist.

9 – 12

https://jamanetwork.com/journals/jama/fullarticle/2499274

Adapted from the original article by Codi Isaac PT

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Appendix H: Patient Handouts – “Kids – Concussions and Head Injuries” and “Concussion in Children – Returning to School and Sport”

The patient handouts can be accessed through the following links:

https://myhealth.alberta.ca/Alberta/Pages/Concussions-in-Children-Care-Instructions.aspx

https://myhealth.alberta.ca/Alberta/Pages/Returning-to-School-and-Sport.aspx

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Appendix I: Health and Behavior Inventory

Figure 6: Health and Behavior Inventory – Child Version

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Figure 7: Health and Behavior Inventory – Parent Current Version

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Figure 7: Health and Behavior Inventory – Parent Retrospecitive Version

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Appendix J: References and Additional Reading

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4. Ahmed OH, Sullivan SJ, Schneiders AG, Mccrory P. iSupport: do social networking sites have a role to play in concussion awareness? Disabil Rehabil. 2010;32(22):1877-1883. doi:10.3109/09638281003734409

5. Arbogast KB, Curry AE, Pfeiffer MR, et al. Point of health care entry for youth with concussion within a large pediatric care network. JAMA Pediatr. 2016;170(7). doi:10.1001/jamapediatrics.2016.0294

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Relevant Guidelines, Procedures, Protocols and Clinical Knowledge Topics

Clinical Knowledge Topic: Minor Head Injury, Adult – Emergency Department (Concussion)

Additional Guidelines

Physiotherapy Alberta College and Association: Concussion Management Toolkit Parachute Canada: Concussion Information and Resources BC Injury Research and Prevention Unit: Concussion Awareness Training Tool (CATT) Centers for Disease Control and Prevention: Heads Up Canadian Academy of Sport and Exercise Medicine

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Appendix K: Clinical Questions & Recommendations Clinical Questions help us to ask pertinent information about the knowledge topic in order to facilitate finding an evidence based answer that will guide decision making. Working groups have the option of identifying 2-3 key clinical questions. The questions chosen will then be prioritized using a Likert scale and evidence search strategy determined. Clinical questions may be formulated based on the PICO format as supported by Sackett1 and Guyatt2 in their User’s Guide to the Medical Literature to define the clinical question. PICO-D format identifies the patient problem or population (P), intervention (I), comparison (C) and outcome(s) (O).

1. Sackett D, Richardson WS, Rosenburg W, Haynes RB. How to practice and teach evidence based medicine. 2nd ed. Churchill Livingstone; 1997. 2. Guyatt GH, Oxman AD, Vist GE, et al; for the GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of

recommendations. BMJ. 2008; 336(7650):924-926. GRADE Methodology - Used to address quality of evidence and strength of recommendations of answers to the clinical questions. Whenever possible answers are identified from recent high quality guidelines or high quality systematic reviews and recommendations provided are based on GRADE definitions. Where guidelines or systematic reviews are not available to answer certain questions rapid reviews are undertaken and/or a consensus approach used to try to answer clinically relevant questions. Only where the evidence is supportive and the benefits clearly outweigh the harm is a “we recommend” strength of recommendation applied.

Table 4. GRADE Quality of Evidence1 High GRADE A

We have high confidence that the true effect lies close to that of the estimate of the effect.

Moderate GRADE B

We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

Low GRADE C

Our confidence in the effect estimate is low: The true effect may be substantially different from the estimate of the effect.

Very low GRADE D

We have very low confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

Table 5. GRADE Strength of Recommendations1 Strong GRADE 1

Strong recommendation, with desirable effects clearly outweighing undesirable effects/burdens (or vice versa). Wording of Recommendation: We recommend in favor of / We recommend against…..

Weak GRADE 2

Weak recommendation, with desirable effects closely balanced with undesirable effects. Wording of Recommendation: We suggest in favor of / We suggest against …..

Insufficient evidence or no consensus

Wording of Recommendation: There is insufficient evidence or the confidence in the effect estimates is so low that the panel is unable to make a recommendation regarding….

1. Guyatt GH, Oxman AD, Vist GE, et al; for the GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008; 336(7650):924-926.

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Clinical Question #1: In pediatric patients diagnosed with concussion, does a period of brain rest improve patient outcomes? Clinical Recommendation #1: No evidence to support “absolute bed rest” to improve outcome after concussion.

Current guidelines, like the Ontario Neurotrauma Foundation guidelines (2014), advocate a conservative approach to return to activities (schooling and sport) once symptoms subside. However, recent evidence supports mild to moderate activities (active rehabilitation).

• Sustained rest may adversely affect the outcome following a concussion. 3 Further, it can lead to physical deconditioning, loss of contact with peers, reactive depression, metabolic disturbances, etc.

• Patients can safely engage in controlled physical activity below the symptom threshold. This may be beneficial to the recovery process although more research is required. 11

• The 2017 Berlin consensus statement recommends that patients should rest for up to 24-48 hours after injury. This is considered reasonable and is followed by simultaneous re-integration into school physical activity. Full return to competitive and sport is meant to follow a step-wise process with a minimum of 24 to 48 hours per step. Both cognitive and physical loads are increased simultaneously, with contact activity occurring after full return to academics is complete.

Different activities may make symptoms worse for different people. Discuss with patient and family the child / adolescent’s regular activities and determine an individualized approach to returning to those activities.

• Rest for 24 to 48 hours post injury at home. Physical and cognitive activity should be minimized in the initial 24-48 hours following a concussion. Gradual reintroduction of activities of daily living that do not provoke/increase symptoms (including walking) can be introduced following this initial period of relative rest. Currently there is no evidence to support keeping a child / adolescent in a dark room and restricting then from all activity until symptom-free. If this is done it may cause chronic fatigue, pain and other related psychiatric/ neurological impairments.

o A gradual return to physical activity is encouraged along side gradual return to cognitive activity. This is a step-wise process and may take one or more weeks as each step is separated by at least 24 hours. Children / adolescents are strongly encouraged not to return to competitive (contact or collision) sport until medical clearance is obtained to avoid re-injury.

o Cognitive rest is encouraged to avoid exacerbation of symptoms for the first 24 to 48 hours after injury. As symptoms begin to diminish, slowly increase activity to improve concentration, memory, and sensitization to light/noise. Include the use of electronics and reading as tolerated, that is in a way or amount that does not exacerbate symptoms. Social interactions are encouraged.

o It is alright for a child to engage in watching television (at a reasonable distance from the screen), for a short period of time. There is no evidence prohibiting this activity. However, child/adolescent should be advised to the potential presence of phonophobia and/or photophobia. Therefore they should be advised NOT to watch television in a dark room and/or with surround sound

o It is common for a child/adolescent to feel restless or agitated by the lack of activity.

• Step 1 - By the 2nd/3rd day post injury, the child should, if not already engaged, begin with gentle activities like moderate reading (i.e. short periods of homework) and screen time with personal electronic devices (e.g. cellphones, tablets, and computers) for 15 to 20 minutes, followed by a break of equal length. A short and easy walk of about 15-20 minutes is also encouraged daily. If these activities are already taking place, increase time spent.

o The intention of this is to start increasing cognitive load and the associated stressors. This may include homework completed at home with breaks for symptom management.

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• Step 2 - If the child/adolescent is able to tolerate these activities well, try reintroducing the child/adolescent into the school environment. Well tolerated physical aerobic activity may be progressed to include individual sport specific activity such as skating, dribbling, throwing and catching.

o Have the child/adolescent attend for half days (preferably the morning hours and stay over the lunch break) and also attend their less stressful classes. The main intention of this step is to have them socializing with their peers rather than completing the school work at this time.

o They are encouraged to go to bed at regular times each night (including over weekends and holidays and are to limit naps instead taking breaks throughout their day, if needed.

o Schooling accommodations can be used to reduce symptom burden for the first 2 weeks. (no exams, sitting at the front of the class, decreasing activities that require more effort, having a quiet space to work/relax, and no homework)

o Physical activity in this phase is meant to add movement. School based physical education meeting the criteria may be engaged in (individual and skill based), however the child / adolescent is encouraged to sit out of more complex drills and situations.

• Step 3 - If they are able to tolerate the above mentioned activities well, they can attempt full days of school and begin homework/attending exams. If symptoms are fully resolved and school work is being completed in full, the child / adolescent may re-integrate into non-contact sport/team practices including physical education at school.

o All missed work and exams should be caught up and academic performance at pre-injury levels of achievement.

o The physical activity goal is to increase exercise, coordination and add cognitive load to physical activities.

o Drills that are cooperative in nature are acceptable. These drills do not involve “challenge for possession” or include high risk skills such as blocking in volleyball, football and rugby or aerials in gymnastics, cheer and skateboarding.

o Resistance training may be included at this stage. o Situations or drills involving scrimmages, games and opportunity for body and head contact are

restricted until medical clearance is obtained.

• Step 4 – Full return to learning is complete and symptoms should be fully resolved at this stage. Medical clearance for return to sport may be obtained by the child / adolescent to initiate contact practices in the desired sport.

o The goal for the child / adolescent is to regain confidence. Full practice speed, training and drills with appropriate learning progressions are expected.

• Step 5 – Full return to sport / activity and game play

Return to Learn and Return to Play can be performed simultaneously, however a full and complete return to school should occur prior to return to competitive (contact and collision) sport environments and include medical clearance for this activity.

Table 2. Return to School Strategy Step 1 Aim Start at home activities

Goal Gradual return to typical activity Activity Usual activities such as reading, texting, screen time, home work. Begin with 5-15

minutes and increase gradually

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Step 2 Aim Start going back to school Goal Initial gradual return to school Activity Start going to school for half days, work up to full days

Consider school supports to foster return Step 3 Aim Return to near-normal routine

Goal Back to school full days all or most days of the week Activity Go to all classes, take transportation, limit naps

Step 4 Aim Return to school full time Goal Return to full academic activity Activity Full-time attendance with a normal, full workload, including exams.

Table 3. Return to Sport Strategy Step 1 Aim Start at home activities

Goal Gradual return to typical activities Activity Usual activities , including light walking at an easy pace for 15-20 minutes and

well-paced household chores Step 2 Aim Light aerobic activity

Goal Increase heart rate, limit deconditioning Activity DO - Walking, swimming, cycling at a light pace

AVOID - Resistance training or weight lifting AVOID - Activity with a risk of re-injury DO - Up to 10-15 minutes, 2x/day

Step 3 Aim Sport-related training and exercise Goal Add movement Activity DO - Individual skills such as stickhandling, jumping/leaping, volleying, juggling,

shooting, dribbling, throwing and catching DO - Up to 20-30 minutes 2x per day AVOID – Activities that would involve collisions or risk impact to the head

Step 4 Aim Non-contact training drills Goal Increased exercise, coordination, and thinking Activity DO - Cooperative training drills with team-mates

DO - Full physical conditioning and exertion including resistance training AVOID - Body or head contact. This includes heading drills (soccer), diving/blocking (volleyball), aerials (gymnastics/cheer) AVOID - Drills that have an offense vs defense component (due to the risk of contact and/or re-injury)

Full Return to Learn Complete Medical Clearance BEFORE a full return to sport

Step 5 Aim Full contact practice Goal Restore confidence in the athlete and coach

Assess functional skill Activity DO - Participate in full practice and normal training activity

Step 6 Aim Return to Sport Goal Normal Game Play, starting with scrimmages with teammates and working up to

regular competitive games.

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Quality of Evidence: Moderate, Grade B Strength of Recommendation: Weak/Insufficient evidence References:

1. Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. Jama. 2016;316(23):2504. doi:10.1001/jama.2016.17396

2. Howell D, Mannix R, Quinn B, Taylor J, et al. . Physical activity level and symptom duration are not associated after concussion. Am J Sports Med. 2016. 44(4):1040-1046.

3. Leddy J, Baker J, Willer B. Active rehabilitation of concussion and post-concussion syndrome. Phys Med Rehabil Clinc N Am. 2016. 27:437-454

4. Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?”: Recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259. doi:10.1097/HTR.0b013e31825ad658

5. McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorak J, Echemendia RJ. et al. Consensus statement on concussion in sport: 4th International Conference on Concussion in Sport held in Zurich, November 2012. 2013. Br J Sports Med. 2013. 47:250-258.

6. Arbogast K, McGinley A, Master C, Grady M, Robinson R, Zonfrillo M. Cognitive rest and school-based recommendations following pediatric concussion: the need for primary care support tools. Clin Pediatr (Phila). 2013. 52(5):397-402

7. Gagnon I, Swaine B, Friedman D, Forget R. Exploring children's self-efficacy related to physical activity performance after a mild traumatic brain injury. J Head Trauma Rehabil. 2005. 20(5):436-449.

8. Gioia G. Medical-School Partnership in Guiding Return to School Following Mild Traumatic Brain Injury in Youth. J Child Neurol. 2016. 31(1):93-108.

9. Giza C, Kutcher J, Ashwal S, Barth J, Getchius T, Gioia G et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurol. 2013. 80(24):2250.

10. Moser, R.., Glatts, C., Schatz, P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sports-Related Concussion. J Pediatr. 2012. 161(5): 922-966.

11. Wantanabe, T, Bell, K, Walker, W, Schomer, K. Systematic Review of Intervention for Post-traumatic Headache. PM R. 2012. 4(2):129-140.

12. Schneider K, Iverson G, Emery C, McCrory P, Herring S, Meeuwisse W. The Effects of Rest and Treatment following Sport-related Concussion: A Systematic Review of the Literature. Br J Sports Med. 2013. 47(5): 304-307.

Clinical Question #2: In pediatric patients diagnosed with concussion, what are the most effective treatments for headaches? Clinical Recommendation #2: Recommendations are classified into 2 time points

• Acute post-traumatic headaches (initial 2-4 weeks post injury) • Persistent post-traumatic headaches (> 4 weeks post injury)

Post-traumatic headaches have several different phenotypes including tension-type, migraine, medication overuse and cervicogenic headache.

There are no established guidelines for the treatment of post-traumatic headache, and practices vary widely.

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Acute post-traumatic headaches (up to 27 days post injury) • Onset is usually within 7 days of head and/or neck injury without history of a premorbid definable

headache disorder o If a pre-existing headache (i.e. migraines) with the characteristics of a primary headache disorder

worsen (often defined as a 2-fold or greater increase in frequency and/or severity), or o occurs in close temporal relation to an injury, both the initial headache diagnosis and diagnosis

of headache attributed to trauma/injury to the head and/or neck are diagnosed. o Usually simple analgesics such as ibuprofen or acetaminophen can be used to manage

these headaches. ▪ Ibuprofen (7.5-10 mg/kg)/acetaminophen (15 mg/kg) initial treatment of choice as

they are well tolerated. ▪ After 2 weeks limit their use to 3 times or less per week to avoid medication

overuse associated headache o ED treatment may include IV fluids, antiemetics and non-steroidal treatments including

ketorolac, and steroids. • If outpatient therapy fails, initiation of intravenous therapy of ketorolac alone, ketorolac

and metoclopramide/prochlorperazine combination, or ondansetron only o There have been no studies exploring these agents for the treatment of acute headache related

to TBIs in the ED (studies have examined their use and efficacy in children presenting with an acute exacerbation of a primary headache only)

Persistent Post-traumatic headaches (> 28 days post injury) • Less frequent presentation. About 1 in 5 children will complain about persistent symptoms. • Management should be targeted to the type of headache and also focused on the needs of the child

o Identification of headache type o Identification of headache triggers o Goals of treatment should include reducing headache frequency, reducing the progression

to chronic daily headaches and lessening associated disabilities o Referral to a headache specialist or pediatrician is often required

Preventative treatments • Useful for children/adolescents with a history of headaches and/or migraine. The main goal is to break

the pain cycle with acute pain medications and provide a referral to a specialist (i.e. pediatric neurologist) for follow-up care.

• Possible medications that could be used include TCAs (amitriptyline and nortriptyline), beta-blockers (propranolol), melatonin and magnesium, antiepileptic (topiramate, valproic acid, gabapentin and zonisamide),

Typical recommendations include practice of good headache hygiene behavior (which is defined as regular bedtimes and waking times with sufficient sleep time), healthy meals, hydration, and the management of stress

Quality of Evidence: Moderate, GRADE B Strength of Recommendation: Weak, GRADE 2 References:

References: 1. Kacperski J, Hung R, Blume H. Pediatric posttraumatic headache. Sem Ped Neuro. 2015. 23(1): 27-34.

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2. Kuczynski A, Crawford S, Bodell L, Dewey D, Barlow K. Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a prospective cohort. Devel Med Child Neuro. 2013. 55(7):636-641.

3. Gelfand AA, Goadsby PJ. A Neurologist’s Guide to Acute Migraine Therapy in the Emergency Room. The Neurohospitalist. 2012;2(2):51-59. doi:10.1177/1941874412439583

4. Blume H. Headaches after Concussion in Pediatrics: A Review. Curr Pain Headache Rep. 2015. 19(9): 1-11. 5. Choe M, Blume H. Pediatric Posttraumatic Headache: A Review. J Child Neurol. 2016. 31(1): 76. 6. Pinchefsky E, Dubrovsky AS, Friedman D, Shevell M. Part I-Evaluation of Pediatric Post-traumatic Headaches.

Pediatr Neurol. 2015. 52(3): 263-269. 7. Pinchefsky E, Dubrovsky A, Friedman D, Shevell M. Part II-Management of Pediatric Post-traumatic

Headaches. Pediatr Neurol. 2015. 52(3): 270-280. 8. Lew H, Lin P, Wang S, Clark D, Walker W. Characteristics and Treatment of Headache after Traumatic Brain

Injury: A Focused Review. Am J Phys Med Rehabil. 2006. 85(7): 619-627.

Clinical Question #3: In pediatric patients diagnosed with concussion, what are the most effective treatments for dizziness/balance disorders? Clinical Recommendation #3: Dizziness is often the second most commonly reported symptom following concussion and has been reported to predict a longer recovery. What children mean by dizziness is variable. For some it may mean light- headedness, nausea, spinning, disequilibrium or even blurred vision. Therefore, it is important to determine what is meant by dizziness and treat as appropriate.

• Light-headedness may respond to increased fluid and salt intake. • Nausea and dizziness may co-occur with migraine like headache. • Balance alterations may occur in a significant number of children, but often will get better without

specific intervention over the first 10 days. • Not all individuals present with a specific type of vestibular disorder. Thus, treatment regimens are

completed using an individualized approach based on persisting impairments.1, 3 The more commonly reported types of vestibular disorders seen following concussion include labyrinthine concussion, central vestibular dysfunction, vestibulo-ocular reflex dysfunction and benign paroxysmal positional vertigo.4

• Vestibular rehabilitation may be of benefit in decreasing symptoms of dizziness and improving function in children and adolescents following concussion.1, 2

• Adolescents and young adults treated with a combination of individualized multimodal physiotherapy (including vestibular rehabilitation and cervical spine treatment) in individuals with persistent symptoms of dizziness, neck pain and/or headaches following concussion were 4 times more likely to be medically cleared to return to sport compared to individuals continuing with a protocol of rest followed by graded exertion.2

• Typical components of vestibular rehabilitation include habituation, adaptation, standing balance, walking and balancing, substitution exercises and canalith repositioning manoeuvers.1, 2, 5

• There is no one recipe for vestibular rehabilitation following concussion and this form of rehabilitation should be performed by physiotherapists or other health care professionals with expertise in this area.

Vestibular rehabilitation has been shown to be safe and effective in multiple populations, including mild traumatic brain injury.5 6

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Quality of Evidence: Moderate/High GRADE A/B (one RCT, other case series) Strength of Recommendation: Moderate/Strong, GRADE 1 References:

1. Alsalaheen B, Mucha A, Morris L, Whitney S, Furman J, Camiolo-Reddy C et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther. 2010. 34:87-93.

2. Schneider K, Meeuwisse W, Nettel-Aguirre A, Boyd L, Barlow K, Emery C. Cervicovestibular physiotherapy in the treatment of individuals with persistent symptoms following sport related concussion: a randomised controlled trial. Br J Sports Med. 2014. 48:1294-1298.

3. Schneider K. Sport-Related Concussion: Optimizing Treatment through Evidence-Informed Practice. J Orthop Sports Phys Ther. 2016. 46:613-616.

4. Ernst A, Basta D, Seidl R, Todt I, Scherer H, Clarke A: Management of posttraumatic vertigo. Otolaryngol Head Neck Surg. 2005. 132:554-558.

5. Hoffer M, Gottshall, K, Moore, R, Balough, B, Westner, D.: Characterizing and treating dizziness after mild head trauma. Otol Neurotol. 2004. 25:135-138.

6. Hillier S, Hollohan, V: Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2007. doi: 17:CD005397.

7. Schneider KJ, Meeuwisse WH, Barlow KM, Emery CA. Cervico-vestibular rehabilitation following sport-related concussion: A follow-up study. (Research letter) BJSM 2017. ePub ahead of print. http://bjsm.bmj.com/content/early/2017/11/09/bjsports-2017-098667.infos

Clinical Question #4: In pediatric patients diagnosed with concussion, what are the most effective treatments for cervical spine involvement and neck pain following concussion? Clinical Recommendation #4:

• Neck pain is a common symptom following concussion. The cervical spine may be injured secondary to trauma and is widely cited as a source of neck pain and headache in the whiplash literature. The upper three cervical segments have been reported as a source of cervicogenic headache. Many of the muscles in the cervical region also refer to the head and may be a cause of headaches and neck pain. 1

• A combination of manual therapy and exercise has been shown to be more effective than passive modalities for individuals with neck pain. A systematic review revealed a moderate benefit from neck strengthening exercise to reduce pain, improve function, and global perceived effect for individuals with mechanical neck disorders. A program incorporating eye/head coordination and proprioceptive training in addition to other exercises has shown moderate efficacy in both the short and long term for individuals with chronic neck pain with and without headache and whiplash associated disorders. A multimodal program, combining exercise with manual therapy, for sub-acute and chronic neck pain with or without headache was found to have strong positive evidence in reducing pain and improving function. 1

• In the area of concussion, limited evidence is available that evaluates isolated cervical spine treatments. However, adolescents and young adults treated with a combination of individualized multimodal physiotherapy (including vestibular rehabilitation and cervical spine treatment) in individuals with persistent symptoms of dizziness, neck pain and/or headaches following concussion were 4 times more likely to be medically cleared to return to sport compared to individuals continuing with a protocol of rest followed by graded exertion. 1

Quality of Evidence: Moderate- GRADE A/B (one RCT, minimal literature directly in this population) Strength of Recommendation: Moderate References:

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1. Schneider K, Leddy J, Guskiewicz K, Seifert T, McCrea M, Silverberg N et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. Published Online First March 24, 2017. doi:10.1136/bjsports-2016-097475

Clinical Question #5: In pediatric patients diagnosed with concussion, what are the most effective treatments for mood symptoms following concussion? Clinical Recommendation #5: Mood changes and anxiety can be common during recovery from a mTBI. Many children worry about failing at school, not being active, or feeling left out. These feelings may make symptoms worse or prolong recovery. Best practice recommendations emphasize the importance of providing social support to improve quality of life and reduce effects of stressors on a child/adolescent s health. Such supports include:

• Emotional guidance (empathy, love, trust, and caring) by caregivers (from parents/guardians, teachers, coaches, friends),

• Informational guidance and appraisal (constructive feedback and positive affirmations), and • Provision of tangible aids/services directly assisting needs of the child/adolescent

o School accommodation letters o Counselling services

Social isolation has been identified as a risk of poor recovery and should be avoided during the recovery process. Hence, up to 3 days post injury the child/adolescent should return to half-days of schooling (ideally the morning half and stay over the lunch hour). They can participate in school work during this time, and interaction with friends and peers should be encouraged. If the child/adolescent is currently seeing a specialist/healthcare provider for mood and anxiety related symptoms pre-injury, encourage a follow-up visit with them to keep the lines of communication open.

Quality of Evidence: Low, GRADE C to Moderate, GRADE B Strength of Recommendation: Strong, GRADE 1 References:

1. Yeates K, Kaizar E, Rusin J, Bangert B, Deitrich A, Nuss K et al. Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury. Arch Pediatr Adolesc Med. 2012. 166(7): 615-622.

2. Kirkwood M, Yeates K, Taylor H, Randolph C, McCrea M, Anderson V. Management of pediatric mild traumatic brain injury: a neuropsychological review from injury through recovery. Clin Neuropsychol. 2008. 22(5): 769-800.

3. Ganesalingam K, Yeates K, Ginn M, et al. Family burden and parental distress following mild traumatic brain injury in children and its relationship to postconcussive symptoms. J Pediatr Psychol. 2008; 33(6): 621-629

4. Gagnon I, Swaine B, Friedman D, Forget R. Exploring children's self-efficacy related to physical activity performance after a mild traumatic brain injury. J Head Trauma Rehabil. 2005. 20(5):436-449.

Clinical Question #6: In pediatric patients diagnosed with concussion, what are the most effective treatments for attention and concentration symptoms following concussion? Clinical Recommendation #6:

Concussion, Pediatric – Emergency V 1 Page 69 of 75

Acute/Sub acute Treatment (< 28 days post injury)

• Supporting the child/adolescent as they return to schooling activities is key. o Families and their children should be encouraged to talk to the school before the child returns. o Return to learn guidelines

o Individualized educational plan (temporary learning accommodations/modifications) should be used, if child is struggling with complaints of attention, memory and learning difficulties, slower response speed and aspects of executive function

o When possible, exemptions can be made so that the student doesn’t have to catch up on all assignments or work missed if necessary but prioritize key areas or projects to work on (such as in- school work and assignments).

• Open communication between children/adolescent and their caregivers (parent, teachers and coaches) is encouraged, as many fear about failure and social alienation.

o Sometime psychological support is necessary aid to help the child make adjustments to the emotional stress that occurs following injury.

o Cognitive reserve is dependent on factors such as: pre-injury academic functioning and intelligence, post-insult cognitive ability, level of education (in adults), socioeconomic status, family functioning, and premorbid learning problems

▪ Pre-injury family psychosocial adversity is associated with increased risk of secondary Attention Deficit Hyperactivity Disorder (ADHD)6

▪ Those with history of ADHD/ existing learning disability (LD)/ etc. ▪ Often symptoms of ADHD and/or LD will increase for a short period of time. We

recommend continuing all treatments and medications when children return to school. We recommend re-contacting your child’s school and physician/psychologist who was helping your child with these difficulties.

Persistent Cognitive Difficulties (Symptoms > 3 months post injury)

• Persistence of neuropsychological impairment (difficulties with attention, memory and learning, response speed and aspects of executive function) after concussion is still debated, while evidence is emerging

• There is little evidence that the disruption in cognitive processes is related to the pathology of concussion injury.

o WHEN cognitive difficulties are suspected, sleep, headaches and mood disturbances should be addressed first, as these can all influence cognitive performance.

o If cognitive difficulties appears related to symptoms, like headache, fatigue, poor sleep – treatment should be directed towards specific complaints

▪ headache reduction, ▪ sleep disturbance – may benefit from corrected sleep hygiene +/- use of temporary

sleep aids (melatonin/ amitriptyline/ short term non-BZD sedatives)

• Recommend a gradual return to activities similar to the ones used during the acute and sub-acute recovery periods

• Neuropsychological/educational psychology evaluations can assist in determining causation and management plans

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Quality of Evidence: Moderate- Grade B Strength of Recommendation: Weak/Insufficient evidence References:

1. Barlow K, Crawford S, Stevenson A, Sandhu S, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatr. 2010. 126(2): e374-e381

2. Blume H, Hawash K. Subacute concussion related symptoms and postconcussion syndrome in pediatrics. Curr Opin Pediatr. 2012. 24:724-730.

3. Gagnon I, Swaine B, Friedman D, Forget R. Exploring children's self-efficacy related to physical activity performance after a mild traumatic brain injury. J Head Trauma Rehabil. 2005. 20(5):436-449.

4. Ryan L, Warden D. Post concussion syndrome. Int Rev Psychiatry. 2003. 15:310-316 5. Anderson V, Eren S, Dob R, Le Brocque R, Iselin G, Davern T et al. Early attention impairment and recovery

profiles after childhood traumatic brain injury. J Head Trauma Rehabil. 2012. 27(3):199-209. 6. Max J, Schachar R, Levin H, Ewing-Cobbs L, Chapman S, Dennis M et al. Predictors of secondary attention-

deficit/hyperactivity disorder in children and adolescents 6 to 24 months after traumatic brain injury. J Am Acad Child Adolesc Psychiatry. 2005. 44:1041–1049.

7. Yeates K, Armstrong K, Janusz J, Taylor H, Wade S, Stancin T et al. Long-term attention problems in children with traumatic brain injury. J Amer Acad Child and Adolesc Psychiatry. 2005. 44:574–584.

8. Wasseman E, Bazarian J, Mapstone M, Block R, van Wijngaarden E. Academic dysfunction after a concussion among US high school and college students. Amer J Public Health. 2016. 106(7):1247-1253

9. Lumba-Brown A, Yeates K, Gioia G, Turner M, Benzel, E., Suskauer S, et al. (2016). Report from the Pediatric Mild Traumatic Brain Injury Guideline Workgroup: Systematic review and clinical recommendations for healthcare providers on the diagnosis and management of mild traumatic brain injury among children. Report to the Board of Scientific Counselors, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA.

Clinical Question #7: In pediatric patients diagnosed with concussion, what are the most effective treatments for exertional symptoms following concussion? Clinical Recommendation #7: In some cases, individuals have ongoing difficulty with increasing activity levels/increased exertion.7 Adolescents performing a moderate level of exercise have been reported to perform better than individuals performing a high or low level of activity.

• Sub-symptom threshold exercise has been suggested as a treatment for individuals with ongoing symptoms and may provide benefit in individuals who are slow to recover (>4 weeks) following a concussion. This exercise has been shown to be safe and may assist with functional recovery in children and youth.

• In an uncontrolled study, children and adolescents performing sub-symptom threshold exercise 5-6 times per week at 55-65% of max heart rate (calculated as 220-age) for up to 15 minutes were reported to return to have functional improvements.

• Evaluation of exertional symptoms may be of benefit and identify individuals who may benefit from sub- symptom threshold training, although the evidence in this area is limited to uncontrolled studies.

Quality of Evidence: Low, GRADE C Strength of Recommendation: Weak, GRADE 2 References:

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1. Schneider K, Iverson G, Emery C, McCrory P, Herring S, Meeuwisse W. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013. 47(5):304–307. doi: 10.1136/bjsports-2013-092190.

2. Leddy J, Baker J, Willer B. Active rehabilitation of concussion and post-concussion syndrome. Phys Med Rehabil Clin N Am. 2016. 27:437–454. doi: dx.doi.org/10.1016/j.pmr.2015.12.003

Clinical Question #8: In pediatric patients diagnosed with concussion, what are the most effective treatments for visual symptoms following concussion? Clinical Recommendation #8: Concussion/mTBI-related visual complaints include blurred/double vision, eye fatigue, the appearance of words moving on the page, loss of place when reading, and difficulty sustaining attention on a visual task.

• Common diagnoses include accommodative disorders, convergence insufficiency, saccadic dysfunction and associated vestibulo-ocular dysfunction (VOD).

• In one study, 69 of 100 adolescents, aged 11-17, had one or more of the above mentioned vision diagnoses1

o Vision diagnoses are associated with poorer verbal memory composite scores, which may reflect the role of the DLPC in both working memory and oculomotor function1

• Identification of visual problems is important because approximately 50% of the brain’s circuits are dedicated to vision5. As well as the visual demands of children/adolescents engaged in full-time school (due to widespread use of electronic interfaces)1.

• Screening tools and diagnostic tests: o Convergence Insufficiency Symptom Survey (CISS)1, King-Devick Test5, Eye movement tracking

4, Vestibular/Ocular Motor Screening (VOMS)6

• Treatments: o Specific school-based accommodations – frequent visual breaks, oral teaching, audio-books,

large- font printed material (vs. small font electronically displayed material), or preprinted notes1

o Accommodative complaints – spectacle correction for near-sighted, oculomotor training (short-term) o Convergence insufficiency – base in prism, near convergence exercises with in-office/home

based programs, oculomotor training • Often a referral to a concussion specialist or eye-care professional is needed for a comprehensive

visual and oculomotor evaluation beyond visual acuity testing, and for possible treatment of accommodation, binocular vision, and eye movements.

**Pediatric patients with acute sports-related concussion who met the clinical criteria for VOD at initial clinical consultation (approx. 7 days post injury) had 4 times the odds of developing PCS.6 However, further studies are need to confirm the prevalence of VOD among boarder pediatric sports-related concussion populations.

Quality of Evidence: Low, GRADE C Strength of Recommendation: Weak, GRADE 2 References:

1. Master C, Scheiman M, Gallaway M, Goodman A, Robinson R, Master S et al. Vision Diagnoses Are Common

After Concussion in Adolescents. Clinical Pediatr. 2016. 55(3): 260. 2. Ventura R, Jancuska J, Balcer L, Galetta SLl. Diagnostic Tests for Concussion: Is Vision Part of the Puzzle? J

Neuro-Ophthal. 2015. 35(1): 73-81. 3. Heinmiller L, Gunton K. A Review of the Current Practice in Diagnosis and Management of Visual Complaints

Associated with Concussion and Postconcussion Syndrome."Curr Opin Ophthalm. 2016. 27(5): 407-412.

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4. Samadani U, Ritlop R, Reyes M, Nehrbass E, Li M, Lamm E et al. Eye tracking detects disconjugate eye movements associated with structural traumatic brain injury and concussion. J Neurotrauma. 2015. 32:548-556.

5. Galetta K, Morganroth H, Moeringer N, Mueller B, Hasanaj L, Webb N et al. Adding Vision to Concussion Testing: A Prospective Study of Sideline Testing in Youth and Collegiate Athletes. J Neuro-Ophthalmol. 2015. 35:235-241

6. Ellis M et al. Vestibulo-ocular dysfunction in pediatric sports-related concussion. J Neurosurg Pediatr. 2015. 16:248-255

Clinical Question #9: In pediatric patients diagnosed with concussion, what are the most effective treatments for associated endocrinopathies following concussion? Clinical Recommendation #9: Significant injury to the hypothalamic-pituitary axis may complicate medical management, but evidence is limited for acute management of mTBI/concussions. Thus there is no need for blood work or neuroimaging to screen for endocrine-related disorders within the first 4 weeks after injury.

• Clinical evaluation with the primary healthcare provider is recommended one-year post injury if the child/adolescent reports fatigue, cold intolerance, poor growth, altered puberty, mood disturbances or altered appetite control. o Clinical investigations and screening for growth hormone deficiency, gonadotropin deficiency, precocious

puberty, ACTH deficiency, central hypothyroidism, hyperprolactinemia, and diabetes insipidus are then warranted.

Current recommendations for screening in the ED, are intended for all patients after moderate or severe traumatic brain injury.

Quality of Evidence: Low, GRADE C Strength of Recommendation: Weak, GRADE 2 References:

1. Rose S, Aubble B. Endocrine changes after pediatric traumatic brain injury. Pituitary. 2012. 15:267-275 2. Masel BE., Urban R. Chronic endocrinopathies in traumatic brain injury disease. J Neurotrauma. 2015.

32:1902-1910 3. Kaulfers A, Backeljauw P, Reifschneider K, Blum S, Michaud L, Weiss M et al. Endocrine dysfunction following

traumatic brain injury in children. J Pediatr. 2010. 157(6): 894-599.

Clinical Question #10: In pediatric patients diagnosed with concussion, what are the most effective treatments for tinnitus following concussion? Clinical Recommendation #10:

• Tinnitus (ringing in the ears) is not commonly seen in an acute/urgent care setting for pediatrics. Rarely present in cases of blast, MVA, fall or assault related injuries.

• Persistent tinnitus may be due to injury (disruption or overrepresentation of signals) of the auditory-thalamic-limbic pathway, however this is not commonly seen in pediatric population.

Nonpharmacological treatments being examined are cognitive-behavioral therapy, tinnitus retraining therapy, phase-out sound cancellation treatment, and low-level laser therapy. Other possible treatment options include antiepileptic medication (i.e. diazepam – which affects GABA transmission within the pathway) or surgical cochlear implant. However, trials are needed to confirm their efficacy

Concussion, Pediatric – Emergency V 1 Page 73 of 75

Quality of Evidence: Low, Grade C Strength of Recommendation: Weak/Insufficient evidence References:

1. Fioretti A, Eibenstein A, Fusetti M. New trends in tinnitus management. Open Neurol J. 2011. 5:12-17.

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Acknowledgements We would like to acknowledge the contributions of the Provincial Clinical Knowledge Working Group members as follows. Your participation and time spent is appreciated.

Pediatric Concussion Knowledge Topic Working Group Membership Name Title Zone Knowledge Lead Katharine Smart Emergency Pediatrics Knowledge Lead Provincial Troy Turner Emergency Pediatrics Knowledge Lead Provincial Topic Lead Tina Samuel Physician Research Associate, Pediatric

Neurology Provincial

Working Group Members

Alf Conradi Child and Youth Standing Committee Chair Physician, Pediatric Intensive Care Specialist

Provincial

Angelo Mikrogianakis Physician, Pediatric Emergency Medicine Calgary Bruce Wright Physician, Pediatric Emergency Medicine Edmonton Brenda Clark Physician, Pediatrics Edmonton

Codi Isaac Physiotherapist, Cervical and Vestibular Rehabilitation

Edmonton

Karen Barlow Physician, Pediatric Neurology Calgary Kate Randall Neuropsychologist, Pediatrics Edmonton

Kathryn Schneider Physiotherapist, Cervical and Vestibular Rehabilitation

Calgary

Keith Yeates Neuropsychologist, Pediatrics Calgary Lawrence Richer / Thilinie Rajapakse

Physician, Pediatric Neurology Edmonton

Clinical Support Services Marcel Romanick Pharmacy Information Management Governance

Committee (PIM-GC) on behalf of Pharmacy Services

Provincial

James Wesenberg on behalf of Laboratory Services - Provincial Networks

Provincial

Bernice Lau on behalf of Diagnostic Imaging Services Provincial Carlota Basualdo-Hammond & Kim Brunet Wood

on behalf of Nutrition & Food Services Provincial

Strategic Clinical Networks Maternal Newborn Child and Youth Strategic Clinical Network Child and Youth Standing Committee and Core Committee

Provincial

Emergency Strategic Clinical Network Core Committee Provincial Clinical Informatics Lead Megan Courtney Registered Nurse Provincial Lorna Spitzke Registered Nurse Karin Domier Registered Nurse

Concussion, Pediatric – Emergency V 1 Page 75 of 75

Additional Contributors

Thank you to all clinicians who participated in the colleague review process. Your time spent reviewing the knowledge topics and providing valuable feedback is appreciated.