Dr. Roger Zemek, MD, is a Pediatric Emergency Physician practicing at the Children’s Hospital of Ontario (CHEO) and a Scientist in the CHEO Research Institute in Ottawa, Ontario, Canada. He’s a Professor in the Departments of Pediatrics and Emergency Medicine and holds a Clinical Research Chair in Pediatric Concussion at the University of Ottawa. He is the Director of Clinical Research at CHEO, and is the Vice-Chair of the Pediatric Emergency Research Canada (PERC) network. He completed his undergraduate studies in Applied Mathematics at Yale University, and his medical school and pediatric residency at Columbia University in New York City, before moving to Canada for his Pediatric Emergency Medicine fellowship training at McGill. He is the principal investigator on multiple federal peer-reviewed grants, with expertise in pediatric concussion. He led the largest concussion study in the world to date examining the predictors for Persistent Post-Concussion Symptoms in children suffering a concussion, and led an international team for the development of guidelines for the management of pediatric concussion.

The guidelines for how we diagnose concussions have shifted and evolved over the years – you no longer need to have had an LOC or amnesia to the event to meet the diagnosis.

In general, kids get more concussions than adults. Boys get more (60-65%) concussions than girls, but girls have symptoms that last longer. In kids, most of the mechanism is due to sports (2/3), around ¼ are falls, and the rest are “other reasons”. In adults, it’s less likely in sports, and more likely due to falls and MVCs.

Amongst sports collision and contact sports have the highest risk: rugby, ice hockey, football, and soccer, but there are regional differences as well across Canada (one of the top 5 reasons for concussion in Alberta is Equestrian related).

Concussion is defined as a traumatic brain injury, induced by biomechanical forces, that are either direct or indirect to the brain

• The brain has to accelerate and/or decelerate
• Rotational forces usually cause more of an injury than directional contact
• DOES NOT have to be a direct hit to the head
  • Body’s moving one way, and collides with another object, leading to the brain shaking, which causes the concussion
• Has to involve the brain & involve symptoms related to brain function (i.e. not just headache 

Concussion = mTBI (mild traumatic brain injury), but mTBI ≠ concussion 

On a standard concussion, on routine neuroimaging (CT or MRI), you’d expect to see a normal brain. We would not expect to see any changes with concussion. 

Signs/Symptoms of concussions are all self reported, but cross 4 main domains:  

1) Physical – headache, nausea / vomiting, dizziness, balance problems, “pressure in head”, blurred vision, sensitivity to light and/or noise, neck pain and balance / gait disturbances 

2) Cognitive – answering questions slowly, problems concentration, not feeling slowed down, confused / disorientation, fatigue or low energy, “don’t feel right”, poor memory. 

3) Emotional – sad, anxious, problems with personality, more irritable, nervousness 

4) Sleep 

Red flag Symptoms – Mechanism of injury, decreased LOC, pupillary changes, neck pain or tenderness, double vision, weakness / tingling in extremities, sever or increasing headache, seizure, LOC, vomiting, agitation / combative. 

Differential Diagnosis

• Rule out bleed 
• Since concussion is a clinical diagnosis, and generally based on self-report data, what was the temporal relationship between injury and onset of symptoms
  • Person that has symptoms very quickly after the injury, is much more likely to have a probable / definite concussion vs days before their 1st sign or symptom. 
• In the acute phase, the symptoms shouldn’t be explained by anything else (e.g. alcohol or drug use, post-ictal, hypoglycaemic etc.) 

Who should go to the hospital? 

At the end of the day, the child needs to be assessed. Do they need to come to ED by EMS, or is this something where the child needs to be removed from the game (which is always the case) – “If in doubt, sit out”. It’s not an option to continue to play. Thus, we have 3 options:

• We got to the ED right now, with EMS
• If child is feeling better and family is refusing, go to regular MD (the same or next day)
• The parents will watch, and if the child get’s worse they’ll either take them to the ED or call us back

It is now law in Ontario (Rowan’s Law) that someone who suffered a concussion in the sports or school setting NEEDs to be assessed by a MD, and before they return to full contact, they need medical clearance.

Assessment:

• Rule out major life threats and c-spine concerns
• GCS
• Concussion Recognition Tool (CRT) 5
  • https://resources.fifa.com/image/upload/concussion-recognition-tool-5.pdf?cloudid=y9y5fpwji70rtzyefdoa
• www.braininjuryguidlines.org
• Don’t use the SCAT 5 – Too comprehensive, thorough, in-depth, and time consuming

Predicting and Preventing Post-concussive Problems in Pediatrics (5P) Study

Zemek R, Barrowman N, Freedman SB, et al; for the Pediatric Emergency Research Canada (PERC) Concussion Team. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. Jama 2016;315:1014–25

• 9 centres across Canada, enrolled <3hrs post injury
• 3000 kids were enrolled
• What were the factors with concussion symptoms that lasted longer than 1 month?
  • Needed to have 3 or more worsening symptoms from their pre-injury baseline
• There were 9 characteristics, across 5 categories, the predicted persistent post-concussive problems lasting longer than 1 month

1. Demographics
   • Older kids are at higher risk of recovery, more slowly, than younger
   • Mostly due to physics. A 5 y/o’s brain is not moving as quickly as the 6 foot 15 year old playing hockey at a much higher speed & risk.
   • Teenagers also complain of their symptoms more than a 5 year old
2. Sex – girls are at higher risk than boys
   • In general, girls necks are longer and thinner, leading to more “whiplash” motion.
   • Hormonal differences in how the brain recovers in injury. Estrogen & progesterone in girls, testosterone in boys, but the exact mechanism is still unknown
   • Girls are more aware of their symptoms
   • Boys generally lie more – say they’re feeling better so that they can go back to playing.
3. Past History
   • Any hx of migraines
   • How long they took to recover from a previous concussion
   • Those who have had a previous concussion, and symptoms lasted >1 week, are at higher risk
4. Cognition
   • Answers questions more slowly
   • Child may not know, but their guardian (or coach) would be able to answer that for us
5. Physical Exam
   • Tandem Stance
   • Ability to stand with feet in front of each other, with eyes closed, and hands on hips. Counted for 15 seconds, and the amount of errors are calculated.
6. Physical Symptoms
   • Headache
   • Sensitivity to noise
   • Fatigue

ED Treatment

In ED, <5% of kids get neuroimaging for concussion

Generally, apply a clinical decision rule (PECARN or CATCH) to determine who needs a scan

Lots of coaching and education to parents with discharge instructions

• Return to activities (cognitive & physical)
  • Cognitive
    • Need 1-2 days off from school, but then back to what you can tolerate (step wise, incremental increases on cognitive load)
      • Rowan’s Law states that schools must comply with the provincial rules and must accommodate
    • Return to physical activity:
      • Goldilocks analogy
        • Getting back into play the same day, is wrong and dangerous
        • It’s now a graded return to play (no set time, it’s individualized)
          • Those who participate in some physical activity do better
            • Low risk: Walk, treadmill, jog, bike ride à as tolerated
            • But NOT higher risk activities that can cause another concussion – MUST HAVE MEDICAL CLEARANCE

Do I need to wake up my child q 2 hrs?

No. If there was a worry about something bad, these kids would be admitted to hospital. There is no evidence to say these kids needs to be woken up in the middle of the night. This was for the kids before CT scans, where we didn’t want to miss a bleed. If there’s a worry based on symptom burden or red flags, these kids will get a CT.

Sleep is very important.

Other Resources

• www.braininjuryguidelines.org
• Parachute
  • www.parachute.ca/en/injury-topic/concussion/
• Concussion Awareness Training Tool (CATT)
  • www.catonline.com
• Massive Open Online Course (MOOC)
  • https://www.ulaval.ca/en/academics/mooc-massive-open-online-course/concussion-prevention-detection-and-management.html