What is the assessment and management of a possible concussion in a 12-year-old patient?

From the Guidelines

A 12-year-old with a possible concussion should be immediately removed from activity and evaluated by a healthcare provider, with emergency department or urgent care visit if they experienced loss of consciousness, persistent vomiting, severe headache, seizures, difficulty walking, confusion, or unusual behavior. While awaiting medical care, the child should rest both physically and cognitively, and monitoring for worsening symptoms is crucial, with no sedating medications administered 1. The healthcare provider's guidance on gradual return to activities should be followed, which typically involves a stepwise approach over 1-2 weeks, with the child avoiding screens, reading, and mental exertion initially, then gradually resuming normal activities as symptoms improve 1. Physical activity should only resume after being symptom-free at rest, starting with light aerobic exercise and progressing to full participation, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. This cautious approach is necessary because a developing brain is more vulnerable to concussion effects, and a second injury before full recovery can lead to prolonged symptoms or rare but serious complications like second impact syndrome.

Key considerations in the assessment and management of a possible concussion in a 12-year-old patient include:

• Immediate removal from activity and evaluation by a healthcare provider
• Monitoring for worsening symptoms and no administration of sedating medications
• Gradual return to activities, with a stepwise approach over 1-2 weeks
• Avoidance of screens, reading, and mental exertion initially, with gradual resumption of normal activities as symptoms improve
• Resumption of physical activity only after being symptom-free at rest, starting with light aerobic exercise and progressing to full participation

The Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children also emphasizes the importance of evidence-based recommendations for healthcare professionals, with a focus on improving the health and safety of this vulnerable population 1. However, the most recent and highest-quality study, the 2024 American Heart Association and American Red Cross guidelines for first aid, should be prioritized in guiding the assessment and management of a possible concussion in a 12-year-old patient 1.

From the Research

Assessment of Concussion

• The assessment of a possible concussion in a 12-year-old patient involves identifying the key features of diagnosis and using postinjury assessment tools 2.
• Clinicians should be aware of the symptoms that may prompt head imaging in the emergency department, such as focal neurological deficit, altered mental status, and intractable vomiting 3.
• A thorough evaluation of the patient's symptoms, medical history, and physical condition is necessary to determine the appropriate course of management.

Management of Concussion

• The management of concussion includes rapid removal from play, symptomatic treatment, and return to learn/play recommendations 2.
• Physical and cognitive rest alone may be sufficient for most patients with sport-related concussions, but some patients may require more involved therapy, such as additional education, academic accommodations, physical therapy, cognitive rehabilitation, and medication 4.
• Exercise has been recommended as an appropriate therapy for adolescents with acute concussion/mTBI, while strict rest and high-intensity physical activity may have detrimental effects 5.
• Medications such as acetaminophen and nonsteroidal anti-inflammatory medications may be used to manage symptoms, and patients may be referred to a sports concussion clinic or a neuropsychologist for further evaluation and treatment 3.

Return to Activity

• Return to learn/play recommendations should be based on the patient's individual needs and symptoms, and clinicians should be aware of the potential risks of recurrent concussions and prolonged recovery 2.
• A gradual return to activity protocol may be necessary to prevent exacerbation of symptoms and ensure a safe return to play 5.
• Clinicians should provide patients and their families with clear instructions and guidelines for return to activity, including follow-up appointments and monitoring for any changes in symptoms 3.

Special Considerations for Pediatric Patients

• Pediatric patients with concussion may present with distinct characteristics and symptoms, such as visio-vestibular abnormalities and changes to sleep and daily habits 6.
• Clinicians should be aware of the potential for less supervision at the time of injury and less direct access to established concussion healthcare following injury in pediatric patients with recreation-related concussion (RRC) and non-sport or recreation-related concussion (non-SRRC) 6.
• A multidisciplinary approach to management, including collaboration with specialists such as neuropsychologists and physical therapists, may be necessary to ensure optimal care for pediatric patients with concussion 3, 5.