What is the appropriate workup for a pediatric patient with a head concussion (cerebral concussion)?

From the Guidelines

The workup for a child with a suspected concussion involves a comprehensive assessment, including a detailed history, thorough neurological examination, and use of the Glasgow Coma Scale, with neuroimaging considered for severe cases, as recommended by the most recent guidelines 1. The assessment should include evaluating the severity of the injury, mechanism of injury, loss of consciousness, amnesia, seizures, vomiting, and changes in behavior or mental status.

• A thorough neurological examination should be performed, assessing:
  • Pupillary response
  • Cranial nerves
  • Motor strength
  • Sensation
  • Coordination
  • Balance
• The Glasgow Coma Scale (GCS) should be used to evaluate consciousness level, with scores below 15 warranting closer monitoring.
• Neuroimaging, typically a CT scan, is not routinely needed for mild concussions but should be considered for children with severe headache, repeated vomiting, seizures, focal neurological deficits, loss of consciousness lasting more than 30 seconds, or worsening symptoms, as outlined in the American College of Radiology Appropriateness Criteria 1.
• Observation for 24-48 hours is crucial, monitoring for red flags like persistent vomiting, severe headache, confusion, or unusual drowsiness.
• Rest is the mainstay of treatment, with gradual return to cognitive and physical activities, as recommended by the Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children 1.
• Acetaminophen can be used for headache management (10-15 mg/kg every 4-6 hours, not exceeding 5 doses in 24 hours), but NSAIDs should be avoided initially due to bleeding risk.
• Follow-up evaluation is important to monitor recovery, with most children improving within 7-10 days, though some symptoms may persist longer, as noted in the American Academy of Pediatrics clinical report on sport-related concussion in children and adolescents 1.

From the Research

Diagnostic Approach

The appropriate workup for a pediatric patient with a head concussion (cerebral concussion) involves a comprehensive evaluation, including:

• A concussion-specific physical examination 2
• Use of a standardized symptom scale to identify and assess symptoms 2, 3
• Evaluation of cognitive functions and assessment of dynamic cognitive exertional effects 4
• Post-concussion symptom assessment involving the child and parent 4

Key Considerations

When evaluating pediatric patients with concussion, it is essential to consider:

• The presence of altered mental status, which can magnify the effect of symptoms 3
• The potential for delayed diagnosis, which can lead to persistent symptoms and longer recovery times 2
• The importance of individualized, moderated concussion rehabilitation management, including a 10-step guide to symptom management 4

Management Strategies

Effective management of pediatric concussion requires:

• A multimodal, developmentally adapted approach 4
• Active rehabilitation and symptom management 4
• Consideration of school challenges faced by the recovering student 4
• Medical clearance by a licensed health care provider before returning to sport 5