- Email: [email protected]
Shake, Rattle, and Roll: The Impact of Undiagnosed Concussions in Pediatrics
PEDIATRIC UPDATE
SHAKE, RATTLE, AND ROLL: THE IMPACT OF UNDIAGNOSED CONCUSSIONS IN PEDIATRICS Author: Michelle Tracy, RN, MA, CEN, Greenbae, CA Section Editors: Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P, Michelle Tracy, RN, MA, CEN, CPN, and Sue M. Cadwell, RN, MSN
Earn Up to 10.5 CE Hours. See page 596.
A
concussion conjures up the image of someone who has had head trauma severe enough to cause loss of consciousness and evaluation in an emergency department but who has no injury seen on a computed tomography scan of the brain. Conversely, a concussion, which is a temporary loss of brain function, can happen with any type of head trauma, without any lapse in consciousness. These head injuries occur in a variety of situations including falls (even those occurring as toddlers learn to walk), impact sustained during sporting events, and impact occurring as infants’ heads come in contact with the sides of their cribs during sleep activities or while rocking themselves to sleep. As a result of the seriousness of the long-term effects of concussions, there has been a momentum in safety awareness for the prevention of head injuries and education on how to recognize head injury symptoms. On September 18, 2004, Jake Snakenberg, aged 15 years, died from second-impact syndrome (SIS) in Colorado during a football game. SIS is a condition in which the brain swells rapidly and catastrophically after a person suffers a second concussion before symptoms from an earlier one have subsided. This deadly second blow may occur days, weeks, or minutes after an initial concussion, and even the mildest grade of concussion can lead to SIS. Jake had had a “blow” a week prior, but there seemed to be no injury, except for tingling in the hands. Jake and his parents did not seek out a medical evaluation, and his coach put him in the next game. As a linebacker, Jake suffered a fatal head injury caused by a tackle and the resulting force to the head. His already swollen brain could not tolerate the impact, and he died.1 A concussion is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechaniMichelle Tracy, Member, San Francisco Chapter, is Director of Emergency Services, Marin General Hospital, Greenbrae, CA. For correspondence, write: Michelle Tracy, RN, MA, CEN, 89 Mariner Green Dr, Corte Madera, CA 94925; E-mail: [email protected]. J Emerg Nurs 2012;38:580-1. Available online 29 September 2012. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.08.004
580
JOURNAL OF EMERGENCY NURSING
cal forces. A concussion may be caused by a direct blow to either the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to the head. It typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. A concussion may result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness.2 Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged.3 The Brain Injury Association of America states that “brain injury is not an event or an outcome. It is the start of a misdiagnosed, misunderstood, under-funded neurological disease.”4 Almost half a million (473,947) ED visits for traumatic brain injury are made annually by children aged 0 to 14 years.5 However, this statistic does not speak to the number of children who are not evaluated by a medical provider after having had head trauma, nor does it represent the thousands of concussions that are misdiagnosed in our emergency departments annually. Head trauma that occurs without appropriate medical assessment can result in undiagnosed concussions. The longterm effects of undiagnosed concussions can be serious. According to The Franklin Institute Online (Protect – Watch Your Head), the frontal lobe is affected 70% of the time in childhood injuries.6 The executive functions of the frontal lobe involve the ability to recognize future consequences resulting from current actions, to choose between good and bad actions (or better and best), to override and suppress unacceptable social responses, and to determine similarities and differences between things or events. In other words, the frontal lobe is involved in higher mental functions. The frontal lobe also plays an important part in retaining longer-term memories, which are not task based. These are often memories associated with emotions derived from input from the brain’s limbic system. The frontal lobe modifies those emotions to generally fit socially acceptable norms.3 Postconcussive syndrome is a series of symptoms that may persist for weeks or months after an injury occurs. The symptoms, though not severe, impede the normal activity of the child. These symptoms include vision problems, headaches, fatigue,
VOLUME 38 • ISSUE 6 November 2012
Tracy/PEDIATRIC UPDATE
insomnia, irritability, intolerance of loud environments, emotional labiality, and difficulty concentrating. Children with frontal lobe injuries have long-term effects that can include the inability to control emotions and behavior. Their long-term memory may be impaired, whereas their short-term memory stays intact. They may have a normal IQ but still have difficulty with learning. Concussions became a focus in Colorado as the death of Jake Snakenberg spurred an awareness of the danger of head trauma and the need for early symptom recognition. The REAP Project, which stands for reduce, educate, accommodate, and pace, is a community-based model for concussion management that was developed in Colorado. The origin of REAP stems from a groundbreaking study that was funded by the Centers for Disease Control and Prevention in 2004. In a typical high school in Colorado, researchers observed 92 children who had concussions over a 3-year period. These students taught many valuable lessons to the researchers on the management of concussions. The Colorado Centers for Disease Control and Prevention study highlighted that good concussion management is not dependent on any one neurocognitive test or intervention but instead depends on education and collaboration. The REAP Project is based on the premise that concussion is best managed by a multidisciplinary team that is made up of the following members: the student/athlete, the family, the school team, and the medical team. The approach is to educate all of the members and then to manage the student’s/athlete’s school load and outside activities and to focus on reduce and rest. Within 1 year, 2009-2010, REAP received 156 referrals.7 On March 29, 2011, the Governor of Colorado, John Hickenlooper, signed Senate Bill 11-040, also known as the “Jake Snakenberg Youth Concussion Act” into legislation. This act, which went into effect on January 1, 2012, has the following provisions:
• Every middle school, high school, recreation district, and club coach shall take annual training in concussion recognition, which can be taken online. • Youths suspected of having had concussions are to be removed immediately from games and practices and parents notified. • Athletes cannot be returned to play until cleared by a physician, osteopath, nurse practitioner, physician assistant, or psychologist with special training. Specially trained chiropractors can clear athletes who are part of the US Olympic training program. • Athletic trainers are allowed to supervise an athlete’s return to play after medical clearance.8 A critical way to assess these brain functions before and after an injury, and so a critical way both to diagnose a concussion and to monitor recovery from it, is the ImPACT (Immediate Postconcussion Assessment and Cognitive Testing) test (ImPACT
November 2012 VOLUME 38 • ISSUE 6
Applications, Pittsburgh, PA). ImPACT can be given to children aged 10 years or older. It measures attention span, reaction time, visual memory and verbal memory, working memory, response variability, sustained attention and selective attention, and nonverbal problem solving. If a child has a head injury, the ImPACT test can determine whether a concussion occurred and, if so, the relative severity of the concussion and the focus of any therapy to help recover from the concussion.9 The insurmountable task of understanding the brain and its functions and abilities seems to become clearer as research is conducted into the phenomenon of concussions. With the knowledge base, public awareness, funding, and continued efforts to promote safety and prevention, this neurologic disease will decrease in number and severity. REFERENCES 1. Signs weren’t obvious in concussion death of Jake Snakenberg. The Denver Post. Available at: http://www.denverpost.com/preps/ci_16358037. Published 2010. Accessed July 4, 2012. 2. Sports Concussion Center of Colorado. Concussion information. Available at: http://sportsccc.com/concussinfo.html. Accessed July 8, 2012. 3. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med. 2009;19(3):185-200. 4. Brain Injury Association of America. Welcome to the Brain Injury Association of America. Available at: http://www.biausa.org. Accessed July 8, 2012. 5. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. 6. Nnama H. The long-term effects of childhood brain injuries. Available at: http://www.livestrong.com/article/188828-the-long-term-effects-of-childhood-brain-injuries. Published July 29, 2010. Accessed July 3, 2012. 7. Rocky Mountain Youth Sports Medicine Institute, Center for Concussion. REAP the benefits of good concussion management. Available at: http://issuu.com/healthone/docs/reap_sept_2010?mode=embed&layout=http%3A%2F%2Fskin.issuu.com%2Fv%2Flight%2Flayout. xml&showFlipBtn=true. Accessed July 8, 2012. 8. State of Colorado Senate Bill 11-040. Available at: http://www.cde.state. co.us/HealthAndWellness/download/Brain%20Injury/SB11-040.pdf. Accessed July 2, 2012. 9. Gillette Children’s Specialty Healthcare. Importance of ImPACT. Available at: http://www.gillettechildrens.org/default.cfm?PID=1.17.4.2.1.2. Accessed July 8, 2012.
Submissions to this column are encouraged and may be sent to Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P [email protected] or Michelle Tracy, RN, MA, CEN, CPN [email protected] or Sue M. Cadwell, RN, MSN [email protected]
WWW.JENONLINE.ORG
581
SHAKE, RATTLE, AND ROLL: THE IMPACT OF UNDIAGNOSED CONCUSSIONS IN PEDIATRICS Author: Michelle Tracy, RN, MA, CEN, Greenbae, CA Section Editors: Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P, Michelle Tracy, RN, MA, CEN, CPN, and Sue M. Cadwell, RN, MSN
Earn Up to 10.5 CE Hours. See page 596.
A
concussion conjures up the image of someone who has had head trauma severe enough to cause loss of consciousness and evaluation in an emergency department but who has no injury seen on a computed tomography scan of the brain. Conversely, a concussion, which is a temporary loss of brain function, can happen with any type of head trauma, without any lapse in consciousness. These head injuries occur in a variety of situations including falls (even those occurring as toddlers learn to walk), impact sustained during sporting events, and impact occurring as infants’ heads come in contact with the sides of their cribs during sleep activities or while rocking themselves to sleep. As a result of the seriousness of the long-term effects of concussions, there has been a momentum in safety awareness for the prevention of head injuries and education on how to recognize head injury symptoms. On September 18, 2004, Jake Snakenberg, aged 15 years, died from second-impact syndrome (SIS) in Colorado during a football game. SIS is a condition in which the brain swells rapidly and catastrophically after a person suffers a second concussion before symptoms from an earlier one have subsided. This deadly second blow may occur days, weeks, or minutes after an initial concussion, and even the mildest grade of concussion can lead to SIS. Jake had had a “blow” a week prior, but there seemed to be no injury, except for tingling in the hands. Jake and his parents did not seek out a medical evaluation, and his coach put him in the next game. As a linebacker, Jake suffered a fatal head injury caused by a tackle and the resulting force to the head. His already swollen brain could not tolerate the impact, and he died.1 A concussion is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechaniMichelle Tracy, Member, San Francisco Chapter, is Director of Emergency Services, Marin General Hospital, Greenbrae, CA. For correspondence, write: Michelle Tracy, RN, MA, CEN, 89 Mariner Green Dr, Corte Madera, CA 94925; E-mail: [email protected]. J Emerg Nurs 2012;38:580-1. Available online 29 September 2012. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.08.004
580
JOURNAL OF EMERGENCY NURSING
cal forces. A concussion may be caused by a direct blow to either the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to the head. It typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. A concussion may result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness.2 Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged.3 The Brain Injury Association of America states that “brain injury is not an event or an outcome. It is the start of a misdiagnosed, misunderstood, under-funded neurological disease.”4 Almost half a million (473,947) ED visits for traumatic brain injury are made annually by children aged 0 to 14 years.5 However, this statistic does not speak to the number of children who are not evaluated by a medical provider after having had head trauma, nor does it represent the thousands of concussions that are misdiagnosed in our emergency departments annually. Head trauma that occurs without appropriate medical assessment can result in undiagnosed concussions. The longterm effects of undiagnosed concussions can be serious. According to The Franklin Institute Online (Protect – Watch Your Head), the frontal lobe is affected 70% of the time in childhood injuries.6 The executive functions of the frontal lobe involve the ability to recognize future consequences resulting from current actions, to choose between good and bad actions (or better and best), to override and suppress unacceptable social responses, and to determine similarities and differences between things or events. In other words, the frontal lobe is involved in higher mental functions. The frontal lobe also plays an important part in retaining longer-term memories, which are not task based. These are often memories associated with emotions derived from input from the brain’s limbic system. The frontal lobe modifies those emotions to generally fit socially acceptable norms.3 Postconcussive syndrome is a series of symptoms that may persist for weeks or months after an injury occurs. The symptoms, though not severe, impede the normal activity of the child. These symptoms include vision problems, headaches, fatigue,
VOLUME 38 • ISSUE 6 November 2012
Tracy/PEDIATRIC UPDATE
insomnia, irritability, intolerance of loud environments, emotional labiality, and difficulty concentrating. Children with frontal lobe injuries have long-term effects that can include the inability to control emotions and behavior. Their long-term memory may be impaired, whereas their short-term memory stays intact. They may have a normal IQ but still have difficulty with learning. Concussions became a focus in Colorado as the death of Jake Snakenberg spurred an awareness of the danger of head trauma and the need for early symptom recognition. The REAP Project, which stands for reduce, educate, accommodate, and pace, is a community-based model for concussion management that was developed in Colorado. The origin of REAP stems from a groundbreaking study that was funded by the Centers for Disease Control and Prevention in 2004. In a typical high school in Colorado, researchers observed 92 children who had concussions over a 3-year period. These students taught many valuable lessons to the researchers on the management of concussions. The Colorado Centers for Disease Control and Prevention study highlighted that good concussion management is not dependent on any one neurocognitive test or intervention but instead depends on education and collaboration. The REAP Project is based on the premise that concussion is best managed by a multidisciplinary team that is made up of the following members: the student/athlete, the family, the school team, and the medical team. The approach is to educate all of the members and then to manage the student’s/athlete’s school load and outside activities and to focus on reduce and rest. Within 1 year, 2009-2010, REAP received 156 referrals.7 On March 29, 2011, the Governor of Colorado, John Hickenlooper, signed Senate Bill 11-040, also known as the “Jake Snakenberg Youth Concussion Act” into legislation. This act, which went into effect on January 1, 2012, has the following provisions:
• Every middle school, high school, recreation district, and club coach shall take annual training in concussion recognition, which can be taken online. • Youths suspected of having had concussions are to be removed immediately from games and practices and parents notified. • Athletes cannot be returned to play until cleared by a physician, osteopath, nurse practitioner, physician assistant, or psychologist with special training. Specially trained chiropractors can clear athletes who are part of the US Olympic training program. • Athletic trainers are allowed to supervise an athlete’s return to play after medical clearance.8 A critical way to assess these brain functions before and after an injury, and so a critical way both to diagnose a concussion and to monitor recovery from it, is the ImPACT (Immediate Postconcussion Assessment and Cognitive Testing) test (ImPACT
November 2012 VOLUME 38 • ISSUE 6
Applications, Pittsburgh, PA). ImPACT can be given to children aged 10 years or older. It measures attention span, reaction time, visual memory and verbal memory, working memory, response variability, sustained attention and selective attention, and nonverbal problem solving. If a child has a head injury, the ImPACT test can determine whether a concussion occurred and, if so, the relative severity of the concussion and the focus of any therapy to help recover from the concussion.9 The insurmountable task of understanding the brain and its functions and abilities seems to become clearer as research is conducted into the phenomenon of concussions. With the knowledge base, public awareness, funding, and continued efforts to promote safety and prevention, this neurologic disease will decrease in number and severity. REFERENCES 1. Signs weren’t obvious in concussion death of Jake Snakenberg. The Denver Post. Available at: http://www.denverpost.com/preps/ci_16358037. Published 2010. Accessed July 4, 2012. 2. Sports Concussion Center of Colorado. Concussion information. Available at: http://sportsccc.com/concussinfo.html. Accessed July 8, 2012. 3. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med. 2009;19(3):185-200. 4. Brain Injury Association of America. Welcome to the Brain Injury Association of America. Available at: http://www.biausa.org. Accessed July 8, 2012. 5. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. 6. Nnama H. The long-term effects of childhood brain injuries. Available at: http://www.livestrong.com/article/188828-the-long-term-effects-of-childhood-brain-injuries. Published July 29, 2010. Accessed July 3, 2012. 7. Rocky Mountain Youth Sports Medicine Institute, Center for Concussion. REAP the benefits of good concussion management. Available at: http://issuu.com/healthone/docs/reap_sept_2010?mode=embed&layout=http%3A%2F%2Fskin.issuu.com%2Fv%2Flight%2Flayout. xml&showFlipBtn=true. Accessed July 8, 2012. 8. State of Colorado Senate Bill 11-040. Available at: http://www.cde.state. co.us/HealthAndWellness/download/Brain%20Injury/SB11-040.pdf. Accessed July 2, 2012. 9. Gillette Children’s Specialty Healthcare. Importance of ImPACT. Available at: http://www.gillettechildrens.org/default.cfm?PID=1.17.4.2.1.2. Accessed July 8, 2012.
Submissions to this column are encouraged and may be sent to Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P [email protected] or Michelle Tracy, RN, MA, CEN, CPN [email protected] or Sue M. Cadwell, RN, MSN [email protected]
WWW.JENONLINE.ORG
581