Unsuspected Post-Concussive Symptoms (PCS) in Children Requiring Cervical Spine Clearance Becky Cook, DNP, CNP, RN Kaaren Shebesta MSN, CNP, RN Mary Ellen Watts, BSN, RN Erin Butt, MSN, CNP, RN Suzanne Moody, MPA, CCRP Richard A. Falcone, Jr, MD, MPH Cincinnati Children’s Hospital Medical Center November 14, 2014
Pediatric Trauma Society 2014 Disclosures • I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity • I do not intend to discuss an unapproved/ investigative use of a commercial product/device in my presentation
Pediatric Trauma Society 2014 Objectives • Discuss high rate of PCS in children requiring c-spine clearance and role of symptom assessment (SA). • Emphasize importance of providing anticipatory guidance about PCS to patients released in cervical collars.
Pediatric Trauma Society 2014 Background • Whiplash & concussion often coincide • PCS: – Prolonged recovery: ADLs, school, sports – Increased risk of secondary injuries • Barriers: – Young children unable to describe PCS – Older children feel invulnerable – Concussion • Minimized due to primary injury • Not appreciated
Pediatric Trauma Society 2014 Symptom Assessment (SA) • Valuable: – Document PCS – Timely referral to specialty services – Monitor symptom resolution – Support care interventions – Support patient / family education & reassurance – Discharge education significantly reduces: • Symptom reporting • Behavioral changes
Pediatric Trauma Society 2014 SA score: • 22 symptoms • Scale: 0 – 6 • Score range: 0 - 132 • Normal score: – Boys: 0 - 6 – Girls: 0 - 8 • Abnormal score referral: – Sports Medicine – Neurology – Pediatric Rehab Adapted from: Lovell, et al, 1998
Pediatric Trauma Society 2014 Unsuspected PCS • Purpose: Determine the incidence of PCS in children seen for c-spine clearance • Methods: – Incorporated symptom assessment (SA) – Retrospective chart review – Patients seen in NP Trauma Clinic for c-spine clearance (June 2012 – June 2013) • Emergency Department • Inpatients
Pediatric Trauma Society 2014 Patient Demographics • N = 244 Mechanism of Injury – Age: 5 – 17 yrs • 5 yr: 11 (4%) Sport 20.5% • 6 – 9 yrs: 28 (12%) 38.1% MVC • > 10 yrs: 205 (84%) Fall 18.9% – Gender: Other 22.5% • Male: 124 (51%) • Female: 120 (49%) – Documented SA: 179 (74%) • SA Range: 0 – 95 • Mean: 17.4
Pediatric Trauma Society 2014 Abnormal SA Score • N = 98 (55%) 33 • Age: 5 – 17 yrs 32 • 5 yr: 1 (1%) 31 Mean SA Score • 6 – 9 yrs: 10 (10%) • > 10 yrs: 87 (89%) 30 Female • Gender: Male 29 • Male: 36 (37%) 28 • Female: 62 (63%) • SA Range: 7 – 95 27 • Mean: 31 26 9 - 95 7 - 82 SA Range
Pediatric Trauma Society 2014 Abnormal SA Score
Pediatric Trauma Society 2014 Unsuspected PCS N =179 52 (29%) 127 (71%) Concussion Dx No concussion Dx 39 (75%) 13 (25%) 59 (46%) 68 (54%) Abnormal Normal Abnormal Normal SAS SAS SAS SAS
Pediatric Trauma Society 2014 Referral to Head Injury Clinic • N = 98 – 83 (85.6%) follow up • Pediatric Rehab • Sports Medicine • Neurology – Mean of 2.1 visits 1-6 visits total
Pediatric Trauma Society 2014 Implications • Careful screening identified a high rate of unsuspected PCS in children requiring c-spine clearance • Formal assessment of PCS incorporated into the evaluation • Anticipatory education regarding PCS when released from ED/inpatient setting in a cervical collar
Pediatric Trauma Society 2014 Unsuspected PCS • Limitations – Retrospective review over a 1 year time period – No data for children < 5 years – Did not distinguish ED vs inpatient outcomes • Next steps: – Inpatient SA screening prior to discharge (done) – Collaboration with ED: Incorporating concussion education – Prospective evaluation – Screening tool for young children
Pediatric Trauma Society 2014 References • Barlow, KM, Crawford, S., Stevenson, A, Sandhu, SS, Belanger, F, & Dewey, D. Epidemiology of post-concussion syndrome in pediatric mild traumatic brain injury. Pediatrics. 2010; 126 (2): e374-e381. • Blinman, TA, Houseknecht, E, Snyder, C, Wiebe, DJ, & Nance, ML. Postconcussive symptoms in hospitalized pediatric patients after mild traumatic brain injury. Journal of Pediatric Surgery. 2009; 44 (6): 1223-1228. • Benson B, Meeuwisse W, Rizos J, Kang J, Burke C. A prospective study of concussions among National Hockey League players during regular Season games: the NHL---NHLPA concussion program. CMAJ. 2011;183(8):905---911. • Carroll LJ, Cassidy JD, Peloso PM, et al. Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury . J Rehabil Med . 2004;43(suppl):84-105. • Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Heads up: brain injury in your practice. A tool kit for physicians. 2008. Atlanta, GA. • Gioia, GA, Isquith, PK, Schneider, JC, & Vaughan, CG. New approaches to assessment and monitoring of concussion in children. Topics in Language Disorders. 2009; 29 (3): 266- 281. • Hooper SR, Alexander J, Moore D, Sasser HC, Laurent S, King J et al. Caregiver reports of common symptoms in children following a traumatic brain injury. NeuroRehabilitation . 2004; 19(3): 175-189.
Pediatric Trauma Society 2014 References • Lovell MR, Collins MW: Neuropsychological assessment of the college football player. J Head Trauma Rehab 13: 9–26, 1998 • Mittenberg, W, Canyock, EM, Condit, D, & Patton, C. Treatment of post-concussion syndrome following mild traumatic brain injury. Journal of Clinical Experimental Neuropsychology. 2001 ; 23 : 829-836. • Ponsford, J, Willmott, C, Rothwell, A, Cameron, P, Ayton, G, Nelms, R, Curran, C, & Ng, K. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001; 108 (6): 1297-1303. • Ponsford J, Willmott, C, Rothwell, A, Cameron, P, Ayton, G, Nelms, R, et al. Cognitive and behavioural outcome following mild traumatic head injury In children. J Head Trauma Rehabil. 1999;14(4):360-- - 372. • Powell, JM, Ferraro, JV, Dikmen, SS, Temkin, NR, & Bell, KF. Accuracy of mild traumatic brain injury diagnosis. Archives of Physical Medicine & Rehabilitation. 2008; 89: 1550-1555. • Sesma HW, Slomine BS, Ding R, McCarthy ML. Executive functioning in the first year after pediatric traumatic brain injury. Pediatrics. 2008; 121: e1686-1695. • Stevens, PK, Penprase, B, Kepros, JP, & Dunneback, J. Parental recognition of postconcussive symptoms in children. Journal of Trauma Nursing. 2010; 17 (4): 178-182.
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