Unsuspected Post-Concussive Symptoms (PCS) in Children Requiring - - PowerPoint PPT Presentation

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Unsuspected Post-Concussive Symptoms (PCS) in Children Requiring - - PowerPoint PPT Presentation

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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,

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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

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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

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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.

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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
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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
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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

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Pediatric Trauma Society 2014

Unsuspected PCS

  • Purpose: Determine the incidence
  • f 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
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Pediatric Trauma Society 2014

Patient Demographics

38.1% 22.5% 18.9% 20.5%

Mechanism of Injury

Sport MVC Fall Other

  • N = 244

– Age: 5 – 17 yrs

  • 5 yr: 11 (4%)
  • 6 – 9 yrs: 28 (12%)
  • > 10 yrs: 205 (84%)

– Gender:

  • Male: 124 (51%)
  • Female: 120 (49%)

– Documented SA: 179 (74%)

  • SA Range:

0 – 95

  • Mean:

17.4

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Pediatric Trauma Society 2014

Abnormal SA Score

  • N = 98 (55%)
  • Age: 5 – 17 yrs
  • 5 yr: 1 (1%)
  • 6 – 9 yrs: 10 (10%)
  • > 10 yrs: 87 (89%)
  • Gender:
  • Male: 36 (37%)
  • Female: 62 (63%)
  • SA Range:

7 – 95

  • Mean:

31

26 27 28 29 30 31 32 33 Mean SA Score

Female Male SA Range 9 - 95 7 - 82

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Pediatric Trauma Society 2014

Abnormal SA Score

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Pediatric Trauma Society 2014

Unsuspected PCS

N =179 52 (29%)

Concussion Dx 39 (75%) Abnormal SAS 13 (25%) Normal SAS

127 (71%)

No concussion Dx 59 (46%) Abnormal SAS 68 (54%) Normal SAS

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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

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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

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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

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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.

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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.