Office management of mild head injury in children and adolescents

Juan Antonio Garcia-Rodriguez; Roger E. Thomas

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Re:Guidelines for Diagnosing and Managing Pediatric Concussion: A 'one-stop shop' for primary health care providers
Juan Antonio Garcia-Rodriquez

Published on: 16 September 2014
Guidelines for Diagnosing and Managing Pediatric Concussion: A 'one-stop shop' for primary health care providers
Roger Zemek

Published on: 28 August 2014

Published on: (16 September 2014)

Re:Guidelines for Diagnosing and Managing Pediatric Concussion: A 'one-stop shop' for primary health care providers
Juan Antonio Garcia-Rodriquez, Continuing Professional Development Director
Other Contributors:
Collaborative information about concussion in pediatric population.
Ref: Guidelines for Diagnosing and Managing Pediatric Concussion: A 'one-stop shop' for primary health care providers. Dr. Roger Zemek. Children's Hospital of Eastern Ontario
We would like to reply to Dr. Zemek's letter to the editor about the new Guidelines for Diagnosing and Managing Pediatric Concussion and his reference to our p...
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Collaborative information about concussion in pediatric population.
Ref: Guidelines for Diagnosing and Managing Pediatric Concussion: A 'one-stop shop' for primary health care providers. Dr. Roger Zemek. Children's Hospital of Eastern Ontario
We would like to reply to Dr. Zemek's letter to the editor about the new Guidelines for Diagnosing and Managing Pediatric Concussion and his reference to our published clinical review of the office management of mild head injury in children and adolescents.
We are very pleased to know that the theme of concussion in the pediatric population is the focus of much attention recently at different levels and in different institutions and associations. Clear and readily available information about concussion is an obvious need that Family physicians, Emergency Physicians and Pediatricians are currently facing.
Our recommendations and those of the guidelines' follow each other very closely. The guideline recommendations are organized into five topics in tables at the beginning of the document and simply clicking on the number automatically jumps the reader to the details of each recommendation later in this very extensive (34 MB) guideline. Their topics are: 1. In advance consider neuro-cognitive testing if the child plays high risk sports. 2. On Presentation ("what are the red flags?"). 3. On discharge (what do we tell parents?). 4. On interim assessment (when can the child/adolescent return to learn/play? and 5. Reassessment after one month."
The intention of our review is to provide practical, current approaches and specific tools for family physicians to help diagnose, manage and provide information to families, teachers and coaches. We gladly appreciate that the guidelines advocated by Dr. Zemek have a similar purpose, which is basically to equip physicians with updated information to facilitate their work to identify patients suffering from concussion, its complications, and to guide adequate focused management.
Our review, in summary, advocates for a full clinical initial evaluation that requires not only a complete history and a comprehensive focused physical exam, but also identification of the mechanism of injury, the evolution, the timeline of the symptoms and determination of any factors that could affect its presentation or management. We stated that Family Physicians should be very well aware of the available standardized tools and where to quickly find them in order to assess the general symptoms and cognitive status of the pediatric patient. Adequate observation of the concussed patient is paramount and the Family Physician should guide parents in this process by providing the correct information and providing education; the available resources we presented can be used to accomplish this task. When complications need to be ruled out, the physician can make evidence-based decisions whether to request imaging studies by using information from the CATCH study.
The management of concussion is based on the status and progress of the individual patient, and the treating doctor should coordinate adequate follow-up assessments, allow return to study or to play in a safe manner and use neuropsychological testing when needed.
We gladly welcome the presented guidelines, which contribute to cooperative work directed to facilitate the efforts of treating physicians and to improve the attention offered to children and adolescents.
Juan Antonio Garcia-Rodriguez, MD, MSc (Med Edu), CCPF, Dips Sports Med. Continuing Professional Development Director Assistant Professor, Department of Family Medicine. University of Calgary
Roger E. Thomas, MD, PhD, CCFP, MRCGP Professor, Department of Family Medicine. University of Calgary
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (28 August 2014)

Guidelines for Diagnosing and Managing Pediatric Concussion: A 'one-stop shop' for primary health care providers
Roger Zemek, Director of Pediatric Emergency Research
I wanted to commend the editorial board of Canadian Family Physician for the focus on pediatric concussion on the recent June 2014 issue. Persistent concussion impacts the quality of life across many domains: impaired cognition, memory and attention affecting school attendance and performance, mood and social engagement, reduced peer contact due to removal from sports/recreational activities. A retrospective chart revi...
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I wanted to commend the editorial board of Canadian Family Physician for the focus on pediatric concussion on the recent June 2014 issue. Persistent concussion impacts the quality of life across many domains: impaired cognition, memory and attention affecting school attendance and performance, mood and social engagement, reduced peer contact due to removal from sports/recreational activities. A retrospective chart review of a family and sport medicine physician's office, as well as a survey of two Toronto community teaching hospitals emphasized the importance of implementing step-wise return-to-learn and return-to-play. Both authors commented that there is a need for clear management plans to facilitate recovery following concussion. Further, Drs. Garcia-Rodriguez and Thomas reviewed the current literature to suggest possible validated tools in order to assess child and adolescent concussion. Finally, in a thoughtful commentary, Dr Carson and team emphasized the need to implement best practice.
We wholeheartedly agree. In fact our team released the first comprehensive pediatric concussion guidelines on June 25, 2014. These pediatric guidelines were developed by an expert panel including over 30 members across Canada and the United States and were sponsored by the Ontario Neurotrauma Foundation. Our project team included representation from the full spectrum of pediatric health disciplines (emergency medicine, family practitioners, neurologists, rehabilitation professionals, etc.). Our team reviewed more than 4,000 academic papers, and over the course of two years created the first comprehensive pediatric concussion guidelines for healthcare professionals, parents and/or caregivers, schools and/or community sports organizations.
These new Guidelines for Diagnosing and Managing Pediatric Concussion provide a "one-stop shop" for busy healthcare providers by employing evidence-based recommendations to standardize the diagnosis and management of concussion in children aged 5 to 18 years old, from the initial assessment through to the period of recovery (which might last months.) Furthermore, it fills a need to standardize the reintegration into school and social activities, both of which are crucial to children and adolescents during formative years.
The guidelines include numerous tools and clear instructions for all levels of user. For the family physician or the emergency department physician, algorithms are provided to guide the decision whether or not to obtain CT scans, and examples of written discharge handouts for the patients and families are included. For family physicians and nurse practitioners managing persistent symptoms in the community, the guidelines provide recommendations for monitoring and managing ongoing symptom management and tools and decision tools to help navigate 'return- to-learn' and 'return-to-play'. The guidelines also include templates for 'doctor letters' to the school describing recommended level of activities to facilitate communication with the school. For family physicians that advise coaches, parents and teachers, the guidelines provide resources they may share with coaches and school boards in order to improve the whole community response to concussion recognition and management. We believe these guidelines address the current gap in literature emphasized in the conclusions of both Dr. Stoller's survey Dr. Carson's chart review.
We completely concur that family physicians are the cornerstone to improving the management of pediatric and adolescent concussion. While no large epidemiological studies have determined the true prevalence of pediatric concussion and of persistent post-concussive symptoms (PCS), it appears that children appear to be at higher risk than adults for PCS. In fact, rather than the often-quoted rate of 10-20% at 7-10 days, the incidence of PCS is likely closer to 30% at one month in children and adolescent, but we are optimistic that we will soon be able to predict which children may still have symptoms at one month. With consistent application of best evidence-based management using comprehensive guidelines, our hope is to reduce the impact of concussion and PCS on children and adolescents.
The guidelines are free and available at www.onf.org/documents/guidelines-for-pediatric-concussion and www.concussionsontario.org/guidelines-for-pediatric-concussion.
Roger Zemek, MD, FRCPC Chair, Guidelines for Diagnosing and Managing Pediatric Concussion Director of Pediatric Emergency Research, Children's Hospital of Eastern Ontario, Ottawa, ON; Assistant Professor, Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, ON
1 Carson JD, Lawrence DW, Kraft SA, et al. Premature return to play and return to learn after a sports-related concussion: Physician's chart review. Can Fam Physician. 2014 60:e310-e315. 2 Stoller J, Carson JD, Garel A, et al. Do family physicians, emergency department physicians, and pediatricians give consistent sport-related concussion management advice? Can Fam Physician. 2014 60:548-52. 3 Garcia-Rodriguez JA and Thomas RE. Office management of mild traumatic head injury in children and adolescents. Can Fam Physician. 2014 60:523- 531. 4 Carson JD, Rendely A, Lebru CM, Warden J, and Arcand A. Family physicians can champion sport-related concussion management: It's about time. Can Fam Physician. 2014 60:505-507. 5 Zemek RL, Farion KJ, Sampson M, McGahern C. Prognosticators of persistent symptoms following pediatric concussion: a systematic review. JAMA Pediatr. 2013 167(3):259-65. 6 Zemek R, Osmond M, Barrowman N for PERC Concussion Team. Predicting and Preventing Postconcussive Problems in Pediatrics (5P) Study: protocol for a prospective multicenter clinical prediction rule derivation study in children with concussion. BMJ Open 2013; 3(8) e003550.
Conflict of Interest:
None declared
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Competing Interests: None declared.