NEURO Flashcards
What is a concussion?
Concussion = mild traumatic brain injury (TBI)
Trauma-induced transient alteration in mental status that may involve loss of consciousness
T/F a concussion always results results from direct trauma to the head
F - Usually from direct impact to head, can also be caused by indirect forces to the brain – sudden acceleration, deceleration or rotational forces of the head, neck or body
Outline the signs and symptoms of concussion
Common findings: headaches, brief amnesic period around event (<30 mins), faintness, N/V, vision changes/blurring, drowsiness, loss of consciousness, confusion
Other S/S divided into categories of physical, emotional, cognitive and sleep-cycle disturbance :
- Physical: dizziness, impaired balance, photophobia, noise sensitivity, numbness/tingling
- Emotional: irritability, nervousness, depression, labile mood
- Cognitive: difficulty concentrating, slower processing, disorientation, fatigue
- Sleep: difficulty falling asleep, sleeping more or less than usual
Longer term S/S of persistent concussion symptoms/post-concussion syndrome can include headaches, dizziness, sleep disturbances and psychological/cognitive symptoms.
What does return to activities look like a child with a concussion? How would you educate the child’s caregivers on this?
- Needs physical and mental rest for next 1 to 2 days
- Slowly reintroduce light noncontact, supervised, aerobic activities as long as are not worsening symptoms (if worsening, try again tomorrow)
- If activities such as watching TV, reading, playing video gains, or visiting with others worsen symptoms, should take a break from these activities. They can be slowly reintroduced when he is well enough that they don’t cause an exacerbation of symptoms
- should not participate in any activities that risk a secondary injury (cycling, skateboarding, etc) while he is recovering, as this predisposes him to a severe head injury. He needs to avoid strenuous physical and cognitive activities until he is fully recovered from his concussion
- Parachute.ca has a great handout on “return to sport”
Warning signs that would warrant a trip to the ED after a child has a concussion?
(especially first 24-48 hours)
Headache that worsens
Drowsy/cannot be awakened
Cannot recognize people/places
Repeated vomiting (>2 times)
Increased confusion or become very irritable
Seizures
Weak or numb limbs
Slurred speech
Can no longer do things they could before the injury
How can a kid’s pain after concussion be managed at home? What should the child focus on during the recovery period?
- can use analgesics such as ibuprofen and Tylenol to manage headaches.
Physical and mental rest, good sleep hygiene, nutrition, and hydration
T/F Repeated concussions are no biggie
False! A concussion will now predispose the child to future concussions…and consecutive concussion are more serious (even fatal) with increased healing time
Little bobby gets kicked in the head during a soccer game. He feels nauseous. Should be return to the game?
No! Need full evaluation of concussion symptoms immediately. He should not return to play if there are signs and symptoms of concussion
Big boy Lenny got a concussion at his hockey game. You instruct his parents he needs a 50% reduction in symptoms before he can return to hockey. Is this right?
No
It is very important that Big Boy Lenny not return to his sport until his concussion symptoms have resolved and he has been evaluated and cleared by a physician or NP
This timeline is highly varied and may take weeks to months. His return to the sport will take place in stages.
T/F A concussion typically warrants a head CT or other imaging.
F
Imaging not typically warranted unless focal neurologic signs or other red flags (including suspicion of C-spine injury)
Can’t use Canadian CT head rules for kids. Can use PECARN screener (thanks Michaela!) - CT warranted if GCS <15, etc…
What health history is important to include when evaluating a child with concussion?
Significant injuries, including previous head injuries/concussions? If so, when was the most recent concussion, and how long was the recovery?
Have they ever been hospitalized for a head injury?
Existing neurologic conditions such as seizures or headaches
Learning disability, dyslexia
ADD/ADHD
Clotting disorders
Depression, anxiety, or a psychiatric disorder (ATT, n.d.)
Family history of same?
What tool can you use to evaluate a kid with possible concussion?
Child SCAT5
(SCAT5 used for adults)
T/F You should instruct a parent to wake their child every hour after a concussion.
False! Getting good sleep is important. They should sleep when they want to.
Generally, what should parents be checking in their child after concussion?
Parents DO need to keep a close watch over their kid for the first 24-72 hours for any unusual behavior. This check includes making sure the child:
- know their name
- knows who the parent is
- knows where they are
- wakes up easily as usual
- Can hold a hand tight with both hands
- Has no blood or fluids in ears or nose
- is breathing easily
- isn’t feeling a lot of pain
- watching for concerning signs like loss of balance or strength, changes in vision, unusual body jerks (go to ED!)
Like adults, Pediatric patients can have either primary or secondary headaches. What are the three common primary headache disorders?
Migraine, tension-type headache, cluster headache (trigeminal autonomic cephalalgia). Cluster headaches are very rare in children
What is the most common chronic headache condition in children?
Migraines
Headaches are just one symptom/presentation of migraines, what’s another variant of migraine that can occur in children?
Abdominal migraine, cyclic vomiting and benign paroxysmal vertigo
What might be common causes of secondary headache in children? (ie. Headaches secondary to an underlying medical condition)
Usually fever or infection. Ex. URTI, influenza
Could also be due to a space-occupying lesion or CNS infection, medication side-effect, medication overuse, , hypertension
T/F: Headaches are rare in children
False. Headaches are common in children and prevalence increases as they age.
How do migraines present in children?
Duration of headache is typically shorter than in adults and increases with age
Migraines in children are most often bilateral (bifrontal or bitemporal)
How do you determine the type of headache a child is experiencing ?
Same as adult, history and physical exam, imaging only if concerning features present
What are some red flags related to headaches that might prompt you to order imaging?
Children under 6
Children with abnormal neuro exams
Other normal headache red flags
Outline migraine treatment for children
Early use of medication when the headache pain is still mild – acetaminophen or ibuprofen recommended rather than triptans. Triptans can be used if needed in children 5 and older
Outline management of tension-type headaches in children
Emotional support and non-addicting analgesic medications. If chronic, may benefit from tricyclic antidepressants (ex. Amitriptyline) or CBT
Describe abdominal migraines
Characterized by recurrent episodes of abdominal pain in an otherwise health child who is normal between attacks.
Pain typically midline and poorly localized, moderate to severe in intensity with at least 2 associated features (anorexia, nausea, vomiting, pallor)
Headache is not a prominent feature and may be overlooked if not asked about, photo and phonophobia are uncommon
T/F: Abdominal migraines usually present between age 2 and 10 and affect up to 4% of children
TRUE
T/F: Most children who had abdominal migraines as go on to have migraine headaches as adults
TRUE
Most children stop having abdominal migraine attacks by early adolescence, but evolve to develop migraine headaches (70%)
How are abdominal migraines diagnosed?
History and physical rule out concerning causes such as GI disorders or kidney disease. Many causes of acute abdo pain must be considered in the differential.
Abdominal migraine is a clinical diagnosis with no confirmatory tests
