An Adolescent with Head Injury after an ATV Accident

Pediatric Pathways

An Adolescent with Head Injury after an ATV Accident

After reading this article and answering the review questions the reader will be able to:

  1. Classify the severity of traumatic brain injury (TBI)
  2. Describe common symptoms experienced after TBI
  3. Describe the impact of TBI on neurocognitive and emotional development
  4. Outline a reasonable approach to returning to activities after TBI

Case

A 16-year-old male, Aiden, was riding his ATV and rolled it over on a downhill turn. His younger brother, who was riding in another ATV behind him, witnessed the accident. He reports that Aiden was not wearing a helmet and had loss of consciousness for approximately two minutes after the accident.

Aiden has a contusion and an abrasion on his right forehead and complains of headache, so he is taken to the ED by his parents. In the ED, he is awake but confused and complaining of headache. Because he has neck pain, he is placed in a cervical collar to immobilize his c-spine. He has a large contusion on his right forehead with no “step-off.” Aiden has no neurologic deficits and the remainder of his physical exam is negative. His GCS is 14 for confused speech. A head CT is performed and demonstrates a non-depressed, linear, frontal skull fracture with an intraparenchymal cerebral contusion. He is admitted to the PICU for hourly neurochecks, and demonstrates no worsening of his neurologic exam overnight.

The following day he is alert and oriented but amnestic for the period from 20 minutes before until two hours after the accident. He is transferred to general care and his c-spine is cleared clinically by demonstrating full range of motion of his neck, no spinal tenderness and normal neurological exam of his upper extremities. He continues to improve, and is discharged from the hospital on post-injury day two.

He returns to follow-up at the Brain Care Clinic two weeks post-injury. At this visit, he reports that for the first five days after returning home, he was very fatigued and had headaches one to two times a day which improved with ibuprofen and rest. His headaches have slowly improved and, on post-injury day seven, he returned to half-day school. He reports needing breaks during the shortened day due to fatigue, and he is still having daily headaches after school. Despite these symptoms, he states he feels like he is falling behind in school and is worried about his grades. Over the past few days since returning to school full-time, he reports needing multiple breaks during the day for fatigue and headache. He has difficulty focusing on his homework.

His physical exam and neurologic exam are normal, including normal balance, gait, and coordination. He is asked to complete a symptom severity score sheet ranking symptoms from 0 (no symptom) to 6 (worst ever). His symptom severity score is 26, endorsing the following symptoms: headaches, irritability, feeling mentally foggy, difficulty concentrating, fatigue, feeling slowed down, and difficulty remembering. His parents report that he is normally a very pleasant and easy teenager, but since the accident he is quick-tempered and moody. A computer based neurocognitive assessment using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is performed. Results of this testing demonstrate slowed processing speed and reaction time, as well as memory scores that were below expected levels compared to boys his age.

Pediatric Traumatic Brain Injury

Over 50,000 children are hospitalized each year with traumatic brain injury (TBI). The great majority of these admissions are for mild or moderate injuries and do not result in major neurologic deficits. However, children with mild or moderate TBI are at high risk for neuropsychological sequelae, which can impact their cognitive, emotional and social development.

Given the high incidence of mild TBI, the consequences of these milder brain injuries are a major contribution to the overall population burden of TBI in children. Most of our understanding of the pathophysiology of TBI comes from animal models which demonstrate that trauma to the brain triggers a complex cascade of physiologic processes which contribute to injury formation. Early after injury, the insult triggers release of neurotransmitters resulting in excitotoxic neuronal injury. Disruption in cell membrane ion pump function results in cell swelling, rupture and release of inflammatory cytokines. Additionally, stretch and shearing forces during the insult may result in a diffuse axonal injury leading to impaired neuronal function.

There is a wide spectrum of severity of injury, and the degree of injury is often difficult to predict based solely on mechanism. Additionally, injuries may not be evident on neuroimaging; therefore, the clinical exam is the most important indicator of injury presence and severity.

TBI is defined by the CDC as a blunt or penetrating injury to the head resulting in any of the following: decreased level of consciousness, amnesia, neurologic deficits, neuropsychologic abnormality, or intracranial lesion. The Glasgow Coma Scale (GCS) is a widely used and objective scale of verbal, motor, and eye responses after TBI (Table 1). GCS correlates with functional outcome after brain injury,1 and a modified GCS has been developed for use in infants.

TBI severity is commonly stratified based on GCS into severe (GCS ≤ 8), moderate (GCS 9-12), and mild (GCS ≥ 13) (Table 2). Mild injuries can be further classified as complicated or uncomplicated based on presence or absence of an intracranial lesion or skull fracture. Stratifying TBI severity in this way creates a common terminology, which facilitates accurate communication between members of the healthcare team, helps translate clinical research into practice guidelines, and is useful in discussing prognosis with families.

The term concussion is often used to describe a TBI that occurs in sports and is usually on the mild end of the spectrum of TBI, rarely requiring admission to the hospital.

Table 1. Glasgow Coma Scale (GCS)

Eye Opening Response

Verbal Response

Motor Response

> 2 yrs old

     < 2 yrs old

> 2 yrs old

     < 2 yrs old

> 2 yrs old

     < 2 yrs old

Spontaneous

4

Spontaneous

Oriented

5

Coos/babble

Spontaneous

6

Spontaneous

To voice

3

To voice

Confused

4

Irritable

Localizes to pain

5

Withdraw from touch

To pain

2

To pain

Inappropriate words

3

Cries to pain

Withdraws from pain

4

Withdraw from pain

None

1

None

Incomprehensible sounds

2

Moans to pain

Flexor posturing

3

Flexor posturing

 

None

1

None

Extensor posturing

2

Extensor posturing

Total GCS  =  3-15

None

1

None

Table 2. TBI

Uncomplicated Mild TBI

GCS = 13-15, Head CT = normal

Complicated Mild TBI

GCS = 13-15, Head CT = intracranial lesion or skull fracture

Moderate TBI

GCS = 9-12

Severe TBI

GCS = 3-8

 Initial Evaluation of TBI

Initial evaluation and management of acute TBI focuses on identifying injuries that will require immediate surgical or medical treatment. Evaluation begins with a focused physical and neurologic exam. The indications for neuroimaging in patients presenting to the emergency room after head injury has been the subject of some debate. Concerns regarding unnecessary radiation exposure in minor head injury patients prompted a large study by the Pediatric Emergency Care Applied Research Network (PECARN) in an effort to identify appropriate indications for CT scan.2

Factors associated with clinically important TBI included: GCS<15, other signs of altered mental status such as agitation or somnolence, or suspected skull fracture. Management guidelines for children admitted with severe TBI have recently been published.3 Briefly, children with GCS ≤ 8 require endotracheal intubation to ensure adequate oxygenation and ventilation, and admission to the intensive care unit to monitor and treat intracranial hypertension. A large subdural hematoma or expanding epidural hematoma identified on CT scan is an indication for neurosurgical evaluation for emergent surgical decompression.

Management of mild and moderate TBI depends on the imaging findings and ED course. Children who have not returned to baseline mental status or those with intracranial injuries will require admission to the hospital. Serial neurologic exams should be performed and worsening mental status taken as a sign of possible expanding hematoma or cerebral edema. Fortunately, most children admitted with uncomplicated mild TBI will require no medical or surgical interventions and are discharged home in 24-48 hours.

Common Symptoms Following TBI

TBI frequently results in impaired cognition, memory difficulty, sleep disturbance, mood changes, fatigue, and headaches (Table 3). There are also less well-known symptoms, such as having a short temper or being sensitive to bright lights or loud noises. Changes in personality and emotional functioning are common following even a mild TBI.

Regardless of TBI severity, any given patient may have any combination of these symptoms. It is difficult to predict the symptoms and severity a patient will experience. For this reason, it can be beneficial to warn parents to anticipate these symptoms to aide in better coping for parents and the entire family. After mild TBI, symptoms typically improve over the course of 1-2 weeks post-injury, but may last longer in about 10-15% of patients.

Table 3. Common Symptoms after TBI

PHYSICAL

COGNITIVE

EMOTIONAL

Headaches

Feeling in a “fog”

Irritability

Dizziness

Cognitive slowing

Sadness

Balance problems

Poor concentration

Increased nervousness

Nausea/Vomiting

Easily distracted

Feeling more emotional

Fatigue or drowsiness

Memory problems

Short fuse/tempter

Change in appetite

Trouble problem-solving

Personality changes

Change in sleep

Short term memory

Apathy

Sensitivity to light or noise

 

Decreased motivation

Numbness or tingling

 

Lack of awareness

Cognitive and Emotional Development after TBI

While most children with TBI recover completely, it is clear that brain injury can negatively impact cognitive and emotional development. One year after injury, 15% of children with mild TBI and 60% with moderate or severe TBI continue to require services such as educational accommodation or physical/occupational therapy.4 Additionally, it is increasingly recognized that TBI may result in new emotional or psychiatric disorders. Recent studies have demonstrated that 30-50% of mild complicated TBI patients are diagnosed with new psychiatric disorders at 3 months post-injury.5 The incidence of psychiatric disorders after severe TBI is as high as 80% in some studies.6

Children with previous psychiatric disorders are at particular risk of developing new disorders after sustaining a brain injury. In any particular patient it is difficult to predict the duration and severity of symptoms. However, a number of coexisting and premorbid factors have been linked to slower recovery from TBI (Table 4). These include a patient or family history of psychiatric conditions or learning disabilities. Children with recurrent TBI’s, even if they are all mild, tend to have longer recoveries with each new injury.

Table 4. Factors Associated with Slower Recovery

Loss of consciousness (not a factor in adults)

Presence of mild bleed or skull fracture

History of ADHD, depression, anxiety

History of learning or behavior disorder

Lower level of premorbid functioning

History of headaches or migraines

History of developmental delays

History of one or more concussions

Family psychiatric history

Family history of learning disabilities

Familial instability

Lower socioeconomic status

Evaluation During Recovery from TBI

Formal neuropsychological testing is useful for evaluating patients post-TBI to identify deficiencies or delays, guide recommendations for therapies and school accommodations, and to help patients and their families navigate the recovery from TBI. We recommend neuropsychological evaluation in all children requiring hospitalization for a TBI, regardless of severity.

In our multidisciplinary Brain Care Clinic, a brain injury specialist from the critical care team evaluates all children, typically 1-2 weeks after injury. Children are also evaluated by a pediatric neurologist, if indicated based on their post-injury course and symptoms. Children under 3 years of age undergo a screening assessment by a developmental specialist. In older children, a neuropsychologist performs a neurocognitive screen consisting of either a neuropsych “mini-battery” or the computer based ImPACT test, based on the patient’s age, injury severity and symptoms.

We most commonly see cognitive impairments in frontal lobe functioning, including difficulty with sustained attention, increased distractibility and loss of impulse control. Deficits in reaction time and memory are also frequently identified in our assessments, and are an indication of ongoing recovery, even in the absence of reported symptoms. We typically see a step-wise improvement in recovery, which is enhanced with brain rest and a gradual return to cognitive and physical activities (outlined below).

It is common for patients to demonstrate symptoms of depression or anxiety after TBI, either new-onset or an exacerbation of a preexisting disorder. We also carefully assess for Post Traumatic Stress Disorder (PTSD). The initial assessment is designed to assess physical, cognitive, and emotional symptoms, and provides objective measures that are followed throughout recovery. More in-depth testing is performed if persistent deficits are identified, and in all children recovering from severe TBI. This consists of the Bayley Scale of Infant Development in younger children and complete neuropsychological testing in older children.

When emotional disorders or PTSD are identified, children are referred for therapy and/or psychiatric evaluation, depending on severity.

Return-to-Learn

The cornerstone of TBI management is brain rest. Cognitive and physical activity early after TBI is associated with increased symptom severity and worse cognitive function.7 While clinical studies of the efficacy of cognitive rest after TBI are limited, expert opinion and published guidelines for treatment of concussion and mild TBI agree on the important role of brain rest early after injury.8 Brain rest begins in the hospital, creating an environment where stimulation is minimized, visitors are limited and rest is encouraged. Prior to discharge, the child and caregivers should be educated about the expected course of recovery and strategies provided for gradually resuming activities.

Table 5. Stepwise Approach to Return-to-Learn

STAGE

ACTIVITY

OBJECTIVE

No Activity

Complete cognitive rest – no school, homework, reading, texting, video games, or computers

Recovery

Gradual re-introduction of cognitive activity

Relax previous restrictions on activities and add back for short periods of time (5-15 minutes)

Gradual controlled increase in sub-symptom threshold cognitive activities

Homework at home

Homework in longer increments (20-30 minutes)

Increase cognitive stamina by repetition of short periods of self-paced cognitive activity

School Re-entry

Part day of school after tolerating 1-2 cumulative hours of homework at home

Re-entry into school with accommodations

Gradual re-integration into school

Increase to full day of school

Accommodations decrease as cognitive stamina improves

Resumption of full cognitive workload

Introduce testing, catch up with essential work

Full return to school

Although every treatment plan should be individualized based on specific circumstances, a minimum of three to seven days of brain rest following a TBI requiring hospital admission is appropriate. Activities that require sustained attention are most likely to induce symptoms. Therefore, strict cognitive rest includes no school/homework, no computer time, no video games, no reading, and limiting TV.

Clearly, a balance needs to be maintained between limiting activity and maintaining the emotional and social well-being of the child. Activities which are generally well tolerated include drawing, legos, cooking, and short phone conversations. We recommend a stepwise approach to resuming mental activities (Table 5). When the child is symptom-free with restricted physical and cognitive activity, gradual reintroduction of activities is attempted. A symptom score sheet is useful for monitoring symptoms and identifying triggers (Table 6).

Importantly, reintroduction of cognitive activities precedes increasing physical activities. When children are able to tolerate homework at home, return to school begins with half-days. Children should be empowered to take breaks as needed if symptoms develop during the school day. Guidance should be provided to the school alerting them to the child’s injury and recommending accommodations that should be provided at school (Table 7).

It may be helpful for the school to forgive missed work to help reduce stress and prevent “piling on” to a student who may already be struggling to handle their current work. When children are tolerating half-days well, full days can begin with continued accommodations. Missed school days can be a source of anxiety for the student and their family. However, attempting to return to school before it is tolerated will likely prolong recovery and may result in more total school missed than taking a gradual approach. Educating patients and parents to this fact, and to the importance of brain rest, helps to alleviate this frustration. Although the return to full days can be prolonged in some patients, after a mild TBI most students will be able to tolerate their full academic responsibilities in less than a week.

Table 6. Symptom Score

Headache

0-6

Sensitivity to light

0-6

Balance problems

0-6

Sadness

0-6

Trouble falling asleep

0-6

Numbness/tingling

0-6

Drowsiness

0-6

Difficulty concentrating

0-6

Irritability

0-6

Vomiting

0-6

Feeling more emotional

0-6

Fatigue

0-6

Feeling mentally foggy

0-6

Sleeping less than usual

0-6

Visual problems

0-6

Sensitivity to noise

0-6

Nausea

0-6

Nervousness

0-6

Dizziness

0-6

Feeling slowed down

0-6

Sleeping more than usual

0-6

Difficulty remembering

0-6

TOTAL

 

 

Adapted from the Total Symptom Score section of the Immediate Post-concussion Assessment and Cognitive Test (ImPACT)

Table 7. School Accommodations after TBI

Breaks as needed in a quiet place

Preprinted class notes

Additional time for assignments

Excuse non-essential work

Avoid double workload of make-up plus new work

Additional help and tutoring as needed

No testing until tolerating full day of school

First testing untimed

Adapted from Master et al. 20129

Physical activity can be reintroduced in a similar stepwise fashion, after extended cognitive activity is tolerated. Beginning with light aerobic exercise, increasing to more strenuous workouts as tolerated. Note that children with skull fractures or an intracranial process will need to avoid high impact physical activity and contact sports until the injury is fully healed and cleared by the pediatric neurosurgeon, usually at least three months. All children and their families should be counseled on the importance of avoiding a recurrent head injury, especially while still symptomatic after TBI.

Conclusion

TBI is a common cause of morbidity in children, and can impact both their short and long-term cognitive and emotional development. Educating patients and families to the importance of brain rest, and following a step-wise return to mental and physical activity helps to decrease anxiety and increase the likelihood of a timely recovery. Children should be evaluated for cognitive and emotional deficits early after injury and followed through recovery in order to best direct therapies and guide the return to activity.

The child described in the clinical scenario sustained a complicated mild TBI as a result of an ATV accident. His symptoms and the results of his neurocognitive assessment are typical of ongoing recovery from brain injury. The worsening of his symptoms coincided with attempting to return to full day of school when he was not yet tolerating half days.

We recommended reducing school back to half days, and then when symptom-free increasing the length of the school day. This plan and recommendations for accommodations at school were provided to the patient and communicated to his school. When the patient returned to the clinic two weeks later, his symptoms had improved and he was tolerating full school days. His Symptom Severity Score had improved to 4, and his ImPACT scores had improved to the normal range. Recommendations were provided to begin step-wise increase in physical activities. 

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References

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