Sport-specific exercise (skating in hockey, running in soccer).
4.
Noncontact, more progressive training drills; resistance training.
5.
Full-contact practice after medical clearance.
6.
Game play.
Modified from McCrory P, Meeuwisse W, Johnston K, et al: Consensus statement on concussion in sport: the 3rd International Conference on
Concussion in Sport, held in Zurich, November 2008. Br J Sports Med 2009;43:i76-i84.
disturbance (drowsiness), or physical signs (loss of consciousness, amnesia). Acute symptoms usually reflect a functional disturbance rather than structural injury, and no abnormalities are seen on standard imaging. The majority of concussions resolve within 10 days, although the recovery may be slower in children, and in a small percentage of cases, the symptoms are prolonged.
Repeated concussions, especially within a short time frame (days or weeks) carry a significant risk of permanent brain injury (second impact syndrome). Children must not be permitted to resume physical activities until well after the symptoms resolve (Table 184-3).
Head trauma can result in epidural, subdural, parenchymal, and subarachnoid intracranial hemorrhages, as well as brain contusions (Table 184-4). Symptoms include headache, vomiting lethargy, decreased consciousness and seizures. The classic presentation of epidural hemorrhages involves a lucid interval, where, following primary brain injury, a child has a decreased level of consciousness, then returns to normal for several hours before developing rapidly progressive neurologic symptoms. Subdural hemorrhages may result from direct trauma or rotational forces from vigorous shaking (shaken baby syndrome). In neonates and infants with open fontanelles, signs and symptoms may be absent or nonspecific. Occasionally, epidural, subdural, or intracranial hemorrhage or a rapid, life-threatening increase in ICP develops unexpectedly in children due to cerebral edema.
Skull fractures may be linear, diastatic (spreading the suture), depressed (an edge displaced inferiorly), or compound (bone fragments breaking the skin surface). Linear and diastatic fractures necessitate no treatment, but indicate trauma capable of producing an underlying hematoma. Small, depressed fractures have the same significance as linear fractures, but if the depression is more than 0.5 to 1 cm, surgical elevation of bone fragments and repair of associated dural tears are generally recommended. Compound fractures or penetrating injuries necessitate emergent surgical debridement and tetanus
Onset over minutes to hours Lucid interval followed by progressive neurologic deficits Lens-shaped extracerebral hemorrhage compressing brain
Chronic subdural Onset over weeks to months Anemia, macrocephaly Seizures, vomiting Crescentic, low-density mass on CT
Focal neurologic deficits Brain swelling with transtentorial herniation CT findings: multifocal low-density areas with punctate hemorrhages Surgical evacuation or observation Prognosis good with prompt treatment, otherwise poor
Subdural taps or subdural shunt as necessary Prognosis can be good
Medical treatment of elevated intracranial pressure * Prognosis guarded
CT, Computed tomography. *Mannitol, elevation of head of bed, diuresis, hyperventilation, steroids.
prophylaxis. The risk of associated brain contusion and early seizures is high in compound fractures.