Concussion - What did I miss?

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Specializes in School Nursing, Ambulatory Care, etc..

A couple of days ago, one of our frequent customers came in reporting she vomited after hitting her head on the floor during PE.  Everything was completely normal with the assessment.  She was A&O x 3, normal balance, normal extremity movement and strength, mood stable, full memory of event and moments before and after, etc.  The only issue was the student's report of vomiting, which is her frequent report when she comes in.

I called the parent due to the report of vomiting and instructed to have student evaluated at the ER or urgent care.  The next day, the parent let me know student was diagnosed with a concussion.   The student was cleared by the ER to return to school the next day - the parent was here picking her up because the student texted mom to let her know she was feeling bad and had blurry vision.  

Multiple questions come to mind.  First, what did I miss?  I've seen concussions happen in school before, and she didn't present with any "classic" symptoms.  Second, why did the doctor release her to return to school the very next day?  Doesn't the CDC recommend at least 24 hours before returning to work or school?  I'm really puzzled by this one.

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Specializes in School Health.

Hey hon! You did great! You didn't miss anything at all! Everyone has different reactions. Sometimes concussions can be asymptomatic until several days or even weeks later. Usually doctors send students with concussions back to school with accommodations to slowly reintegrate back to school full time. I'd recommend the parent request that from the doctor. 

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Specializes in pediatrics, school nursing.

I don't think you missed anything. You recommended further evaluation because of the report of a head injury followed by the report of vomiting. You took the matter seriously. 

I often use this (https://www.ventureacademyca.org/uploads/2/2/8/7/22875116/tbi_schools_checklist_508-a.pdf) to help guide my clinical decision making. When I decide to send a kid out, I send this with the family to bring to the doctor. I include initial vitals and repeat vitals every 30 minutes.

As for why the student was allowed to return to school, maybe they felt the symptoms weren't serious enough to warrant more time home or maybe the parent was pushing for clearance ASAP. Either way, I would want a "return to school" letter from the diagnosing physician with plans for accommodations. When I've had to wait for them, I usually am hyper cautious and any time a kid reports mild symptoms, I will give tylenol (if allowed) but recheck them in an hour and if there is no change or worse symptoms, I send them home and essentially let the family know that that will be the plan until I hear differently from a physician. 

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Specializes in Adult and Pediatric Vascular Access, Paramedic.

I wouldn't worry too much. 

A concussion is essentially a dx given after nothing is  found by CT scan.  There isn't anything you can do for that anyway, regardless, other than symptom management.     In all honesty, there aren't any tests to diagnose a concussion, it's more of an assumed diagnosis based on a negative CT, so you didn't miss anything, and did the correct thing by telling a parent to have the child examined by a physician.  

 

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This topic does bring to mind a question I had: when do you all assess for a concussion? Like what symptoms are they having where we might start to suspect it's more than a simple bump?

Im guessing a headache that doesn't go away or lessen after 15 minutes and major neuro changes, but outside of that there seems to be some gray area. 
 

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Specializes in Adult and Pediatric Vascular Access, Paramedic.
sergel02 said:

This topic does bring to mind a question I had: when do you all assess for a concussion? Like what symptoms are they having where we might start to suspect it's more than a simple bump?

Im guessing a headache that doesn't go away or lessen after 15 minutes and major neuro changes, but outside of that there seems to be some gray area. 
 

Just wondering if you read my post?   Concussion is a diagnosis of elimination, meaning there are no specific symptoms or tests that can be done to confirm it, and it is often times thought of as a relatively minor injury that requires no intervention.

If you lightly hit your head on a cabinet at home and go to the hospital because you are bored at home and you have a headache or had a headache or even the most mild sporatic symptoms, and they do a CT of your head which shows nothing is wrong on the CT, they will diagnose you with a concussion.  IN other words you could go to the hospital because you tapped your head lightly, even if your brain likely experienced no significant trauma from that head tap, and the doctor will tell you you have a concussion because the CT is negative, even if they don't do a CT they will say this.  It's like going to the doctor for a sore throat and if you negative for strep they just tell you you have a viral illness, because they don't really know why your throat hurts. 

 

 

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AnnieOaklyRN said:

Just wondering if you read my post?   Concussion is a diagnosis of elimination, meaning there are no specific symptoms or tests that can be done to confirm it, and it is often times thought of as a relatively minor injury that requires no intervention.

If you lightly hit your head on a cabinet at home and go to the hospital because you are bored at home and you have a headache or had a headache or even the most mild sporatic symptoms, and they do a CT of your head which shows nothing is wrong on the CT, they will diagnose you with a concussion.  IN other words you could go to the hospital because you tapped your head lightly, even if your brain likely experienced no significant trauma from that head tap, and the doctor will tell you you have a concussion because the CT is negative, even if they don't do a CT they will say this.  It's like going to the doctor for a sore throat and if you negative for strep they just tell you you have a viral illness, because they don't really know why your throat hurts. 

 

 

I yes I did, but I've heard various definitions which kind of confuse me as a newer school nurse. It seems like there are some symptoms to monitor for like the Ken's listed here: https://www.aans.org/patients/conditions-treatments/concussion/

 

which seems to indicate perhaps I should think less if a kid has a concussion, and more what signs and symptoms are they experiencing after a head injury, and whether that warrants further evaluation to see if it's a major injury that can be found. 
 

I think coming from acute care, we never even used the term concussion, but rather just did a full neuro assessment after a head injury and went from there. I know MTBI is used but even that was rarely seen in charting and notes.

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Specializes in School Nursing, Ambulatory Care, etc..

Thank you, everyone.  I've been really beating myself up about this one...maybe beating myself up isn't the right phrase.  I've been doubting, both myself and the parent report (still haven't received the discharge summary/instructions as promised).  

@AnnieOaklyRN - thank you for providing more information about what a CT shows or doesn't.  Between your and @sergel02's responses, I went down a rabbit hole and read information provided in the JNS and by the NCAA.

@k1p1ssk - thank you for reminding me about the CDC's Heads Up information and assessment sheet.  I've printed the assessment sheet and will start implementing it.

One more question:  Do you (this is a collective "you") measure VS when a student reports getting hit on the head (basketball, volleyball, etc) or hitting their head?  If so, are you just doing one set or multiple and why?

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Specializes in pediatrics, school nursing.

As far as when I do a full assessment vs. sending back to class, my first question is always "where does it hurt?" - most kids will indicate that the pain is where they hit their head and that it worsens with palpation, which to me, indicates it is just tender at the site of impact and not a headache. I then ask if they have discomfort anywhere else. If they were to tell me their tummy hurts, too, I ask if they hit their tummy or if it hurts on its own (obviously using more developmentally appropriate language based on the age of the student). I ask about light/noise sensitivity, dizziness, visual changes, and do a quick neuro exam of the eyes. 

If their only symptom is tenderness or mild headache, I usually give ice and tell them to return if it's not better in 15minutes or if it starts to worsen at all. 

99% of my head bumps "happened at recess" an hour ago and now it's suddenly bothering them during their least favorite subject. Those ones are tough though, because it could be latent symptoms, OR they're using it as an excuse. But I generally use the same criteria as above, and they go back to class unless they are particularly symptomatic. 

If I suspect concussion, they go home with the expectation that they get seen by their PCP or in the ED. If they don't go home, but the head injury was bad enough that it caused even short-lived additional symptoms, or it left a mark/swelling, I at least call home.

As @AnnieOaklyRN said, It is a diagnosis of exclusion, so pretty much EVERY head injury that gets evaluated by a doctor is going to be given a diagnosis of concussion, unless there are other findings. Restrictions are going to match the level of severity. 

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BunnyBunnyBSNRN said:

Thank you, everyone.  I've been really beating myself up about this one...maybe beating myself up isn't the right phrase.  I've been doubting, both myself and the parent report (still haven't received the discharge summary/instructions as promised).  

@AnnieOaklyRN - thank you for providing more information about what a CT shows or doesn't.  Between your and @sergel02's responses, I went down a rabbit hole and read information provided in the JNS and by the NCAA.

@k1p1ssk - thank you for reminding me about the CDC's Heads Up information and assessment sheet.  I've printed the assessment sheet and will start implementing it.

One more question:  Do you (this is a collective "you") measure VS when a student reports getting hit on the head (basketball, volleyball, etc) or hitting their head?  If so, are you just doing one set or multiple and why?

Take what I say as a grain of salt since I'm a baby school nurse, but I generally don't do a full set of vitals, unless it seems clinical significant. If I didn't for every head bump I'd be doing them all day LOL. 
 

In the hospital it was protocol to always do a full set after a fall, but school feels a bit different. If I have concerns outside a headache I may do a more in depth neuro exam. Usually it's 1st graders though so I'm still figuring out how to do one on that age. Luckily most of them are fine after an ice pack and some rest. 

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