Head injuries

[OhioBPH]

Okay, the policy in the district is that any child who suffers an injury above the neck be evaluated for a head injury. Which means 30 mins in the clinic and completion of the CDC Concussion Checklist. This checklist advises referring EVERY child with ANY symptom to a health care provider. Which means that since EVERY child with a head injury says they have a headache I'm referring kids almost daily. I understand the serious nature of head injuries, and I understand sending home detailed info, but sending every kid to the doctor?

What do you do?

[OldDude]

I'm on the elementary level. Head injury "protocol" in our district applies to athletic competitions or organized practices so we, otherwise, assess each head injury individually according to the mechanism of injury, "signs" of injury or abnormality, as well as symptoms. I'm glad, because as you mentioned, I'd be sending 5 or 10 kids from the playground to the doctor every day. I thinks it's a stretch to apply the CDC checklist to a 5 year old at recess.

[ruby_jane, BSN, RN]

Every kid who hits their head here gets an assessment, but not the full-on concussion screen you describe unless they're flagrantly symptomatic. Every family gets a phone call with me telling them about our protocol.

If I had to do a 30 minute eval rather than PERRL and an abbreviated neuro assessment I don't know I'd get through the day most days. This seems to be an abundance of caution. Was there an incident at some point?

[Amethya]

Is there a good guideline how to check kids for concussions? I don't know much about PERRLA or anything, but I do call parents if the child hit his head and they say they feel dizzy, tired, head hurts and/or confused.

[OhioBPH]

If I had to do a 30 minute eval rather than PERRL and an abbreviated neuro assessment I don't know I'd get through the day most days. This seems to be an abundance of caution. Was there an incident at some point?

No, but we are part of a HUGE school health program that serves over 30 school districts and I think that this plan was chosen to avoid any liability.

[JenTheSchoolRN, BSN, RN]

Every kid who hits their head here gets an assessment, but not the full-on concussion screen you describe unless they're flagrantly symptomatic. Every family gets a phone call with me telling them about our protocol.

If I had to do a 30 minute eval rather than PERRL and an abbreviated neuro assessment I don't know I'd get through the day most days. This seems to be an abundance of caution. Was there an incident at some point?

I do the same, but I pull out the CDC eval when the incident triggers my gut, which can happen more often for me. I call home for every head injury. But I've got the older ones, so it is usually a bit more "robust" of an injury. Gym is brutal here as we have it outside and I swear, some kids, are just out of blood with their competitive spirit. I've had a student be diagnosed with a concussion after getting a basketball to the head in gym class. (Who I didn't refer out at the time based on assessment, to be honest, just called home and was more symptomatic the next day so per my instruction, mom took student to doctor).

[OhioBPH]

The other part of my question is, do you ask about any specific symptoms, or do you just ask "how are you feeling now?" Middle schoolers will say yes to ANYTHING to get out of class. The CDC recommends of a student has any ONE S/S of a concussion they should see a doctor.

This includes: appearing dazed or stunned, being confused, answering slowly, cannot remember events before or after injury, LOC, behavior or personality change, forgets schedule, headache or pressure in head, N/V, Balance problem or dizziness, fatigue, blurry/double vision, sesitivity to light or noise, numbness or tingling, "does not feel right", difficulty thinking clearly or concentrating or remembering, feeling slowed down, feelign sluggish hazy or groggy, being irritable, sad or more emotional than usual, feeling nervous.

You guys, some of this describes EVRY MS student. Some of that describes ME! I have double vision frequently due to a chronic head tilt, I get a headache almost every day, and this head injury protocol is making me irritated and nervous.

[WineRN]

I would talk to your supervisor and admin about a possible protocol change. Similar to what was stated above, I do a case by case assessment and call on EVERY head injury. I have a few parents with clumsy kids who I call on pretty regularly for head injuries that know my concussion guideline speech by heart.

But you really don't know when symptoms might start. I had a staff member who recently was out for a week due to a concussion from a student punching her in the head, she wasn't symptomatic until the following day.

[moreoreo]

Middle schoolers will say yes to ANYTHING to get out of class.

This is also true of elementary school students. When I started, I asked all the questions -- are you dizzy, do you feel sleepy, etc., and found that they liked to answer yes and then describe themselves with those same words later.

Like OldDude, if I referred out any symptom of every head injury I would be dismissing handfuls of students at a time during recess. Just yesterday I had three come in together who said they all bumped heads on each other.

I do have a head injury letter and the CDC concussion checklist but I only use these if a child is genuinely symptomatic. If I used these on every child who bumped their head while picking up their pencil, on a classmate in the hallway, on the playground outside, on their own knee, etc., I would be useless at accomplishing anything else. I have sent a few children with significant lumps but only one child who was having concussion symptoms.

Most of my kiddos who "bumped their heads" feel better after a few minutes with an ice pack and want to go back to class. Some come to see me and ask if they can go back outside right away. Assessing their mental status/pupils (even this at times feels silly)/gait/etc. takes less than a minute. I agree that your school's policy seems a bit much. I would lose it if I had to watch each of them for 30 minutes. There just isn't enough room for that.

[OyWithThePoodles, RN]

But it all honesty, ANY head injury that arrives to an ER that isn't a skull fracture is pretty much going to be diagnosed as a concussion. If there's a bump and the kid c/o a bad headache, whether they actually have one or not, is dx'd as a concussion.

I call on all head injuries. I don't ask specific questions, as the answer will always be yes. I ask "how are you feeling?". Then I let the teacher know of things to watch for. I call home and let the parent know that if anything changes I will give them another call. And of course I fill out an accident report. The bane of my existence.

[ruby_jane, BSN, RN]

Which means 30 mins in the clinic and completion of the CDC Concussion Checklist.

QUOTE]

Guess what I just had to do??? We have an athlete that took a helmet-to-helmet hit yesterday. Both trainers are out (one sick, one just on vacation). No baseline because he started late BUT because you mentioned it, I actually googled the CDC and came up with a copy of the ACE to assess and give to mom.

I probably would have remembered this existed...eventually.

Thanks, school nursing buddy who is miles away from me.

[Trixie13, BSN, RN]

I'm not a school nurse (yet--longtime lurker ), but I downloaded a nice app from the CDC for when I do camp nursing--it's called Head's Up. Has good info for parents.

P.S. Currently I do telephone triage and our protocols state a mild headache (relieved by OTCs) is normal for the first 24 hours after a head injury--it's interesting that the CDC is so vague about it.