Head injury question

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What is typical protocol for a kid brought to the ER for signs/symptoms of a concussion?

I'm a school nurse and my son hit his head hard on the ground getting tackled in a football game. (I'm not asking for personal advice-this happened last fall and I want to know what to do in future). My husband was a coach and he noticed he wasn't acting right several minutes later so I went down and checked him. I did a neuro check on him. His responses were very slow, he was confused, didn't remember what happened along with bad headache. We had him rest for a few minutes and he started feeling very nauseated and sleepy. We took him to the ER where they made us wait almost 2 hrs. The dr finally sees him and his responses are back to almost normal and he's feeling better except for a bad headache/stomachache. The only thing the dr did was another neuro check. No scans of any kind. He released him to go home. He didn't go back to school for 3 days because his head was hurting and everything wore him out. We ourselves cut out his video games and limited TV to give his brain a break. It took him about 3 weeks at least to feel back to normal.

So my question is, if this happens again do I even bother taking him in, are there other signs I need to look for that would warrant a trip, should I go to a different ER, should I have waited longer? Since he had signs of a concussion I thought I should have him checked but the dr didn't do anything I hadn't already done. They made me feel stupid for bringing him in quite frankly and being a nurse I don't take my kids to dr unless I feel they REALLY need to go. I'm confused about what to do. Thanks for any advice.

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Specializes in Emergency, Telemetry, Transplant.

I'm not going to tell you what to do in the future, since this would constitute medical advice.

I will say this--"concussion" is a medical diagnosis based on physical exam. There is no imaging study that will show whether or not he had a concussion. If the doctor, based on his neuro exam, felt there was nothing more sinister (such as, some type of a brain bleed), nothing would be gained by any neuro imaging.

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I think any time you are concerned about an urgent or emergent health problem with your child, you should seek medical attention, whether that means calling your pediatrician, going to an urgent care or after hours clinic, or going to the Emergency Department.

There are a lot of concerns about exposing children to ionizing radiation, from increased cancer risk to decrease in IQ points for each scan performed. Emergency physicians typically follow an algorithm/protocol that determines whether a head CT is necessary.

The physician who saw your son probably took into account several factors such as the GCS, neuro exam, mechanism of injury, presence or absence of palpable skull fracture, etc., to determine whether a head CT was indicated, and based upon all of these factors, it was not indicated.

I can tell you that we frequently see concerned parents bringing children in with concussive symptoms, and rarely do we do any neuroimaging studies. I have once seen a skull fracture in an infant, and once in a five year old boy. In both instances, GCS, neuro and physical exams and mechanisms of injury indicated that imaging studies were indicated, but really we didn't need imaging to tell us these kids had serious injuries.

I feel like the algorithms/protocols are very reliable, as far as what I've seen. Your account of your ED visit sounds pretty standard to me.

Again, any time you are concerned your child might have an urgent or emergent medical need, you should seek medical attention at the appropriate level.

As far as feeling stupid for bringing your son in, I would never do anything to make a parent feel stupid for feeling concerned about their child. I love seeing the kiddos! I saw two yesterday for minor complaints, but I had fun breaking the ice with them and getting them to let me take their temperatures and listen to their chests, and gave them stuffed animals on the way out. It's the children that are too sick to interact with me that are harder to deal with emotionally.

And, as I frequently tell my adult patients that tell me how dumb they feel for coming in with chest pain, it's better to come in and have it be nothing than to stay home and have it be "the big one".

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Ok good to know! Thank you! I definately don't want him or any kids exposed to more radiation that necessary. I've just always heard if they have symptoms get them to hospital right away. Now I'm wondering if waiting a while would hurt. I guess if symtoms keep getting worse go and if improve maybe not. Have you seen symtoms improve and there still be a big issue that should've been seen? Just curious. If I see a bunch of symptoms I'm still going as I'm not a dr. and would kick myself if I was wrong but we do have several parents in the school system that get really mad if you recommend their child go to dr and child checks out fine. I would be relieved if my kid was ok but they get mad I made them waste their money. Still for liability reasons I have to recommend dr follow-up a lot of times.

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I would imagine that as a school nurse, when you observe that a student is experiencing concerning signs/symptoms, you contact the parents and recommend a medical evaluation. Am I right?

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Specializes in Emergency Department.

What I'm going to say is the symptoms you're describing are consistent with concussion, including the time afterward. If you see those symptoms in anyone post collision, you probably should have them be seen by a physician sooner rather than later. The symptoms can subside very quickly. I know quite a bit about concussion evaluation, far more than I've been taught in RN school. For me to launch into what I know about concussion evaluation would certainly put me right on the edge, if not well over, the scope of this site. My background includes sports medicine.

As others have said, concussion is diagnosed by exam. Imaging may be used to rule out other things, but imaging alone won't show anything specific to concussion.

Even if you think they think you're stupid for bringing the kid in, this is one area where you should not care if they think you're stupid. This is because other problems can mimic concussion and lead to bad outcomes instead and some of these problems may not show up right away.

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Specializes in LTC.

Here is an article that is very informative Sport-Related Concussion in Children and Adolescents

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Specializes in Emergency Nursing.

It's better to be safe, you did the right thing for having the doctor check him out! It's always different when it's family; sometimes you have to stop being a nurse and just be a parent.

We rarely CT young people with those symptoms. The radiation just isn't worth it. And then they get mad because "we didn't do anything." Well, if they doctor thinks a CT is unwarranted it's better they save you from the radiation. The 90 year old on coumadin is another story.

And from personal experience, concussions suck. My last one was pretty bad: nausea, my mind felt fuzzy for weeks, ringing in my ears, bad headaches, mood swings, trouble concentrating, lethargy.... keep an eye on the little guy and be patient. If things don't seem right after a while I'd personally consult a neurologist.

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The CDC had a lot of great information about concussions and actually give a timeline for letting children ease back into sports after a concussion.

CDC - Concussion - Traumatic Brain Injury - Injury Center

Great information for parents, coaches and nurses.

There are also baseline concussion tests available for coaches so they have something to compare if they are worried about a concussion.

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Thanks for all the good info and articles! That has helped clear things up a lot! I appreciate it and have learned some new things which is always good. It's also good to know I wasn't being silly for taking my son to the ER when I saw the symptoms. Thanks again!

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Second impact concussions, if they return to sports too soon and get reinjured are very serious.

MN requires all coaches to do mandatory concussion training, and are very serious about letting kids return to sports after a concussion.

Glad you followed your instincts and continued to ask questions. We all can learn something new every day.

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Specializes in kids.

You did all the right things. The more concussions they have, the more severe the symptoms/damage can be. You did right to limit tv video etc. When I have a kiddo at school (HS) with a head injury, I email teachers and guidance and asst principal, because the symptoms can play out in a variety of ways. All our student/athletes do a baseline neuro cognitive assessment(ImPact testing -www.impacttest.com ) This is ONE tool in the process that determines return to play. There are other programs out there as well.

It sounds like he had a doozy of a concussion and as such it would warrant medical followup in the event he gets hurt again.

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