Pediatric Primary Care (114 page)

3.  Confusion and inability to maintain focus.

4.  Disorientation.

5.  Slurred or incoherent speech.

6.  Incoordination.

7.  Memory deficits.

8.  Emotional.

9.  Any period of unconsciousness.

10.  Grade 1 concussion.

a.  Transient confusion.

b.  No loss of consciousness.

c.  Concussion symptoms or mental status abnormalities resolve in less than 15 minutes.

11.  Grade 2 concussion.

a.  Transient confusion.

b.  No loss of consciousness.

c.  Concussion symptoms or mental status abnormalities last more than 15 minutes.  

12.  Grade 3 concussion.

a.  Any loss of consciousness, either brief (seconds) or prolonged (minutes).

F.  Diagnostic tests.

1.  Sideline/immediate evaluation.

a.  Orientation–to time, place, person, and situation.

b.  Concentration–digits backward, months of year in reverse.

c.  Memory–recall 3 words or objects, details of contest, names.

d.  Physical tests–40-yard sprint, pushups, knee bends.

•  Any associated symptoms with these tests are abnormal findings.

e.  Neurological tests.

•  Pupils, coordination, sensation.

2.  Head CT–for Grade 2 concussion with symptoms that worsen or last longer than 1 week and for Grade 3 concussions.

3.  Immediate post-concussion assessment and cognitive testing (ImPACT) testing to assess cognitive functioning, done soon after concussion and before return to activities, mostly for Grade 3 concussions.

G.  Differential diagnosis.

H.  Treatment.

1.  Remove from contest.

2.  Monitor for progressive neurological changes.

3.  ED for Grade 3 concussions.

4.  When to return to play: need to be asymptomatic with normal neurological assessment at rest and with exertion.

a.  Grade 1–after 15 minutes same day.

b.  Multiple Grade 1–1 week.

c.  Grade 2–1 week.

d.  Multiple Grade 2–2 weeks

e.  Grade 3 with brief LOC–1 week.

f.  Multiple Grade 3–1 month or longer.

I.  Complications.

1.  Seizures.

2.  Second impact syndrome–repeat concussion that occurs before the brain recovers from the first, can slow recovery or increase likelihood of long-term problems including brain damage, brain swelling, and even death.

3.  Depression–not being able to participate in their sport.

4.  Rare case for development of blood clot on brain.

J.  Follow up.

1.  See return to sports guidelines above, need to be cleared first.

2.  Call or go to ED for:

a.  Unequal pupils.

b.  Drowsy and cannot awaken.

c.  Worsening headache.

d.  Weakness, numbness.

e.  Repeated vomiting.

f.  Seizure.

g.  Slurred speech.

h.  Increased confusion.

i.  Unable to recognize people or places.

j.  LOC.

K.  Education.

1.  Use protective equipment that fits properly and is well maintained.

2.  Practice safe playing techniques/good sportsmanship.

3.  Know signs and symptoms of concussion, when to sit out and when to return.

V.  STATUS EPILEPTICUS

A.  30 minutes or more of continuous seizure activity or a series of seizures without return to full consciousness between seizures.

B.  Etiology.

1.  Idiopathic.

2.  Central nervous system (CNS) neoplasms, stroke, infections, electrolyte abnormalities, trauma, metabolic disorders, toxic ingestion, hypoxic insult.

3.  History of epilepsy.

4.  Noncompliance with antiepileptic medications.

5.  History of injury–MVA, fall.

C.  Occurrence.

1.  50,000–200,000 cases per year.

2.  Mortality rate 20%, mostly from underlying case of brain injury.

3.  Can occur in all age groups, more in elderly.

4.  Males and females affected equally.

D.  Physical findings.

1.  Absence status.

a.  Confusion, lethargy.

b.  EEG with continuous or intermittent but frequent spikes and slow wave discharges.

2.  Focal motor status.

a.  Continuous jerking of restricted muscle groups.

3.  Complex partial status.

a.  Confused, dazed, automatisms often present.

b.  Most often series of seizures, remaining confused between seizures.

4.  Generalized tonic-clonic status.

a.  Continuous convulsions or repetitive convulsions without resolution of postictal depression between episodes.

E.  Diagnostic tests.

1.  EEG.

2.  Head CT initially, may do MRI later if warranted.

3.  CMP (focus on glucose, Na+, Ca++), toxicology screen, WBC.

4.  LP if CNS infection in differential.

F.  Differential diagnosis.

G.  Treatment.

1.  Maintain vital signs and ABCs.

2.  Administer DIASTAT AcuDIAL after 5 minutes of seizure activity.  Call 911 if seizure continues.

3.  Ativan IV: 0.1 mg/kg at 2 mg/min.

4.  Diazepam IV: 0.3-0.5mg/kg at 2 mg/min.

5.  Fosphenytoin, phenobarbital, phenytoin (Dilantin), divalproex sodium (Depakote IV).  Monitor for respiratory depression.

6.  Correct any abnormal laboratory findings.

7.  Treat any underlying infection.

H.  Complications.

1.  Respiratory failure.

2.  Aspiration.

3.  Hypotension.

4.  Acidosis.

5.  Hyperthermia.

I.  Follow up.

1.  Coordinate with specialists for any associated injuries or complications.

2.  See neurologist in 2 weeks.

3.  Start maintenance antiepileptic medication, call for any side effects or further seizures.