The diagnosis of concussion in a pediatric emergency department
Kathy Boutis1, Kirstin Weerdenburg1, Ellen Koo1
1Division of Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Canada.
Insights
Pediatric emergency physicians diagnosed concussion in fewer children than recommended by international guidelines. This suggests missed concussion cases and opportunities for crucial management advice.
Area of Science:
- Pediatric Emergency Medicine
- Neurology
- Sports Medicine
Background:
- Concussion diagnosis in children is critical for appropriate management.
- International consensus statements provide guidelines for concussion diagnosis.
- Variability in physician diagnosis compared to established criteria warrants investigation.
Purpose of the Study:
- To compare concussion diagnoses by pediatric emergency physicians with Zurich consensus criteria.
- To identify clinical factors associated with physician concussion diagnosis in children.
Main Methods:
- Prospective, cross-sectional study in a tertiary pediatric emergency department.
- Enrolled children aged 5-17 with head injuries.
- Collected data on demographics, injury mechanism, symptoms, physician diagnosis, and advice.
Main Results:
- Emergency physicians diagnosed concussion in 40.4% of children, while 89.5% met Zurich criteria (P<.0001).
- Factors associated with physician diagnosis included age ≥10, delayed presentation, collision sports, headache, and amnesia.
- Significant discrepancy observed between physician diagnosis and consensus guidelines.
Conclusions:
- Pediatric emergency physicians diagnosed concussion less frequently than international guidelines suggest.
- Physician diagnoses relied on fewer variables than recommended, potentially leading to missed cases.
- Underdiagnosis may result in missed opportunities for essential cognitive and physical management advice.
Objectives:
To compare the proportion of children diagnosed with a concussion by pediatric emergency physicians vs the proportion who met criteria for this injury as recommended by Zurich Fourth International Conference on Concussion consensus statement and to determine clinical variables associated with a physician diagnosis of a concussion.
Study Design:
This was a prospective, cross-sectional study conducted at a tertiary care pediatric emergency department. We enrolled children ages 5 through 17 who presented with a head injury and collected data on demographics, mechanism of injury, head injury-related symptoms/signs, physician diagnosis, and discharge advice.
Results:
We identified 495 children whose mean age was 10.1 years (SD 3.4 years); 308 (62.2%) were male. Emergency physicians diagnosed concussion in 200 (40.4%; 95% CI 36.1, 44.7) children, and 443 (89.5%; 95% CI 86.8, 92.2) met criteria for concussion in accordance with the Zurich consensus statement (P<.0001). Age≥10 years (OR 1.8), presentation≥1 day after injury (OR 2.4), injury from collision sports (OR 5.6), and symptoms of headache (OR 2.2) or amnesia (OR 3.4) were the variables significantly associated with an emergency physician's diagnosis of concussion.
Conclusions:
Pediatric emergency physicians diagnosed concussion less often relative to international consensus-based guidelines and used a limited number of variables to make this diagnosis compared with current recommendations. Thus, pediatric emergency physicians may be missing cases of concussion and the corresponding opportunity to provide critical advice for cognitive and physical management.
