FIGURE 113.2 Epidural hematoma. A head computed tomography scan shows the
classic biconvex hyperdensity of an epidural hematoma.

Subarachnoid hemorrhage involves traumatic injury to the vessels
supplying the pia matter. As the cerebral subarachnoid space extends to the
spinal subarachnoid, the accumulation of blood may be extensive and layers
along the bony surface.
There are no specific criteria for surgical intervention with cerebral
hemorrhage. In the patient who is deteriorating because of increased ICP,
care may require escalation from temporizing measures, as described above,
to evacuation of the clot, and finally to decompressive craniectomy.

CONCUSSION
CLINICAL PEARLS AND PITFALLS


Common features involve somatic symptoms, physical signs,
behavioral or emotional changes, cognitive impairments, and/or
sleep disturbances.
Eighty percent to 90% of symptoms resolve within 7 to 10 days.
Goal of therapy is physical and cognitive rest.
Concussion is a clinical syndrome of biomechanically induced brain
dysfunction without apparent radiographic injury. The panel consensus
statement from the 5th International Conference on Concussion in Sport
defines concussion as “a traumatic brain injury induced by biomechanical
forces.” Several common features that incorporate clinical, pathologic and
biomechanical injury constructs that may be utilized in defining the nature
of a concussive head injury include:
1. Concussion may be caused either by a direct blow to the head, face, neck
or elsewhere on the body with an “impulsive” force transmitted to the
head.

2. Concussion typically results in the rapid onset of short-lived impairment
of neurologic function that resolves spontaneously. However, in some
cases, symptoms and signs may evolve over a number of minutes to hours.
3. Concussion may result in neuropathologic changes, but the acute clinical
symptoms largely reflect a functional disturbance rather than a structural
injury and, as such, no abnormality is seen on standard structural
neuroimaging studies.
4. Concussion results in a range of clinical symptoms that may or may not
involve loss of consciousness. Resolution of the clinical and cognitive
symptoms typically follows a sequential course. However, it is important
to note that in some cases symptoms may be prolonged.
5. The use of grading scales for concussion is no longer recommended as
there is no evidence that such assignments are predictive of cognitive
deficits.

Current Evidence
Evaluation for TBI accounts for more than 800,000 ED visits per year, with
approximately 75% of those visits defined as concussion or mild TBI.
There has been a tremendous emphasis on sports-related concussions and


TBI, especially in children and adolescents. From 2010 to 2016, an
estimated 283,000 children annually sought ED care related to sports or
recreational TBI. This may be due, in part, to increased identification and
codifying of concussion as well as local and state policies regarding sports
injuries. The state of Washington was the first to pass a concussion in sports
law in 2009, and by 2013 all 50 states including the District of Columbia
had enacted legislation regarding concussions in sports for youth and/or
high school athletes. This legislation focuses on education,
recommendations for removing athletes from play, and permission to return

to play. Many states require return to play permission be obtained by a
healthcare professional, which may influence the number of TBI-related
visits. Please refer to Chapter 41 Injury: Head , for a detailed discussion
regarding pathophysiology and signs and symptoms.
Clinical Considerations
Clinical Recognition. The features of concussion are nonspecific and some
may be indicative of ciTBI. The most common symptoms include
headache, dizziness, gait abnormalities, confusion, disorientation, difficulty
concentrating, nausea, vomiting, loss of consciousness, amnesia both
retrograde and anterograde, light and noise sensitivity, visual changes, sleep
disturbances, emotional lability, and irritability. The physical examination
in patients with concussions is typically normal. The evaluation should
include a comprehensive neurologic examination including mental status,
gait, and visio-cerebellar function 1 . Any focal neurologic findings during
the physical examination should alert the clinician to the potential for ciTBI
and prompt the need for neuroimaging.
Multiple concussion assessment tools have been utilized in children and
adolescents. The list includes, and is not limited to, the Sport Concussion
Assessment Tool Version 5 (SCAT 5), Child-SCAT5, Balance Error Scoring
System (BESS), Standardized Assessment of Concussion, individual
sideline assessment tools, and the Centers for Disease Control (CDC) and
Prevention’s Acute Concussion Evaluation (ACE) tools. Many of these
tools have not been validated in children, and the lack of standardized
assessment tools creates challenges for providers. Most of these instruments
are in depth, detailed and time consuming. Their use in the ED has not been


found to be helpful. While many sports professionals administer
preparticipation assessments utilizing these tools, it is not standard, and
those results may not be accessible to the clinician during the initial

posttraumatic evaluation.
Diagnostic Imaging. Neuroimaging, whether CT or MRI, is not routinely
performed, except as a concern for ciTBI arises. As previously discussed,
features that warrant emergent neuroimaging include altered mental status,
evidence of depressed or basilar skull fracture, posttraumatic seizure,
prolonged loss of consciousness, worsening headache, and focal neurologic
examination findings. CT is widely available and quickly detects significant
ciTBI. MRI may be preferred to CT to avoid radiation exposure but is not
as widely available and time may be of the essence with neurologic
deterioration. MRI may be performed as an outpatient if the patient has
worsening or prolonged duration of symptoms after the initial evaluation.
Preliminary evidence reveals that functional MRI as well as proton
magnetic resonance spectroscopy and diffusion tensor imaging may identify
abnormalities associated with cognitive deficits. These imaging modalities
are quite specific and not currently accessible at most centers.
Management. If the injury occurs during a sporting event, an on-field or
sideline evaluation is done to determine disposition. If there is no licensed
healthcare provider immediately available to make that determination, the
patient should be removed from participation. This necessitates a complete
evaluation by a physician, which may involve an ED visit. As with any
trauma evaluation, the initial assessment should focus on Airway,
Breathing, Circulation, Disability, and Exposure per trauma guidelines.
Please review Chapter 7 A General Approach to the Ill or Injured Child for
additional details.
After excluding ciTBI or other traumatic injuries, strategic concussion
management includes symptomatic relief and restriction of activity with
physical and cognitive rest. Most authors recommend a graduated return to
activities. Judicious use of pain medication and antiemetics should be
recommended as not to mask symptoms. Their use may be necessary, but
should be taken into account when recommending return to activities. Most

consensus statements recommend returning to physical activities once the