Mild Traumatic Brain Injury in Children - Pediatric Nursing

1 Pediatric Nursing /November-December 2013/Vol. 39/No. 6267 Recent media attention hasincreased awareness of thelong-term impact of concus-sions on athletes followingthe recent $765 million settlementbetween the National Football League(NFL) and 18,000 retired footballplayers with long-term concussive-re -lated injuries (ESPN, 2012). Conse -quently, more attention is focused onthe impact of concussions for chil-dren, adolescents, and young health care providers under-stand and are concerned about howtraumatic Brain injuries (TBIs) in chil-dren can affect school performance,behavior, and general health andwell-being. Longer-term impact of re -peated concussions on Children dis-orders, including Alzheimer s, demen-tia, Parkinson s, Amyotrophic LateralSclerosis (ALS), or psychiatric diag-noses, such as depression and anxiety may not be an immediate Traumatic Brain Injury (mTBI) isa common occurrence in pediatricpatients, with consequences for short-and long-term sequelae (Rapp &Curley, 2012) and potentially signifi-cant mortality and morbidity (Cen -ters for Disease Control and Preven -tion [CDC], 2013).

2 The National Institute of Neuro -logical Disorders and Stroke (NINDS)defines TBI as an acquired braininjury caused by sudden traumaresulting in damage to the Brain tis-sue. There are three categories of TBI: mild , moderate, and severe (NINDS,2013). The focus of this article will beon the evaluation and managementof Traumatic Brain injuries in the Nursing EducationTraumatic Brain injuries (TBIs) in childhood, especially those related to participa-tion in sports and recreation activities, are receiving increased public is beginning to show that even mild TBIs (mTBIs) may not be mild atall, and could have serious long-term effects on the health, behavior, and cogni-tive abilities of Children . With the development of the Centers for Disease Controland Prevention s TBI tools for professionals, a more evidenced and systematicway is available to help recognize and manage mTBI.

3 New research on predictorvalues showing that symptoms may not be the best way to assess the severity ofmTBI will help to change how mTBIs are managed in the future. mild Traumatic Brain Injury in ChildrenChristine Narad MasonObjectives and instructions for completing the evaluation and statements of disclosure can be found on page Narad Mason, DNP, C-PNP, is aChildren s Neurosurgery Pediatric NursePractitioner, Children s National MedicalCenter, Children s Neurosurgery, Fairfax, and EtiologyIt is estimated that approximatelyhalf a million Children between theages of birth and 14 years are admittedto emergency rooms each year in theUnited States for TBIs (Faul, Likang,Wald, & Coronado, 2010). Childrenfrom birth to four years of age, andthose 15 to 19 years of age, are themost likely to suffer from a differences exist, with malesbeing 59% more likely to experience aTBI compared to females, especiallyfrom birth to four years of age (Faul etal.)

4 , 2010). Data from emergency room visitscollected by the CDC from 2002-2006show that over 50% of TBIs in childrenfrom birth to 14 years of age are causedfrom falls (Faul et al., 2010). In fact,TBIs account for over 18% of yearlyemergency room visits, with a 62%increase in falls for Children youngerthan 14 years of age compared to databefore 2002. In this same age group,25% of Children were injured whenthey collided into a moving or station-ary object. Motor vehicle accidentsaccount for 7% of TBI incidents andfor of TBI deaths in all agegroups. Almost 3% of TBIs in childrenfrom birth to 14 years of age are causedby assault (see Figure 1). All of these aresignificant numbers begging to answerthe question, Why are Children morelikely to have a TBI? Although the details of biome-chanical and biochemical assault onthe Brain after Injury is beyond thescope of this article, the simple answeris that the anatomy of a child s body isdifferent than that of an adult andlends itself to Brain injuries.

5 The basicpathophysiology for TBI is that follow-ing a blow to the head, the brainundergoes an acceleration and thendeceleration, causing stretching ofneuronal fibers, changes in excitatoryamino acid neurotransmitters, alterna-tions in blood flow, oxygenation, andat times, anatomical Injury to thebrain (Giza et al., 2013; Russo Buzzini& Guskiewicz, 2006). Once the injuryhas occurred, the inflammatory pro -cess begins and edema ensues, some-times resulting in the anoxic cascade. Appreciating the differences inchildren s anatomy and physiologymakes it easier to understand whyinfants and young Children are moresusceptible to TBIs and have differentsymptoms than older Children or ado-lescents. In infancy, the skull is sub-divided into eight bones with sutures(separations) between the the adolescent skull, thesepatent sutures allow the infant s skullto spread wider and grow larger if aninjury occurs to the Brain .

6 Thus, theinfant can sustain a significant bleedor Brain swelling and quickly accom-modate without an increase in the cra-nial pressure (Enix, Mullin, Green, &Kahn, 2007). Older Children and ado-lescents cannot tolerate a rapid in -crease in intracranial pressure be causethe closure of skull bones renders theskull rigid and unyielding. This fusionprocess typically occurs by two yearsof age. In addition, younger childrengenerally have fewer events with lossof consciousness when compared toolder Children who exhibit more clas-sic signs of a concussion. 268 Pediatric Nursing /November-December 2013/Vol. 39/No. 6 The term concussionis very broadand conjures up different connota-tions for people. The term concussionis used to describe a set of symptomsthat happen after the Brain sustains atraumatic Injury and is categorized onthe continuum of mild to the term mild , which indi-cates a minor Injury , mTBI can havesignificant detrimental effects, espe-cially in Children (Rapp & Curley2012; Taylor, 2012).

7 Anatomical differences make in -fants and Children more vulnerable toextensive injuries following headtrauma. The Brain of a child has widespaces located between the skull andbrain (subarachnoid spaces) contain-ing blood vessels that can becomedamaged after experiencing shearingforces and movement (Barth, Freeman,Broshek, & Varney, 2001). The in -fant s head-to-body ratio is much larg-er than an adult s, and the neck ismore flexible, which increases thepotential for greater movement anddamage from jarring forces. When aforce is applied to the head or thehead strikes a stationary object, thebrain moves back and forth inside theMild Traumatic Brain Injury in Children3% Injury TypeFallsMother Vehicle-TrafficUnknown/Other Struck By/AgainstAssault25%15%7%50%Figure Brain Injury by Injury Type for Children Birth to 14 Years of AgeSources.

8 Centers for Disease Control and Prevention, Symptoms of mild Traumatic Brain InjurySymptomDescriptionCommentDizziness /vertigoOccurs with or without changes in due to acceleration/deceleration of the , throbbing, constant orincreased duration or severity withincreased activity, sensitivity to headaches or post- Traumatic migraines maydevelop, requiring symptomatic disturbanceDouble vision, blurred increased pressure in the that occurs more than twice in onehour initially is a red flag for increased concern and may necessitate a CT vomiting can indicate an underlying hemor-rhage and places the child at risk for dehydration, whichcan increase of consciousnessLoss of consciousness for less than of consciousness does not have to be present tohave a Brain Injury and is less common in or difficultysleepingIncreased sleepiness, sluggish, feeling foggy. Very common after TBI.

9 Child should also be observedfor depressive symptoms. Some Children will have diffi-culty sleeping and develop insomnia. Lack of sleep willincrease fatigue symptoms or sleep out/blankspellsTrouble concentrating or frequent forgetful-ness. Answers questions slowly or forgetsthe have no memory of the Injury event. Can be worsewhen the child is tired. May be an indication of post- Traumatic seizures, requiring additional investigation withan disruptionsMood and personalitychangesAnger and temper outburst above andbeyond the child s baseline. Shorter toler-ance for limit outbursts are common and will often lessenfurther from the event; however, a subgroup of childrenmay go on to have long-term personality with memoryForgetfulness or trouble understanding oraccessing new or old information, troubleconcentrating, is often a decrease in school performance inschool-age Children . Sources:Adapted from Anderson, Heitger, & Macleos, 2006; Centers for Disease Control and Prevention, 2013; Cohen, Gioia,Atabaki, & Teach, 2009, Giza et al.

10 , 2013; Russo Buzzini & Guskiewicz, 2006. skull. This causes the Brain fibers to bestretched, blood vessels to bleed, andinflammation to occur. Once this hap-pens, the child may begin to showsigns of a concussion. In mild casesthe child may experience a headache;however, the more severe and/orrepetitive the Injury , the more likelysignificant damage may occur, such ashemorrhage and severe Brain Injury . Symptoms of mTBI (see Table 1)also occur in moderate and severePEDIATRIC Nursing /November-December 2013/Vol. 39/No. 6269 TBIs, only to a more acute and intensedegree. Common symptoms for mTBIare confusion, drowsiness, change insleeping pattern (more or less),headache, blurred vision, ringing inthe ears, balance problems, dizziness,vomiting, nausea, sensitivity to lightand noise, and numbness or tinglingin the extremities. Later symptomsinclude trouble in school, behaviorproblems (increased aggression andshort temper), memory problems,and attention and concentrationproblems.