A 14-year-old boy is brought to the emergency department by his parents after sustaining a head injury an hour ago. He was playing hockey and collided with another player, after which he fell and hit his head on the ice. The patient immediately developed a headache, followed by a single episode of vomiting. He remained awake, and his symptoms have since resolved. Vital signs are normal. The patient is alert and oriented to person, place, and time. He is unable to cite the months backwards. Neurologic examination is otherwise normal. CT scan of the head is normal. The patient asks whether he may play in a hockey game tomorrow morning. Which of the following is the best recommendation for return to competitive play in this patient?

Question

A 14-year-old boy is brought to the emergency department by his parents after sustaining a head injury an hour ago.  He was playing hockey and collided with another player, after which he fell and hit his head on the ice.  The patient immediately developed a headache, followed by a single episode of vomiting.  He remained awake, and his symptoms have since resolved.  Vital signs are normal.  The patient is alert and oriented to person, place, and time.  He is unable to cite the months backwards.  Neurologic examination is otherwise normal.  CT scan of the head is normal.  The patient asks whether he may play in a hockey game tomorrow morning.  Which of the following is the best recommendation for return to competitive play in this patient?

Quizplus · Accepted Answer

11ec25c8_d162_e962_bc81_dd8d48b5b86f_MD0003_00 This patient's headache and cognitive dysfunction after head trauma are due to a concussion, or mild traumatic brain injury. Concussions are common in children and adolescents who participate in contact sports (eg, hockey, football). Pathogenesis involves axonal shearing from rotational acceleration of the brain after a fall or strike to the head. Concussion is generally diagnosed based on the presence of neurocognitive symptoms after a trauma causing shear stress (eg, tackling, head hitting the ground). Clinical findings can include headache, dizziness, confusion, sleepiness, and difficulty concentrating (eg, inability to cite months backwards). Neuroimaging is not required for diagnosis but may be performed to exclude structural intracranial injury (eg, contusion, hematoma) in patients with high-risk features (eg, vomiting, loss of consciousness). The initial treatment of a concussion is symptom management (eg, nonsteroidal anti-inflammatory drugs, ondansetron) as well as physical and cognitive rest for 24-48 hours. After this period of rest, athletes may follow a gradual return-to-play protocol (over a minimum of 5 days) that involves increasing intensity of physical activity (eg, light exercise → noncontact sport → competitive play). Patients should remain symptom-free before progressing to the next level. Most patients resume normal activities within a month. (Choices B and D) Returning to full, competitive play immediately or after 24 hours will likely exacerbate or prolong concussion symptoms. In addition, recurrent head injury from any contact sport during the initial recovery period can lead to second impact syndrome, which is characterized by cerebral edema and can be fatal. In contrast, patients should begin with rest followed by light activity after a concussion and gradually advance to avoid reinjury. (Choice C) Prolonged, strict rest after a concussion is associated with delayed recovery and deconditioning. Early return to light exercise is safe as long as the progression of intensity is gradual. (Choice E) Neuroimaging may be performed for persistent, worsening concussion symptoms to exclude structural intracranial injury. However, this patient has a normal CT scan of the head, and follow-up MRI would not help determine when he can participate in sports. Educational objective: Concussion, or mild traumatic brain injury, is characterized by neurologic symptoms (eg, headache, difficulty concentrating) without structural intracranial injury. Initial treatment is with cognitive and physical rest for 24-48 hours, followed by a gradual return to play with slowly increasing physical intensity. References: American Medical Society for Sports medicine position statement: concussion in sport. (http://www.ncbi.nlm.nih.gov/pubmed/23243113)

A 14-Year-Old Boy Is Brought to the Emergency Department by His