MCQs In Emergency And Critical Pediatrics

Q 1:

A 12-year-old boy who plays wide receiver is undercut by a tackler while leaping to catch a pass. He drops the ball and, after getting to his feet, is confused and walks to the opposing team’s side of the field. He remains confused while walking into the locker room for halftime but then seems normal by the start of the second half. However, he continues to have some amnesia for the details of the play in which he was tackled.

Of the following, the recommendation you are MOST likely to make as team physician is

A. daily neurologic examinations for 2 weeks

B. emergency department evaluation and clearance before returning to play

C. return to play at the start of the second half

D. return to play in 30 minutes if symptoms resolve

E. return to play in 7 to 10 days if symptoms resolve

Answer :

E

The boy in the vignette has experienced a concussion characterized by transient cognitive symptoms of amnesia and disorientation after a fall. In this setting, it is best to disallow return to play during this game. He should be evaluated in the office but does not need daily neurologic examinations for 2 weeks. He may return to play in 7 to 10 days if symptoms completely resolve.

The symptoms described are mild enough (no loss of consciousness) that urgent referral to the emergency department is not warranted. However, he should be sent to the emergency department for evaluation if he experiences repeated vomiting, severe or progressively worsening headache, a seizure, unsteady gait, weakness or numbness, slurred speech, unusual behavior, signs of a basilar skull fracture, or worsening mental status.

Guidelines regarding concussion and sports continue to evolve as they are informed by research on traumatic encephalopathy in contact sports. The most important feature of current guidelines for return to play is that assessment needs to be careful and that return to play should not occur until all cognitive symptoms have resolved. An experienced physician should examine the student and ascertain that all symptoms have resolved at rest and with exercise before the student returns to play. Provocative exercise may include a 40-yard sprint, 5 pushups, 5 situps, and 5 knee bends; the examiner evaluates for emergence of headache, dizziness, nausea, visual symptoms, and mental or emotional changes.

Neuroimaging is not indicated according to this presentation. However, if headache or cognitive symptoms worsen over the next week or if seizures or focal neurologic deficits are identified, imaging should be considered. Findings on imaging of brain swelling or contusion would be an indication to terminate participation for the rest of the season.